An Open Label Phase II Single Centre Study Investigating the Safety and Efficacy of LTX-315 and Adoptive T-cell Therapy in Patients With Advanced/Metastatic Soft Tissue Sarcoma (ATLAS-IT-04)
Phase: PHASE2
Conditions: Soft Tissue Sarcoma
Sponsor: Lytix Biopharma AS

“An open-label phase II single-centre study investigating the safety and efficacy 
of LTX-315 and adoptive T-cell therapy in patients with advanced/metastatic 
soft tissue sarcoma” 
 
Clinical Trial Protocol 
Version 3.0, 31st March 2020 
NCT: 03725605 
 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 2 of 96 
 
 
 
Medical Monitor 
 
 
 
 
 
 
 
Notification of serious adverse events 
 
 
 
 

Protocol C17-315-04 
Protocol Version 3.0, 31-Mar-2020 
Page 4 of 96 
PRINCIPAL INVESTIGATOR SIGNATURE PAGE 
Study number: 
C17-315-04 
Study Title: 
An open-label phase II single-centre study investigating the 
safety and efficacy of LTX-315 and adoptive T-cell therapy in 
patients with advanced/metastatic soft tissue sarcoma 
Principal Investigator: 
Signature: 
Date: 
Inge Marie Svane, Professor, MD, PhD 
April 2, 2020

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 5 of 96 
 
CONTRACT RESEARCH ORGANISATIONS  
 
Clinical Project Manager: 
 
 
 
 
 
 
Study Statistician: 
 
 
 
 
 
 
Central Laboratories: 
 
 
 
 
 
                                            
 
 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 6 of 96 
 
 
Summary of Key changes 
Section (Number & 
Title)  
Description of Change  
Brief Rationale 
Synopsis(1 Inclusion 
criteria) 
5.2 Inclusion criteria 
Add patients with stable 
disease. 
Patients with STS progress rapidly and 
estimated median survival time is 10 
months. By including patients with 
metastatic disease the patients will receive 
the TIL product at an earlier time point after 
progression. This change may also enhance 
the recruitment rate of patients to the study. 
Synopsis(1 Inclusion 
criteria) 
5.2 Inclusion criteria 
Change of lesion size from 
> cm to > cm. 
A lesion with longest diameter (LD) of 
cm 
may include sufficient tumor tissue and TILs 
to expand T cells for ACT. This change may 
also enhance the recruitment rate of 
patients to the study. 
Synopsis(1 Inclusion 
criteria 
Inclusion criteria 5.2 
7.4.1.1 Biopsies 
7.4.1.4 Identification 
of tumour-antigen 
specific T-cells 
9.4.1.1 Objective 
response rate 
Appendix IV 
Change from irRC to RECIST 
only. 
RECIST v.1.1 is the standard way to 
evaluate response. irRC is developed for 
assessment of response upon treatment 
with immune checkpoint inhibitors which 
may result in pseudoprogression. 
Synopsis (secondary 
endpoint 1 and 2) 
3.2 Secondary 
endpoint 
Change in CD3+ T-cell and 
CD3+CD8+ T cell density in 
non-injected tumour tissues 
from Baseline (Step 1, Week 
1, Day 1) to EoT (Step 2, 
Week 7) if the patient has a 
feasible bystander lesion and 
accept it to be biopsied.  
Total number of CD3+CD8+ T 
cells and % CD3+CD8+T cells 
of total CD3+ T cells in final 
Endpoint changes to better describe 
assessment of objective 2. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 7 of 96 
 
Section (Number & 
Title)  
Description of Change  
Brief Rationale 
TIL infusion product .                  
Synopsis 
7.4.1.1. Biopsies 
If a non-injected lesion regress 
>30% and is feasible for 
biopsy, an optional biopsy of 
this lesion will allow a 
comparison with the TIL 
product and blood before and 
after LTX-315. 
Add a biopsy of non-injected lesion if a 
clinical response (>30% regression) in one 
non-injected lesion. This will allow for 
analysis of whether T-cell clones generated 
after LTX-315 treatment has infiltrated non-
injected lesions.  
Synopsis 
4.2 Study rationale 
6.3 Treatments   
Administrated 
LTX-315 will be administered 
on dosing days (i.e. Step 1, 
Days 
 
 
for patients that were 
in stable disease upon 
enrollment in the study). 
Treatment schedule will be changed from 
day 
 to day 
 for 
patients in PD at enrollment. The rationale 
for this is that better abscopal and immune 
effects have been observed in patients 
treated with intensive treatment in week 1 
(in the C12-315-03 study). Patients in SD at 
enrollment may have two additional dosing 
days at day 
 and 
 to enable induction of 
a stronger immune response induced by 
LTX-315. see rationale for including patients 
with SD. 
Synopsis  
4.1 Study design 
Step 1 (W1 to W3-5). 
Patients that are in stable disease at 
enrollment will have an additional 2 weeks 
before resection compared to patients  that 
have PD. A longer time period before 
resection will enable increased number of 
TILs for expansion of TIL product. 
4.1 Study design 
8.6 Source data 
Treatment period (including 
screening): up to 26 weeks. 
 
Synopsis 
3.2 Secondary 
endpoints 
4.1 Overall study 
design 
5.2 Inclusion criteria 
7.3 End of treatment 
24 month to 15 month follow-
up. 
10 months is mean for overall survival for 
the patient group. Thus, 15 months is a HR 
of 1.5 and for a single arm study this should 
be more than enough for drawing adequate 
conclusions. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 8 of 96 
 
Section (Number & 
Title)  
Description of Change  
Brief Rationale 
and follow-up 
8.3 Data analysis 
and reporting 
8.6 Source data 
9.4.1.1.Objective 
 response rate 
 
9.4.1.2 Clinical  
benefit rate 
 
9.4.1.3 Progression 
 free survival 
 
9.5 Exploratory 
 Analyses 
 
9.6 Other  
Assessments 
2.5 Clinical  
experience 
The LTX-315 injection 
schedule comprised either of 
injection of multiple lesions for 
 dosing days per week for  
weeks 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 
 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 10 of 96 
 
Section (Number & 
Title)  
Description of Change  
Brief Rationale 
Synopsis (Incl. 
criteria No 11) 
5.2 Inclusion criteria 
no 11 
5.4 Recruitment and 
screening 
Re-screening is allowed once 
on a case by case basis as 
judged by the investigator .        
Allow to re-screen a patient once to 
increase recruitment rates. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 11 of 96 
 
TABLE OF CONTENTS 
1 
SYNOPSIS ................................................................................................................. 19 
2 
INTRODUCTION ........................................................................................................ 28 
2.1 
Therapeutic area disease background .................................................................... 28 
2.2 
Sarcoma .................................................................................................................. 28 
2.3 
Standard treatment of soft tissue sarcoma ............................................................ 28 
2.4 
Drug class ................................................................................................................ 29 
2.4.1 
LTX-315 ............................................................................................................ 29 
2.4.2 
LTX-315 Toxicology .......................................................................................... 29 
2.4.3 
LTX-315 Non-clinical safety ............................................................................. 30 
2.4.4 
LTX-315 Non-clinical efficacy ........................................................................... 30 
2.4.5 
TILs from sarcoma ........................................................................................... 31 
2.4.6 
TILs Non-clinical efficacy .................................................................................. 31 
2.5 
Clinical experience .................................................................................................. 31 
2.5.1 
Clinical safety of LTX-315 ................................................................................. 31 
2.5.2 
Clinical studies with adoptive T-cell therapy ................................................... 32 
2.5.3 
Clinical experience with LTX-315 in combination with ACT ............................ 33 
2.5.4 
Translational research ..................................................................................... 34 
3 
STUDY OBJECTIVES AND ENDPOINTS ......................................................................... 34 
3.1 
Study objectives ...................................................................................................... 34 
3.2 
Endpoints ................................................................................................................ 35 
4 
STUDY DESIGN .......................................................................................................... 36 
4.1 
Overall study design ................................................................................................ 36 
4.2 
Study rationale ........................................................................................................ 37 
4.2.1 
LTX-315 dose rationale .................................................................................... 38 
4.2.2 
Drugs used in adoptive T-cell therapy ............................................................. 39 
4.3 
Benefit and risk assessment ................................................................................... 39 
4.3.1 
Benefits ............................................................................................................ 39 
4.3.2 
Risks associated with LTX-315 ......................................................................... 40 
4.3.3 
Risk associated with adoptive T-cell therapy .................................................. 40 
4.3.4 
Risks and disadvantages regarding surgery and test sampling ....................... 43 
4.3.5 
Overall benefit and risk evaluation ................................................................. 43 
5 
SELECTION OF STUDY POPULATION ........................................................................... 44 
5.1 
Population ............................................................................................................... 44 
5.2 
Inclusion criteria ..................................................................................................... 44 
5.3 
Exclusion criteria ..................................................................................................... 45 
5.4 
Recruitment and screening ..................................................................................... 46 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 12 of 96 
 
5.5 
Patient withdrawal .................................................................................................. 46 
6 
TREATMENTS ............................................................................................................ 47 
6.1 
IMPs and non-IMPs ................................................................................................. 47 
6.1.1 
Labelling and packaging ................................................................................... 47 
6.1.2 
Storage and handling ....................................................................................... 48 
6.1.3 
Reconstitution and dispensing ........................................................................ 49 
6.1.4 
Treatment compliance .................................................................................... 49 
6.2 
Selection of drug doses ........................................................................................... 49 
6.2.1 
LTX-315 ............................................................................................................ 49 
6.2.2 
Cyclophosphamide .......................................................................................... 49 
6.2.3 
Fludarabine phosphate .................................................................................... 49 
6.2.4 
TILs ................................................................................................................... 49 
6.2.5 
Interleukin-2 .................................................................................................... 49 
6.2.6 
Pegfilgrastim .................................................................................................... 50 
6.2.7 
Sulfamethizole with trimethoprime ................................................................ 50 
6.2.8 
Aciclovir ........................................................................................................... 50 
6.2.9 
Chlorpheniramine ............................................................................................ 50 
6.2.10 Ranitidine ......................................................................................................... 50 
6.2.11 Montelukast .................................................................................................... 50 
6.3 
Treatments administered ....................................................................................... 50 
6.3.1 
LTX-315 injection schedule .............................................................................. 50 
6.3.2 
Production of TILs ............................................................................................ 52 
6.4 
Concomitant therapy .............................................................................................. 52 
6.5 
Method of assigning patients ................................................................................. 53 
6.6 
Blinding (not applicable) ......................................................................................... 53 
6.7 
Emergency unblinding procedures (not applicable) ............................................... 53 
7 
VISIT SCHEDULE AND ASSESMENTS ........................................................................... 54 
7.1 
Visit schedule .......................................................................................................... 54 
7.2 
Study procedures .................................................................................................... 59 
7.2.1 
Guidelines for supportive care and treatment ................................................ 59 
7.2.2 
Supportive treatment ...................................................................................... 59 
7.2.3 
Local radiotherapy ........................................................................................... 59 
7.3 
End of treatment and follow-up ............................................................................. 59 
7.3.1 
Normal end of treatment ................................................................................ 59 
7.3.2 
Follow-up ......................................................................................................... 60 
7.3.3 
Standard care following study completion ..................................................... 60 
7.4 
Efficacy assessments ............................................................................................... 60 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 13 of 96 
 
7.4.1 
Local inflammatory responses ......................................................................... 60 
7.4.2 
Systemic inflammatory responses ................................................................... 61 
7.4.3 
Immune monitoring ......................................................................................... 61 
7.4.4 
Anti-tumour effects in measurable tumours ................................................... 62 
7.4.5 
Storage of biological samples for future research .......................................... 62 
7.5 
Safety assessments ................................................................................................. 62 
7.5.1 
Vital signs, physical examinations and ECOG performance status.................. 62 
7.5.2 
Electrocardiogram (ECG) ................................................................................. 63 
7.5.3 
Local clinical safety laboratory evaluations ..................................................... 63 
7.5.4 
Pregnancy test ................................................................................................. 65 
7.5.5 
Total blood volume .......................................................................................... 65 
7.6 
Adverse events and serious adverse events ........................................................... 65 
7.6.1 
Definitions ....................................................................................................... 65 
7.6.2 
Reporting of adverse events ............................................................................ 66 
7.6.3 
Causality of AEs................................................................................................ 67 
7.6.4 
Procedure for reporting serious adverse events ............................................. 68 
7.6.5 
AE/SAE follow-up ............................................................................................. 69 
7.6.6 Pregnancy ............................................................................................................ 69 
7.7 
Known adverse reactions to LTX-315 and adoptive T-cell therapy ........................ 69 
7.7.1 
LTX-315 ............................................................................................................ 69 
7.7.2 
Chemotherapy ................................................................................................. 69 
7.7.3 
Cyclophosphamide .......................................................................................... 69 
7.7.4 
Fludarabine phosphate .................................................................................... 70 
7.7.5 
TILs ................................................................................................................... 70 
7.7.6 
Interleukin-2 .................................................................................................... 70 
7.8 
Safety monitoring and precautions ........................................................................ 70 
7.8.1 
Haematological parameters ............................................................................ 70 
7.8.2 
Kidney and urine infections ............................................................................. 71 
7.8.3 
Cardiotoxicity ................................................................................................... 71 
7.8.4 
Infertility .......................................................................................................... 71 
7.8.5 
Interactions ...................................................................................................... 71 
8 
DATA HANDLING AND QUALITY ASSURANCE ............................................................. 72 
8.1 
Data collection ........................................................................................................ 72 
8.2 
Clinical data management ...................................................................................... 72 
8.3 
Data analysis and reporting .................................................................................... 72 
8.4 
Archiving ................................................................................................................. 73 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 14 of 96 
 
8.5 
Study monitoring .................................................................................................... 73 
8.6 
Source Data ............................................................................................................. 73 
8.7 
Audit and inspection ............................................................................................... 74 
9 
STATISTICAL METHODS AND PLANNED ANALYSIS ...................................................... 75 
9.1 
Analysis data sets and populations ......................................................................... 75 
9.1.1 
Full analysis set ................................................................................................ 75 
9.1.2 
Per protocol analysis set .................................................................................. 75 
9.2 
Randomisation (not applicable) .............................................................................. 75 
9.3 
Primary analyses ..................................................................................................... 75 
9.3.1 
Primary efficacy endpoint ............................................................................... 75 
9.3.2 
Primary safety endpoint .................................................................................. 75 
9.4 
Secondary analyses ................................................................................................. 76 
9.4.1 
Total T-cell level in tumour tissues .................................................................. 76 
9.4.2 
Total CD8+ T-cell level ..................................................................................... 76 
9.4.3 
Anti-tumour effect ........................................................................................... 76 
9.5 
Exploratory analyses ............................................................................................... 77 
9.5.1 
Tumour-antigen specific T-cells ....................................................................... 77 
9.5.2 
Changes in immunologicical parameters ........................................................ 77 
9.6 
Other assessments .................................................................................................. 77 
9.7 
Sample size determination ..................................................................................... 77 
9.8 
Handling of missing values ...................................................................................... 77 
10 
REGULATORY AND ADMINISTRATIVE PROCEDURES ................................................... 77 
10.1 
Ethics Committee and good clinical practice .......................................................... 77 
10.1.1 Ethics committee and regulatory authority review ........................................ 78 
10.2 
Changes to the conduct of the study or protocol ................................................... 78 
10.2.1 Protocol amendments ..................................................................................... 78 
10.2.2 Protocol deviations .......................................................................................... 78 
10.3 
Informed consent process ...................................................................................... 78 
10.4 
Investigator’s responsibilities ................................................................................. 79 
10.4.1 Training of staff................................................................................................ 79 
10.5 
Patient privacy ........................................................................................................ 79 
10.6 
Insurance and liability ............................................................................................. 79 
10.7 
Premature study termination criteria ..................................................................... 79 
10.8 
End of study ............................................................................................................ 80 
10.9 
Publication of results .............................................................................................. 80 
10.10 Confidentiality ......................................................................................................... 80 
11 
REFERENCES ............................................................................................................. 81 
12 
APPENDIX I ............................................................................................................... 85 
13 
APPENDIX II .............................................................................................................. 86 
14 
APPENDIX III ............................................................................................................. 87 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 15 of 96 
 
15 
APPENDIX IV ............................................................................................................. 90 
16 
APPENDIX V .............................................................................................................. 93 
17 
APPENDIX VI ............................................................................................................. 94 
 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 16 of 96 
 
ABBREVIATIONS 
Abbreviation 
Term 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
ANC 
Absolute Neutrophil Count 
ALT 
Alanine Transferase 
AST 
Aspartate Transferase 
CBR 
Clinical Benefit Rate 
CCIT 
Center for Cancer Immune Therapy 
CR 
Complete response 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Event 
DCIS 
Ductal Carcinoma in situ 
DLT 
Dose Limiting Toxicity 
EBV 
Epstein-Barr Virus 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
eCRF 
Electronic Case Report Form 
EDC 
Electronic Data Capture 
EDTA 
Ethylene Diamine Tetra-acetic Acid 
ELISPOT 
Enzyme-Linked ImmunoSpot assay 
EoT 
End of Treatment 
ESMO 
European Society for Medical Oncology 
ET 
Early Termination 
FAS 
Full Analysis Set 
GCP 
Good Clinical Practice 
GMP 
Good Manufacturing Practice 
HLA 
Human Leukocyte Antigen 
HTLV 
Human T-cell Leukemia-lymphoma Virus 
IB 
Investigator’s Brochure 
ICH 
International Conference of Harmonisation 
IEC 
Independent Ethics Committee 
IFNγ 
Interferon Gamma 
Ig 
Immunoglobulin  

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 17 of 96 
 
IL-2 
Interleukin 2 
IMP 
Investigational Medicinal Product 
IMPD 
Investigational Medicinal Product Dossier 
INR 
International Normalised Ratio 
IRB 
Institutional Review Board 
IUD 
Intrauterine Device 
LCIS 
Lobular Carcinoma in situ 
LD 
Longest Diameter 
LPD 
Longest Perpendicular Diameters 
LTX-315 
Potential new anticancer drug developed by Lytix Biopharma AS 
MAP 
Mean Arterial Pressure 
MedDRA 
Medical Dictionary for Regulatory Activities 
MHC 
Major Histocompatibility Complex 
MRI 
Magnetic Resonance Imaging 
NCI 
National Cancer Institute 
NED 
No Evidence of Disease 
NOAEL 
No-Observed-Adverse-Effect-Level 
ORR 
Objective Response Rate 
PBMC 
Peripheral Blood Mononuclear Cells 
PD 
Progressive Disease 
PET 
Positron Emission Tomography 
PFS 
Progression Free Survival 
PR 
Partial Response 
PP 
Per Protocol 
PT 
Preferred Term 
PT 
Prothrombin Time 
RECIST 
Response Evaluation Criteria In Solid Tumours 
SaaS 
Software as a Service 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SD 
Stable Disease 
SmPC 
Summary of Product Characteristics 
SOC 
System Organ Class 
SPD 
Sum of Products of Largest Perpendicular Diameters 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 18 of 96 
 
TEAE 
Treatment Emergent Adverse Event 
TIL 
Tumour infiltrating Lymphocytes 
TNFα 
Tumour Necrosis Factor Alpha 
WHO 
World Health Organization 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 19 of 96 
 
1 SYNOPSIS 
Name of Sponsor: 
Lytix Biopharma AS 
Name of Investigational Medicinal Products (IMPs): 
LTX-315 Acetate 20 mg peptide/vial 
Tumour infiltrating Lymphocytes (TILs) 
Sendoxan® 200, 500, 1000 mg/vial 
Fludara® 25 or 50 mg/vial 
Proleukin® 18 million IU/vial 
Name of Active Ingredient: 
LTX-315 Acetate 
TILs 
Cyclophosphamide 
Fludarabine phosphate 
Interleukin 2 (IL-2) 
Title of Study: 
An open-label phase II single-centre study investigating the safety and efficacy of LTX-315 
and adoptive T-cell therapy in patients with advanced/metastatic soft tissue sarcoma 
Protocol Number: 
C17-315-04 
Investigator and Study Centre: 
Inge Marie Svane, Professor, MD, PhD 
Herlev Hospital, Center for Cancer Immune Therapy (CCIT), Herlev Ringvej 75, DK-2730 
Herlev, Denmark 
Phase of Development: 
Phase II 
Primary Objectives: 
• 
To determine the ability of LTX-315 to induce T-cell infiltration prior to TIL expansion 
in advanced/metastatic soft tissue sarcoma 
• 
To determine the safety of LTX-315 as part of adoptive T-cell therapy in 
advanced/metastatic soft tissue sarcoma 
Secondary Objectives: 
• 
To determine the ability of LTX-315 as part of adoptive T-cell therapy to induce T-cell 
infiltration in advanced/metastatic soft tissue sarcoma 
• 
To assess the ability to expand CD8+ T-cells from tumour tissues 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 20 of 96 
 
• 
To assess the anti-tumour effect of LTX-315 as part of adoptive T-cell therapy in 
advanced/metastatic soft tissue sarcoma 
Exploratory Objectives: 
• 
To assess tumour-antigen specificity 
• 
To investigate and characterise immune status and nature of anti-tumour immune 
responses 
Primary Endpoints: 
• 
Change in total T-cell level in tumour tissues from Baseline (Step 1, Week 1, Day 1) 
to end of Step 1 (Step 1, Week 3) 
• 
Adverse events (AE) related to LTX-315 or to the combination of LTX-315 and 
adoptive T-cell therapy from Baseline (Step 1, Week 1, Day 1) to end of treatment 
(EoT) (Step 2, Week 7) 
Secondary Endpoints: 
• 
Change in CD3+ T-cell and CD3+CD8+ T-cell density in non-injected tumour tissues 
from Baseline (Step 1, Week 1, Day 1) to EoT (Step 2, Week 7) if the patient has a 
feasible bystander lesion and accept it to be biopsied.  
• 
Total number of CD3+CD8+ T cells and % CD3+CD8+T cells of total CD3+ T cells in 
final TIL infusion product 
• 
The anti-tumour effect assessed by: 
o Objective Response Rate (ORR) defined as proportion of patients who have 
acheived immune-related complete response (irCR) or immune-related partial 
response (irPR) at EoT (Step 2, Week 7) and up to 15 months after EoT  
o Clinical Benefit Rate (CBR) defined as proportion of patients who have 
achieved irCR, irPR or immune-related stable disease (irSD) at EoT (Step 2, 
Week 7) and up to 15 months after EoT 
o Progression free survival (PFS) evaluated by time from Baseline until immune-
related progressive disease (irPD) or death up to 15 months after EoT 
Exploratory Endpoint: 
• 
Identification of tumour-antigen specific T-cells in tumour tissue and peripheral blood 
mononuclear cells (PBMCs) by major histocompatibility complex (MHC) multimer–
based screens, enzyme-linked immuno-spot assay (ELISPOT) and flowcytometry 
analysis of cytokines including interferon gamma (IFNγ) and tumour necrosis factor 
alpha (TNF⍺) 
• 
Changes in immunological parameters from Baseline (Step 1, Week 1, Day 1) to 15 
months after EoT 
Study Design: 
This is a phase II, open-label, single-centre study in patients with advanced/metastatic soft 
tissue sarcoma and tumours accessible for injection, assessing LTX-315 ability to induce 
increased T-cell infiltration and facilitate T-cell expansion for TIL based adoptive cell therapy 
in soft tissue sarcoma patients. 
All patients will have at least one tumour lesion available for injection with LTX-315 and 1 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 21 of 96 
 
measurable lesion for disease assessment by the use of modified Response Evaluation 
Criteria in Sold Tumours (RECIST version 1.1) An available lesion is a lesion that can be 
injected and is not a non-injected bystander lesion. 
Course of Treatment: 
The course of treatment consists of 2 steps (Step 1 and Step 2) followed by clinical controls 
and evaluation-scans as follow-up. 
Screening (28 days prior to Step 1): informed consent, check of eligibility and inclusion. 
Step 1 (W1 to W3-5): re-check of inclusion, baseline tumour biopsy, LTX-315 injections and 
surgical removal of the LTX-315 injected index tumour lesion followed by production and 
growth of TILs in the laboratory. 
Step 2 (W-2 to W-1, W1 to W7): check of eligibility for Step 2, treatment during 
hospitalisation with chemotherapy, TIL infusion and IL-2 administration, safety and efficacy of 
LTX-315/TIL treatment. 
Follow-up: safety and efficacy of LTX-315/TIL treatment for a follow-up period of 15 months. 
  
The course of treatment can vary between patients depending on the time period from start 
of LTX-315 treatment to surgical removal of injected index tumour lesion (Step 1), and the 
time period from resection to adoptive T-cell therapy (Step 2). The time period before 
resection will depend upon the patients condition and will vary from 3-5 weeks after start of 
LTX-315 treatment. In most cases (e.g. TILs undergoing massive expansion and infusion 
without cryopreservation of intermediate products). Patients that have confirmed PD upon 
enrollment in the study will receive TIL treatment approximately 4-6 weeks after surgery with 
a maximum of 10 weeks. Patients that have confirmed SD upon enrollment in the study will 
receive TIL treatment after confirmed PD during the study.  
 
Summary of LTX-315 injection schedule and method: 
The intra-tumoural injections of LTX-315 may be ultrasound-guided, based on clinical 
judgement. However, ultrasound guidance is not mandatory. Injection and delivery of LTX-
315 should be aimed at the periphery of the lesion. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 23 of 96 
 
based on earlier studies where it was shown safe and effective. 
Number of Patients Planned: 
6 patients who have completed Step 1. 
Patient Selection: 
Inclusion criteria: 
1. (Histologically) Confirmed any patients with advanced or metastatic soft tissue 
sarcoma with stable disease or has progressed after a minimum of 1 systemic 
treatment of advanced/metastatic disease. Patient will have received at least 1 
approved standard of care treatment for advanced/metastatic disease or be deemed 
unsuitable for such treatment by their treating physician 
2. At least 1 index tumour lesion accessible for injection with a longest diameter (LD) of 
≥ cm which is planned for LTX-315 injection 
3. At least 1 measurable (target) non-injected tumour lesion that can be used to assess 
response by Computed Tomography (CT)-scan (as per RECIST) 
4. A life expectancy of at least 3 months 
5. Willing to undergo repeat tumour biopsy and/or tumour resection procedures 
6. Between 18 and 75 years of age 
7. An Eastern Cooperative Oncology Group (ECOG) performance status: 0 – 1 
8. Meet the following blood laboratory requirements: 
a. Absolute neutrophil count (ANC) ≥ 1.5 x 109/L 
b. Platelet count ≥ 75 x 109/L 
c. Haemoglobin ≥ 6.0 mmol/L after blood transfusion if needed 
d. Prothrombin time / International Normalised Ratio (PT/INR) within the 
institution’s normal range 
e. Aspartate Transferase (AST) and Alanine Transferase (ALT) ≤ 2.5 x upper 
normal level 
f. Creatinine ≤ 1.5 x upper normal level 
9. Willing and able to comply with the protocol and agree to return to the hospital for 
follow-up visits and examinations up to 15 months after EoT 
10. Fully informed about the study and have signed the informed consent form 
11. Re-screening is allowed once on a case by case basis as judged by the investigator 
 
Exclusion criteria: 
1. A history of clinical significant active systemic autoimmune disease requiring anti-
inflammatory or immunosuppressive therapy within the last 3 months. Patients with 
history of autoimmune thyroiditis are eligible provided the patient requires only thyroid 
hormone replacement therapy and disease has been stable for ≥ 1 year 
2. Any other malignancy active within the previous 5 years except for carcinoma in situ 
of the cervix, ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS) of the 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 24 of 96 
 
breast 
3. Received an investigational drug within 4 weeks prior to any study drug 
administration, or are scheduled to receive 1 during the study participation 
4. Received external radiotherapy or cytotoxic chemotherapy within 4 weeks prior to 
LTX-315 administration, or have not recovered from AEs (to ≤ CTCAE grade 1) due 
to agents administered more than 4 weeks earlier. Palliative radiotherapy to non-
target and lesions planned for LTX-315 injection within 4 weeks of LTX-315 
administration is allowed 
5. Currently taking any agent with a known effect on the immune system. Patients are 
allowed to be on a stable dose of corticosteroids (up to 10 mg daily prednisolone or 
equivalent) for at least 2 weeks prior to LTX-315 administration 
6. Any other serious illness or medical condition such as, but not limited to: 
a. Uncontrolled infection or infection requiring antibiotics 
b. Uncontrolled cardiac failure: Classification III or IV (New York Heart 
Association) 
c. Uncontrolled systemic and gastrointestinal inflammatory conditions 
d. Bone marrow dysplasia 
7. A known history of positive tests for HIV/AIDS, syphilis, human T-cell leukemia-
lymphoma virus (HTLV), active Epstein-Barr, hepatitis B or C (based on serology) 
8. A history of cerebrovascular or cardiac disorders and would be at particular risk of 
sequelae following a short hypotensive episode 
9. If of child-bearing potential, not willing to use an effective form of contraception such 
as hormonal birth control, intrauterine device or double barrier method from screening 
visit and until 3 months after last study treatment (any of the agents) 
10. Breastfeeding and/or have a positive pregnancy test during screening 
11. Donate sperm from LTX-315 dosing until 3 months after last study treatment (any of 
the agents) 
12. Patients with pregnant or partner of child-bearing potential not willing to use 
contraception from LTX-315 administration until 3 months after last study treatment 
(any of the agents) 
13. Expected to need any other anticancer therapy or immunotherapy to be initiated 
during the treatment period 
14. Clinically active or unstable metastases in the central nerveous system as assessed 
by the treating physician 
15. Any known hypersensitivity to any of the excipients in the non-IMPs including the 
required allergic prophylactic medications (
 
) 
16. Any known or suspected hypersensitivity to any of the IMPs 
Methods and Procedures: 
Biopsies of LTX-315 injected lesion: 
All mandatory biopsies must include up to 3 (18 gauge) core biopsies. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 25 of 96 
 
Biopsies of the index tumour lesion planned for injection with LTX-315 will be done at: 
• 
Baseline (pre-LTX-315 treatment) to assess T-cell infiltration (including CD8+) 
• 
At the time of and as part of the excision of the injected lesion 
• 
6 weeks after TIL infusion if the whole tumour is not resected 
A part of the resected lesion will be used for TIL production and another part for verification 
of diagnosis. The remaining part of the excised tumour will be stored for future research on 
immune responses. 
If an additional lesion is present and feasible for biopsy, this will be used as a bystander 
lesion. The optional lesion will not be injected and will allow a comparison (by biopsy) with 
the injected lesion. 
If a non-injected lesion regress >30% and is feasible for biopsy, an optional biopsy of this 
lesion will allow a comparison with the TIL product and blood before and after LTX-315  
treatment. 
In this scenario a patient would have 3 tumour lesions: 
• 
One for LTX-315 injection 
• 
A second to be followed by CT-scan for RECIST v 1.1 response assessment 
(measurable, non-injected lesion). Optional biopsy of this lesion if it regress >30% 
after treatment  
• 
A third that is a bystander lesion (no LTX-315 injection) but available to biopsy to 
compare with biopsy of the injected lesion 
Identification of somatic mutations in the tumour: 
A PBMC sample will be collected as a source for normal cells for comparison of the DNA and 
RNA sequence in normal cells to the sequence in the tumour tissue. The sample will be 
collected at screening and will enable identification of somatic mutations in the tumour. 
Immune monitoring: 
Change in immune biomarkers (in both peripheral blood and tumour samples) 2 weeks after 
LTX-315 treatment in patients with transdermally accessible tumours will be assessed. 
PBMC will be isolated from blood samples at screening, before and after T-cell therapy. 
In order to investigate and characterise the immune status of the patients and the nature of 
anti-tumour immune responses, the following immune biomarkers in biopsies and PBMCs 
may include but is not limited to CD3, CD4, CD8, CD11, CD14, CD19, CD27, CD56, CD68, 
Ki67 and Granzyme B. T-cell receptor sequencing may be performed to monitor changes in 
the T-cell repertoire induced by treatment. 
Identification of tumour-antigen specific T-cells: 
To generate a clinical effective T-cell response it is important that LTX-315 generates 
tumour-antigen specific T-cells. To identify sarcoma tumour-antigens in LTX-315 patients, 
next-generation sequencing and epitope prediction may be used. Tumour tissue DNA and 
RNA will be compared with data from matched normal tissue (PBMC) in order to identify 
tumour-unique (“somatic”) mutations. Patients will have their human leukocyte antigen (HLA) 
typed, and algorithms will then be used to predict which tumour-epitopes the patient’s tumour 
cells will express. Peptides corresponding to predicted tumour-epitopes will be synthesized 
and used to identify tumour-antigen specific T-cells in freshly expanded TILs as well as in 
PBMCs using MHC multimer–based screens. The effector functions of the tumour-antigen 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 26 of 96 
 
specific T-cells may be analysed by ELISPOT which will reveal whether cytokines such as 
IFNγ and or TNFα is produced by peptide stimulation. Tumour reactive T-cells may be 
identified in PBMC and expanded TILs by co-culturing with autologous/ allogenic tumour 
cells followed by flowcytometry analysis of IFNγ and TNFα. Details are described in a 
separate immunology protocol. 
Radiology Assessments: 
CT-scans, Positron Emission Tomography (PET)-CT-scans or Magnetic Resonance Imaging 
(MRI) will be performed within 28 days prior to Day 1 (Step 1), W-2 prior to TIL infusion, at 
EoT, Week 13 after TIL infusion and thereafter every 3rd months up to 15 months. 
IMPs, Doses and Modes of Administration: 
LTX-315: 
LTX-315 is provided in vials containing 20 mg of peptide – linear nonapeptide with a free 
amino group at the N-terminus and an amidated C-terminus – as a lyophilised powder for 
injection. Prior to use it should be reconstituted with 
 ml sterile saline solution 0.9% giving 
a concentration of 
 mg/ml. In total  mg LTX-315 will be administered per injection time 
point per dosing. 
TILs: 
Sarcoma TILs are T-cells isolated from tumour tissue from a patient with sarcoma. Tumour 
reactive T-cells will be isolated from tumour materials and TILs will be expanded ex vivo into 
high numbers. The specific T-cells are infused intravenously back into the patient during 
hospitalization on the day after the last dose of fludarabine phosphate (Step 2, Day 1). The 
number of T-cells in the product depends on the possible in vitro degree of expansion and is 
therefore variable, but will normally consist of approximately 1010 cells. 
Cyclophosphamide: 
Cyclophosphamide is given as an intravenous infusion for 2 consecutive days in a dose of 60 
mg per kg body weight. The treatment takes place during hospital admission and with 
supplementary hydration and Mesna injections. 
Fludarabine phosphate: 
Fludarabine phosphate is given as an intravenous infusion for 5 consecutive days in a dose 
of 25 mg per m2 body surface (starting the day after the last dose of cyclophosphamide). The 
treatment takes place during hospital admission. 
IL-2: 
A daily subcutaneous injection with IL-2 (2 MIU) will be administered from Step 2, days 1 to 
14. During hospitalisation the injection will be given by a trained nurse. If the patient is well 
enough to be discharged within these 14 days, the patient or relatives will be taught to 
perform the remaining injections. The supplied amount of IL-2 injections for self-
administration will be registered by use of batch number, so that the total amount of 
administered IL-2 can be determined.  
Study Duration: 
The maximum duration of study participation for each patient will be approximately  2 years, 
including the 4 weeks screening period, repeat of Step 1 and the 15 months follow-up after 
EoT. 
 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 27 of 96 
 
Statistical Methods: 
All analyses will be descriptive. Categorical variables will be presented with numbers and 
percentages, and if applicable, number of events. Continuous variables will be presented by 
n, mean, median, standard deviation and range (min and max) as appropriate. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 28 of 96 
 
2 INTRODUCTION 
2.1 Therapeutic area disease background 
Lytix Biopharma AS is developing a potential new anticancer drug, LTX-315 that induces 
long-term anticancer immune responses. LTX-315 induces immunogenic death of tumour 
cells leading to subsequent release of danger signals and a broad repertoire of tumour 
associated antigens. This breaks local tolerance and leads to recruitment of immune cells, 
including tumour specific CD8+ cytotoxic T-cells. Unlike exogenous targeted therapies that 
rely, for example, on receptor over-expression or mutation, this approach is not limited to 
specific tumour types. 
Cancer is treated by a variety of pharmaceutical means, ranging from classical 
chemotherapy to targeted therapy modulating intracellular signalling cascades. In the last 
years various immune therapies have been studied as a means to stimulate the body’s own 
ability to fight the cancer. Most cancers consist of a number of different malignant T-cells and 
since this heterogeneity varies from tumour to tumour, every patient’s cancer is unique in its 
composition. As a consequence, it is extremely challenging to provide each patient with 
personalised treatment. 
Local treatment of transdermally accessible tumours is generally limited to surgery and 
radiotherapy. However, there are a number of studies utilising tumour injection to generate 
an immune response as an internal mechanism for destroying the malignant tissue (29). 
A novel approach of anticancer therapy is to induce the patient’s own immune system which 
could then provide the ideal targeted therapy being specific to the patient’s own cancer. This 
approach however, requires an adequate immune system which may be subject to local 
down-regulation of the immune response. Indeed, it may be in part due to this that the cancer 
cells persist. Removing the causes for such a down-regulation will enhance the activity of the 
patient’s own immune system, and, in doing so, may instigate destruction of these cells. This 
hypothesis represents a promising approach to the personalised treatment of cancer. 
2.2 Sarcoma 
Sarcomas are a heterogenous group of malignant neoplasms arising from cells of 
mesenchymal origin. Numerous histological subtypes exist, and the tumours can occur in 
virtually any anatomical site. Often sarcomas are divided in soft tissue sarcomas that are the 
most frequent with an incidence of 4-5/100.000 per year, and bone sarcomas with an 
incidence of 0.8/100.000 per year (45). The overall incidence of sarcomas in Denmark is 
around 300 per year (8). 
Advanced unresectable or metastatic stages of sarcomas, with the exception of 
gastrointestinal stromal tumour, respond poorly to current treatment, and prognosis is poor. 
Median survival for patients with metastatic soft tissue sarcoma at time of diagnosis was in a 
study from 2011 estimated to 10 months, and 5-year survival for this patient group was 10% 
(44). 
2.3 Standard treatment of soft tissue sarcoma 
The national guidelines for treatment of advanced/metastatic soft tissue sarcoma follow the 
European Society for Medical Oncology (ESMO) recommendations (18). With regard to 
treatment options multi-agent chemotherapy regimens are the standard of care and include: 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 29 of 96 
 
• 
First line treatment has until recently been single agent doxorubicin, but will shortly be 
altered to doxorubicin + olaratumab. A randomised study of doxorubicin + olaratumab 
versus 
doxorubicin 
alone 
in 
previously 
untreated 
(anthracycline 
naïve) 
advanced/metastatic soft tissue sarcoma (46) reported a median PFS of 6.6 months 
with the combination versus 4.1 months with doxorubicin alone. The ORR was 18.2% 
with the combination versus 11.9% with doxorubicin alone 
• 
Second or later line treatment may include: 
o High-dose ifosfamide as 2nd line treatment who received prior standard dose 
ifosfamide 
o Trabectidin 
o Gemcitabine + taxane and/or pazopanib 
In addition to disease related factors (e.g. histological subtype) choice of treatment is guided 
by patient related factors such as ECOG performance status and co-morbidity. 
The patient population that will be evaluated in this study have advanced/metastatic disease 
and will have received one (or possibly multiple) lines of treatment (as described above) for 
advanced/metastatic disease. They have a very poor prognosis with an estimated median 
survival of 10 months and a 5-year survival of 10% (44). 
2.4 Drug class 
2.4.1 LTX-315 
LTX-315 is an oncolytic peptide, derived from lactoferricin, a member of the naturally 
occurring group of peptides referred to as membrane active host defence peptides (23). 
Membrane active host defence peptides bind to negatively charged molecules on the cell 
surface subsequently inducing lysis and cell death (35; 53). LTX-315 is internalized and 
targets intracellular organelles, particularly the mitochondria (15). This membranolytic mode 
of action leads to an effective release of potent immunostimulants (Damage-associated 
molecular patterns, DAMPs) and tumour antigens. The pharmacology studies demonstrate 
that LTX-315 injected directly into tumours induces necrosis and in several cases complete 
regression of the treated tumour. 
LTX-315 is not tumour specific but is designed to generate an immune response to the 
tumour associated antigens, which are presented to the immune system to generate a 
tumour specific response. 
In addition, systemic protective immune responses against tumour re-challenge have been 
observed in several animal models. Unlike in most phase I oncology studies, where the 
target tumour is independent of the route of administration and efficacy is dependent on 
systemic exposure, this study is designed with direct intra-tumoural injection of LTX-315. 
2.4.2 LTX-315 Toxicology 
A repeated-dose toxicity programme with subcutaneous injections in rats and dogs was 
designed to support a clinical dosing cycle of up to  dosing days per week. In both species 
LTX-315 was systemically well tolerated, although local necrosis, inflammation and 
haemorrhage were noted histologically, and hence a no-observed-adverse-effect-levels 
(NOAEL) could not be determined. However these pivotal studies have generated data to 
assist in the selection of the tolerable clinical starting dose in man. See Investigator’s 
Brochure (IB) for more information (28). 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 30 of 96 
 
2.4.3 LTX-315 Non-clinical safety 
In the clinical study C08-315-01 a sudden, transient drop in blood pressure was observed. 
Based on this, non-clinical safety studies were initiated (28). 
Single dose i.v. administration of LTX-315 revealed an adequate safety profile in both dog 
and the rat with a transient, and reversible, decrease of mean arterial pressure (MAP) in both 
species. The reduction in MAP results from changes in peripheral circulation and the 
observed increase in total vascular resistance implies this is not a direct effect on cardiac 
activity. 
A threshold for this effect from LTX-315 on MAP occurs between 
 mg/kg (no effect) and 
mg/kg in the rat. Acute single i.v. and sub-chronic repeated i.v. exposure with 
 mg/kg 
LTX-315 revealed this being the lowest dose for this reduction in MAP. A single dose of 
 
mg/kg equals a dose of approximately  mg in adult humans. 
Consecutive i.v. dosing at 
 mg/kg on the same day caused no reduction in MAP at 
second or third dose. However, a dose escalation revealed a dose-dependent reduction in 
MAP after first dose, while second and third dose revealed the occurrence of a tolerance. 
This may point towards a tachyphylaxis from repeated dosing with LTX-315. Sub-chronic 
LTX-315 i.v. dosing for  days over a period of 
 days,  times per day, in the rat revealed a 
tachyphylactic effect as judged by no changes in MAP was achieved at 
 
dose at 
 mg/kg. 
Studies to assess the effect of LTX-315 on histamine release have included; an in vitro study 
to assess direct histamine release from basophils in human peripheral blood mononuclear 
cells (PBMC), an in vivo study in guinea pigs to assess and visualise indirect histamine 
release following intradermal injection of LTX-315 using intravenously administered Evans 
Blue, and an in vivo study in guinea pigs to evaluate immunoglobulin (Ig) E (IgE) mediated 
histamine release. 
The PBMC study indicated that LTX-315 may cause histamine release from basophils in a 
dose-dependent manner. 
The first in vivo study in guinea pig (investigating cutaneous anaphylaxis) showed no 
evidence of a type 1 immediate hypersensitivity IgE antibody reaction, and the second study 
(investigating cutaneous extravasation) in guinea pigs was inconclusive most likely due to 
high LTX-315 concentrations used, resulting in local necrosis and disruption of vasculature. 
The reduction in MAP results from changes in peripheral circulation and the observed 
change in total vascular resistance implies this is not a direct effect on cardiac activity. 
2.4.4 LTX-315 Non-clinical efficacy 
The feasibility of expanding TILs from sarcoma, as well as performed functional in vitro 
analyses on TILs have been investigated in tumour tissue from sarcoma patients. 
LTX-315 induce complete regression in several rodent sarcoma models. Cured animals 
showed protective immune responses towards tumour growth when re-challenged with 
sarcoma cells. In one of the sarcoma models it was demonstrated that LTX-315 treatment 
eradicated both the treated lesion and untreated distant lesions, indicating a strong and 
immediate systemic effect of LTX-315 therapy. 
Transfer of splenic lymphocytes from cured animals inhibited tumour growth in naïve 
recipient animals, indicating that protective immune responses against the sarcoma cells 
could be adoptively transferred. Transfer of T-cell-depleted splenocytes did not protect 
against tumour development indicating that LTX-315 induce T-cell mediated immune 
responses (28). 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 31 of 96 
 
2.4.5 TILs from sarcoma 
In a preclinical study (33) the feasibility of expanding TILs from sarcomas was investigated, 
as well as performance of functional in vitro analyses on these. Tumour samples from 28 
patients with 8 different sarcoma subtypes were obtained, and it was possible to expand a 
minimum of 40 million TILs from 25 of these. Reactivity analyses using ELISPOT revealed 
reactivity against autologous tumour cells in 11 of 22 tested tumour samples from 7 of 8 
different sarcoma subtypes. 
2.4.6 TILs Non-clinical efficacy 
To this date TILs from 25 of 28 tumour samples have been expanded. TILs were harvested 
and frozen when an estimated number of 100x106 to 200x106 cells were reached. Mean 
expansion time were 32 days (16 – 61). 87,7% (36,4 – 99,1) of these cells were CD3+, and 
of these 66,7% (16,3 – 99,1) were CD4+, and 21,8% (0,1 – 50,6) were CD8+. Most of the 
expanded TILs were effector memory subtype, while a smaller fraction was the more 
differentiated effector T-cells. 
Rapid Expansion Protocol expansion rates ranged from 630 fold to 2.300 fold, and followed 
expansion pattern similar to TILs from malignant melanoma. 
TILs from 6 of 10 tested tumour samples with 4 different sarcoma subtypes (undifferentiated 
pleomorphic sarcoma, myxofibrosarcoma, myxoid liposarcoma and osteosarcoma) 
demonstrated reactivity against autologous tumour cells using ELISPOT. Further 
assessment is ongoing. 
In summary it was possible to expand TILs from approximately 90% of the included tumour 
samples to numbers needed for possible future clinical implementation (33). TILs were a mix 
of CD4+ and CD8+ with CD4+ being predominant. As of yet, TIL reactivity against 
autologous tumour cells from 6 of 10 tested patients have been demonstrated. Thus, in 
conclusion it is feasible to translate TIL based adoptive cell therapy into clinical testing in 
sarcoma patients. 
2.5 Clinical experience 
2.5.1 Clinical safety of LTX-315 
Fifty-three patients in 2 Phase I studies have received LTX-315 monotherapy at varying 
doses and in different schedules. In addition 8 patients have been treated with LTX-315 in 
combination with ipilimumab in patients with malignant melanoma and in 18 patients in 
combination with pembrolizumab in patients with triple negative breast cancer (28). 
Of the 53 patients treated with LTX-315 as monotherapy, the most common LTX-315 related 
Aes reported are low grade (CTCAE grade 1-2) allergy-like Aes. These include most 
commonly flushing (injection site or facial), parasthesia (digits of hands and feet), pruritis, 
rash (injection site or distant from injection site), and hypotension (asymptomatic with systolic 
blood pressure decrease within the normal range in most patients). These allergy-like Aes 
occur from 1st injection onwards, emerge quickly (seconds/minutes) and resolve quickly 
(seconds/minutes) with no clinical sequaelae. 
The LTX-315 injection schedule comprised either of injection of multiple lesions for 2 dosing 
days per week for 3 weeks or injection of a single lesion 3 subsequent dosing days in week 1 
followed by once weekly for 5 further weeks. Patients enrolled in the latter schedule who had 
more than 1 lesion for injection, had the 2nd lesion treated starting in Week 7 and were dosed 
as described for the 1st lesion. LTX-315 has been evaluated at doses between 2-11.6 mg per 
injection with the majority of patients receiving doses between 2-7 mg per injection. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 34 of 96 
 
2.5.4 Translational research 
Further development of T-cell therapy with optimizing and expansion to other cancer forms 
has a high priority at CCIT. CCIT have already established a platform for T-cell therapy for 
malignant melanoma which gives a unique opportunity to study the interactions between 
tumour and immune system and thereby identify possible methods for optimization of T-cell 
therapy, as well as extension to other tumour histology. 
Several studies has shown that the following T-cell characteristics are important for achieving 
a clinical response after T-cell therapy: long telomeres, short time spent in culture, a 
favourable T-cell phenotype (CD27+, CD28+), a high absolute number of T-cells and a high 
number of cytotoxic tumour reactive T-cells in the infusion product (11) as well as an 
increased persistence of T-cell in the peripheral blood after infusion (40; 10; 48). 
At CCIT, the original T-cell expansion method has been modified from ”Standard TIL 
expansion” to ”Young TIL expansion” based on these characteristics and leading to a 
reduction of the length of cell manufacturing from 4-7 weeks to 2-4 weeks. A decreased 
amount of time in culture (Young TIL) provides the TILs with longer telomere sequences and 
more favourable phenotypes (CD27+, CD28+) with the ability of increased proliferation, an 
increased persistence in vivo and a higher anti-tumour activity, all of which are correlated to 
an increased clinical response (40; 10).  
This optimization of TIL production has made it possible to produce clinically usable TIL 
infusion products from more than 90% of the patients (5; 14; 22; 26). Furthermore, during the 
final expansion phase of the Rapid Expansion Protocol, the use of the 
 
(43), which optimizes the conditions of proliferation of T-cells and has made it possible to 
achieve a higher total number of cells as well as tumour reactive T-cells in the TIL infusion 
product, has been introduced. Based on the TIL production protocols developed at CCIT, TIL 
production methods between 3 European cancer research centres has been standardized 
and harmonized and a randomised, multicenter TIL based phase III study (NCT02278887) 
with T-cell therapy versus standard immunotherapy have been initiated with the purpose of 
the approval of T-cell therapy as standard treatment for patients with malignant melanoma. 
3 STUDY OBJECTIVES AND ENDPOINTS 
3.1 Study objectives 
Primary objectives: 
• 
To determine the ability of LTX-315 to induce T-cell infiltration prior to TIL expansion 
in advanced/metastatic soft tissue sarcoma 
• 
To determine the safety of LTX-315 as part of adoptive T-cell therapy in 
advanced/metastatic soft tissue sarcoma 
Secondary objectives: 
• 
To determine the ability of LTX-315 as part of adoptive T-cell therapy to induce T-cell 
infiltration in advanced/metastatic soft tissue sarcoma 
• 
To assess the ability to expand CD8+ T-cells from tumour tissues 
• 
To assess the anti-tumour effect of LTX-315 as part of adoptive T-cell therapy in 
advanced/metastatic soft tissue sarcoma 
Exploratory objectives: 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 35 of 96 
 
• 
To assess tumour-antigen specificity 
• 
To investigate and characterise immune status and nature of anti-tumour immune 
responses 
3.2 Endpoints 
Primary endpoints: 
• 
Change in total T-cell level in tumour tissues from Baseline (Step 1, Week 1, Day 1) 
to end of Step 1 (Step 1, Week 3) 
• 
Adverse events (AE) related to LTX-315 or to the combination of LTX-315 and 
adoptive T-cell therapy from Baseline (Step 1, Week 1, Day 1) to EoT (Step 2, Week 
7) 
Secondary endpoints: 
• 
Change in CD3+ T-cell and CD3+CD8+ T cell density in non-injected tumour tissues 
from Baseline (Step 1, Week 1, Day 1) to EoT (Step 2, Week 7) if the patient has a 
feasible bystander lesion and accept it to be biopsied.  
• 
Total number of CD3+CD8+ T cells and % CD3+CD8+T cells of total CD3+ T cells in 
final TIL infusion productThe anti-tumour effect assessed by: 
o Objective Response Rate (ORR) defined as proportion of patients who have I 
CR or PR at EoT (Step 2, Week 7) and up to 15 months  after EoT 
o Clinical Benefit Rate (CBR) defined as proportion of patients who have 
achieved CR, PR or SD at EoT (Step 2, Week 7) and up to 15 months  after 
EoT 
o Progression free survival (PFS) evaluated by time from Baseline until PD or 
death up to 15 months  after EoT 
Exploratory endpoint: 
• 
Identification of tumour-antigen specific T-cells in tumour tissue and PBMCs by MHC 
multimer–based screens, ELISPOT and flowcytometry analysis of cytokines including 
IFNγ and TNF⍺ 
• 
Changes in immunological parameters from Baseline (Step 1, Week 1, Day 1) to 15 
months  after EoT 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 36 of 96 
 
4 STUDY DESIGN 
4.1 Overall study design 
Figure 1. Study design 
 
The course of treatment consists of 2 steps (Step 1 and Step 2) followed by clinical controls 
and evaluation-scans as follow-up: 
• 
Screening (28 days prior to Step 1): informed consent, check of eligibility and 
inclusion. Identified AEs to be recorded in Medical History 
• 
Step 1 (W1 to W3-5): re-check of inclusion, baseline tumour biopsy, LTX-315 
injections and surgical removal of the LTX-315 injected index tumour lesion followed 
by production and growth of TILs in the laboratory 
• 
Step 2 (W-2 to W-1, W1 to W7): check of eligibility for Step 2, treatment during 
hospitalisation with chemotherapy, TIL infusion and IL-2 administration, safety and 
efficacy of LTX-315/TIL treatment 
• 
Follow-up: safety and efficacy of LTX-315/TIL treatment for a follow-up period of 15 
months. Only AEs considered related to LTX-315 or TIL to be reported 
The course of treatment can vary between patients depending on the time period from 
surgical removal of LTX-315 injected index tumour lesion (Step 1) to adoptive T-cell therapy 
treatment (Step 2). Patients with PD at enrollment will receive TIL treatment approximately 4-
6 weeks after surgery with a maximum of 10 weeks. Treatment period (including screening): 
up to 26 weeks. Patients with SD at enrollment will receive TIL therapy after confirmed PD 
during the study. Follow-up period: up to 15 months. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 37 of 96 
 
Figure 2. Step 1 and Step 2 treatment period 
 
C: cyclophosphamide, F: Fludarabine phosphate, I: IL-2 
 
4.2 Study rationale 
Pharmacodynamic studies of LTX-315 in animal models have demonstrated growth inhibition 
and complete regression following intra-tumoural injections, subsequent tumour specific 
protection and transfer of protection from treated to untreated animals. Abscopal effects have 
been obtained in some preclinical models (28). Accumulating evidence support the 
hypothesis that adoptive immunotherapeutic strategies may be effective as treatment in 
sarcoma. Early clinical observations have shown local tumour regression in sarcoma patients 
upon erysipelas infection and intra-tumoural injections of bacterial derived toxins (50). Also, 
high-dose IL-2 therapy has shown complete response rates in paediatric patients with 
osteosarcoma (41). Histological analyses have shown that a wide range of sarcomas 
express markers of inflammation by the presence of infiltrating lymphocytes and PD-L1-
expression (7), and immune cell infiltration have been proven to have an independently 
positive prognostic impact in soft tissue sarcomas (46). 
Adoptive T-cell therapy is currently an experimental intervention in soft tissue sarcoma. In a 
recent study, treatment with genetically engineered autologous T-cells derived from 
circulating blood cells, have shown significant clinical results in patients with synovial cell 
sarcoma and malignant melanoma (39). Overall, clinical response rates were 60% in both 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 39 of 96 
 
4.2.2 Drugs used in adoptive T-cell therapy 
Activating cytokines (the signal molecules IL-2, IL-7, IL-15, IL-21 etc.) need to be available 
for the tumour specific T-cells to sustain a immunological response against tumour tissue. A 
large number of “irrelevant” T-cells will decrease the availability of these cytokines for the 
relevant T-cells through competition. Thus, a high number of tumour specific T-cells with a 
high specificity as well as a reduction of irrelevant T-cells and regulatory T-cells are needed 
to create an environment that facilitates the T-cell mediated anti-tumour response. 
This study will use combination chemotherapy with 2 days treatment with cyclophosphamide 
and 5 days with fludarabine phosphate to create such an environment. This combination has 
been chosen based on earlier studies where it was shown safe and effective (20; 4). 
4.2.2.1 
Cyclophosphamide 
Cyclophosphamide is an alkylating drug that works by creating covalent bindings with 
biologically important macromolecules. Of special interest is the creation of a binding and 
linkage to DNA. Cell division can be prevented if the linkage is not cancelled by the cells 
repair systems. The binding to important proteins in the cell can damage important cellular 
functions and lead to cell death. Cyclophosphamide is among others used to treat breast 
cancer and in the treatment of haematological diseases as myelomatos (42). 
4.2.2.2 
Fludarabine phosphate 
Fludarabine phosphate is a pro-drug that is converted to the active triphosphate 2-fluoro-ara-
ATP. It is an anti-metabolite which inhibits DNA synthesis while simultaneously reducing 
RNA and protein synthesis. Fludarabine phosphate is used in the treatment of 
haematological diseases as chronic lymphocytic leukemia among others (19). 
4.2.2.3 
Interleukin 2 
IL-2 is physiologically produced by activated T-lymphocytes and stimulates the antigen 
specific and non-specific immune system through specific receptors (31). 
 dose 
IL-2 administered intravenously according to the low-dose regimen (27) is used in Denmark 
as standard treatment for suitable patients with metastatic malignant melanoma. Moreover, 
low-dose IL-2, 2 MIU is used for the treatment of metastatic kidney cancer. In this study, IL-2 
could be given according to the low-dose subcutaneous regimen. 
4.3 Benefit and risk assessment 
4.3.1 Benefits 
LTX-315 is designed to generate an immune response to the tumour associated antigens, 
which are presented to the immune system to generate a tumour specific response. The 
feasibility of expanding TILs from sarcomas was investigated in a non-clinical study. Tumour 
samples from 28 patients with 8 different sarcoma subtypes were obtained, and it was 
possible to expand a minimum of 40 million TILs from 25 of these. Reactivity analyses 
revealed reactivity against autologous tumour cells in 11 of 22 tested tumour samples from 7 
of 8 different sarcoma subtypes. In this study, it is expected that LTX-315 will expand CD8+ 
T-cells from the excised index lesion thus enhancing the effect of TIL treatment in patients 
with soft tissue sarcoma. 
Eligible patients for the study will have progressed on first line systemic treatment for locally 
advanced/metastatic disease, and the prognosis for these patients is poor. By entering this 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 40 of 96 
 
protocol the patient get access to an experimental treatment that could potentially benefit 
disease course. 
4.3.2 Risks associated with LTX-315 
Side effects with LTX-315 administration are modest and predictable and include most 
commonly low grade (CTCAE grade 1-2) allergy-like AEs including symptoms and signs of 
flushing, paraesthesia, pruritis, rash and asymptomatic hypotension. These allergy-like AEs 
occur in approximately 55% of patients (but not necessarily after all LTX-315 injections) and 
emerge quickly (seconds to minutes) and resolve quickly (minutes). 
Prophylactic measures are in place as antihistamines and a leukotriene antagonist will be 
given to all patients prior to LTX-315 treatment. 
4.3.3 Risk associated with adoptive T-cell therapy 
The in vitro mechanism of action of TILs has been shown to be via direct lysis of tumour cells 
and the production of IFNγ upon tumour stimulation (21), which could also be demonstrated 
in in vitro experiments in metastatic melanoma (12). Internal observation shows that also 
TILs obtained from sarcoma specimens have the ability to recognise autologous tumour 
cells. Recognition of the tumour by cytotoxic T-lymphocytes is mediated via the T-cell 
receptor. 
In melanoma, the identity of T-cell specificities that are responsible for tumour regression 
upon infusion of TILs has not been clarified fully but several antigens which can be 
recognised by autologous TILs have been described (2). In melanoma, TILs recognising 
melanocyte differentiation antigens have been described, and destruction of normal 
melanocytes was observed in a substantial number of patients treated with TILs (37% vitiligo, 
14% uveitis) and related side effects have been observed Table 1 and Table 2 summarizes 
the side effects which have been observed. 
However, the cells to be infused in this study are represented by autologous lymphocytes 
which are simply activated and expanded in vitro, with the purpose to boost their natural 
capacity to kill tumour cells. Therefore, as in melanoma, the toxicities predicted from infusion 
of autologous TILs are mild and it is anticipated that the benefits outweigh the risks. 
4.3.3.1 
Analysis of potential side effects 
Intravenous IL-2 administration in itself is known to induce side effects (30). World-wide, 
thousands of patients have been treated with intravenous IL-2 and its side effects have 
become very much manageable. Experience with low-dose subcutaneous IL-2 and 
intravenous intermediate dose IL-2 was obtained at CCIT, where 6 melanoma patients 
received low-dose subcutaneous IL-2 for 14 days (Ellebaek 2012), while subsequent patients 
received low-dose regimen dose IL-2 as single therapy (Adams-Graves 1997). Toxicities to 
low-dose subcutaneous IL-2 were fever/chills only, while decrescendo IL-2 toxicities were 
predictable with high fever, weight gain, rash, loss of appetite, reduced urine production and 
low blood pressure and manageable with standard treatments for these symptoms. All 
symptoms resolved completely within 48 h after the last infusion. 
Other toxicities described for the National Cancer Institute (NCI) study (NCT00080353) of TIL 
therapy in melanoma, in conjunction with lymphodepletion and IL-2 are shown in Table 1 
(toxicities within the first 35 patients were reported). CCIT’s experience is reported in Table 
2. 
Note that only low or decrescendo IL-2 doses were infused, resulting in a reduced toxicity 
profile; other toxicities are similar to those observed in the NCI study. Non-haematological 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 41 of 96 
 
and haematological toxicities were those expected from IL-2 and the non-myeloablative 
chemotherapy. In addition, autoimmunity was observed in the TIL therapy group directed at 
melanocytes (at the NCI). Even though the lymphodepleting regimen of cyclophosphamide 
and fludarabine phosphate was shown to be myelosuppressive, it was not myeloablative, 
and neutrophils and lymphocytes recovered to > 500/mm2 in all patients within 2 to 3 weeks, 
respectively. More importantly, none of patients with metastatic melanoma (n=31, including 2 
patients treated twice with a full regimen) treated so far at CCIT needed stem cell support to 
rescue marrow function. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 42 of 96 
 
Table 1. Toxicities observed in NIH study protocol 99-C-0158 (NCT00080353) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2. Toxicities observed in TIL study/studies at CCIT (3) 
Attribute measured / Toxicities 
(n=24) 
Days in hospital: mean (range) 
21.6 (16 – 39) 
pRBC transfusions: mean (range) 
5.6 (1-25) 
Platelet transfusions: mean (range) 
5.2 (0-14) 
Autoimmunity 
Uveitis (n=1) 
Opportunistic infections 
Not observed 
 
 
Toxicities due to chemotherapy  
(grade 3 and 4) 
Neutropenia (n=18) 
Thrombopenia (n=18) 
Indefinit sepsis (n=3) 
 
 
Toxicities due to TIL 
(all grades) 
Fever, chills (n=19) 
 
 
Toxicities due to intermediate dose IL-2  
(all grades) 
(=6)a 
Fever, chills (n=6) 
Dyspnea (n=2) 
Oliguria (n=2) 
Weight gain (n=4) 
Creatinin increase (n=1) 
a)Only patients treated with intermediate doses of IL-2 (low-dose regimen) have been reported. 
Patients treated with low-dose IL-2 only had fever/chills as IL-2 related toxicity 
 
In the NCI study one patient developed an Epstein-Barr virus (EBV) lymphoproliferative 
disease 4 months after treatment. This patient was seronegative for EBV before TIL infusion, 
and must have contracted an EBV infection shortly after TIL treatment. Although this patient 
had a 90% decrease of tumour load upon TIL treatment, he died of progressive lymphoma 8 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 43 of 96 
 
months later. However, EBV infection of a seronegative patient is considered a very unlikely 
event and therefore EBV seronegativity is not an exclusion criterion in this TIL study as well 
as all patients will receive acyclovir or valacyclovir prophylaxis which was previously shown 
to reduce the incidence of lymphoproliferative diseases in immunosuppressed populations 
(34). 
4.3.3.2 
Predictability of effect 
There are no biomarkers that can predict tumour regression or toxicity of the treatment. 
Patients will therefore be carefully monitored by physical examination, blood tests, PET-CT- 
and/or MRI-scans and if indicated ophthalmic examinations. Blood samples will be taken at 
several time points after TIL treatment to measure sarcoma cancer-reactive T-cells 
retrospectively. 
Haematological toxicities such as low red blood cell and platelet counts are transient but may 
require transfusions of red blood cell or platelets, respectively. Patients will receive filgrastrim 
to shorten the period of neutropenia. In case of febrile neutropenia, patients will be treated 
with broad-spectrum antibiotics. Patients will receive antibiotic profylaxis against important 
opportunistic infections (P. Carinii, yeast infections albicans, herpes infections etc.). 
Opportunistic infections will be treated with the appropriate antiviral or antibacterial drugs. 
Toxicities associated with low-dose IL-2 therapy are also transient and can be easily 
managed using standard interventions and treatments. 
4.3.4 Risks and disadvantages regarding surgery and test sampling 
4.3.4.1 
Risks associated with removing tumour tissue 
Prior to inclusion it will be assessed whether it is possible to remove some of the patients 
own tumour tissue in a minor operative procedure. Surgery will mainly be performed by 
physicians at the Department of Orthopedic Surgery, Copenhagen University Hospital, 
Rigshospitalet or by physicians from other specialties if necessary. The specific procedure to 
be performed is to be decided by the surgeon. Also, it will be at the surgeons’ discretion to 
decide whether the procedure can be performed in the outpatient clinic or if it requires 
admission. 
Depending on the required surgical procedure, risk and possible adverse effects will vary, but 
includes bleeding and infection. The patient will be informed in more details about the risk 
and possible AEs both at inclusion and again prior to surgery. 
The patient will not be able to participate in the study if no tumour tissue is available for 
removal or if removal will put the patient at a too large risk. 
4.3.4.2 
Risks associated with biopsies 
There is a slight risk of infection and/or bleeding when performing a biopsy. Pain and bruising 
might also occur in the area. 
4.3.4.3 
Risks associated with blood tests 
Pain and bruising can occur in the area. 
4.3.5 Overall benefit and risk evaluation 
Based on all the currently available non-clinical and clinical data for LTX-315 and adoptive T-
cell therapy, as well as the design of the planned C17-315-04 study, it is considered safe to 
proceed with the proposed clinical study under the conditions detailed in the protocol. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 44 of 96 
 
5 SELECTION OF STUDY POPULATION 
5.1 Population 
The target population is adult male and female patients with tumour lesions accessible for 
injection (may include cutaneous, subcutaneous, oral or lymph node lesions) who have a 
confirmed diagnosis of advanced/metastatic soft tissue sarcoma who have received at least 
one approved standard of care treatment and/or are deemed unsuitable for such treatment(s) 
by their treating physician. 
Patients must meet all of the inclusion criteria listed in Section 5.2 and not fulfil any of the 
exclusion criteria listed in Section 5.3. 
5.2 Inclusion criteria 
1. (Histologically) Confirmed any patients with advanced or metastatic soft tissue 
sarcoma with stable disease or has progressed after a minimum of 1 systemic 
treatment of advanced/metastatic disease. Patient will have received at least 1 
approved standard of care treatment for advanced/metastatic disease or be deemed 
unsuitable for such treatment by their treating physician 
2. At least 1 index tumour lesion accessible for injection with a longest diameter (LD) of 
≥ cm which is planned for LTX-315 injection 
3. At least 1 measurable (target) non-injected tumour lesion that can be used to assess 
response by Computed Tomography (CT)-scan (as per RECIST 1.1) 
4. A life expectancy of at least 3 months 
5. Willing to undergo repeat tumour biopsy and/or tumour resection procedures 
6. Between 18 and 75 years of age 
7. An Eastern Cooperative Oncology Group (ECOG) performance status: 0 – 1 
8. Meet the following blood laboratory requirements: 
a. Absolute neutrophil count ≥ 1.5 x 109/L 
b. Platelet count ≥ 75 x 109/L 
c. Haemoglobin ≥ 6.0 mmol/L after blood transfusion if needed 
d. Prothrombin time / International Normalised Ratio (PT/INR) within the 
institution’s normal range 
e. Aspartate Transferase (AST) and Alanine Transferase (ALT) ≤ 2.5 x upper 
normal level 
f. Creatinine ≤ 1.5 x upper normal level 
9. Willing and able to comply with the protocol and agree to return to the hospital for 
follow-up visits and examinations up to 15 months  after EoT 
10. Fully informed about the study and have signed the informed consent form 
11. Re-screening is allowed once on a case by case basis as judged by the investigator 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 45 of 96 
 
5.3 Exclusion criteria 
1. A history of clinical significant active systemic autoimmune disease requiring anti-
inflammatory or immunosuppressive therapy within the last 3 months. Patients with 
history of autoimmune thyroiditis are eligible provided the patient requires only thyroid 
hormone replacement therapy and disease has been stable for ≥ 1 year 
2. Any other malignancy active within the previous 5 years except for carcinoma in situ 
of the cervix, ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS) of the 
breast 
3. Received an investigational drug within 4 weeks prior to any study drug 
administration, or are scheduled to receive 1 during the study participation 
4. Received external radiotherapy or cytotoxic chemotherapy within 4 weeks prior to 
LTX-315 administration, or have not recovered from AEs (to ≤ CTCAE grade 1) due 
to agents administered more than 4 weeks earlier. Palliative radiotherapy to non-
target and lesions planned for LTX-315 injection within 4 weeks of LTX-315 
administration is allowed 
5. Currently taking any agent with a known effect on the immune system. Patients are 
allowed to be on a stable dose of corticosteroids (up to 10 mg daily prednisolone or 
equivalent) for at least 2 weeks prior to LTX-315 administration (see Appendix I) 
6. Any other serious illness or medical condition such as, but not limited to: 
a. Uncontrolled infection or infection requiring antibiotics 
b. Uncontrolled cardiac failure: Classification III or IV (New York Heart 
Association) 
c. Uncontrolled systemic and gastrointestinal inflammatory conditions 
d. Bone marrow dysplasia 
7. A known history of positive tests for HIV/AIDS, syphilis, human T-cell leukemia-
lymphoma virus (HTLV), active Epstein-Barr, hepatitis B or C (based on serology) 
8. A history of cerebrovascular or cardiac disorders and would be at particular risk of 
sequelae following a short hypotensive episode 
9. If of child-bearing potential, not willing to use an effective form of contraception such 
as hormonal birth control, intrauterine device or double barrier method from screening 
visit and until 3 months after last study treatment (any of the agents). Acceptable 
hormonal and non-hormonal birth control methods are listed in Appendix II.  
10. Breastfeeding and/or have a positive pregnancy test during screening 
11. Donate sperm from LTX-315 dosing until 3 months after last study treatment (any of 
the agents) 
12. Patients with pregnant or partner of child-bearing potential not willing to use 
contraception from LTX-315 administration until 3 months after last study treatment 
(any of the agents). Acceptable hormonal and non-hormonal birth control methods 
are listed in Appendix II. 
13. Expected to need any other anticancer therapy or immunotherapy to be initiated 
during the treatment period 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 46 of 96 
 
14. Clinically active or unstable metastases in the central nerveous system as assessed 
by the treating physician 
15. Any known hypersensitivity to any of the excipients in the non-IMPs including the 
required allergic prophylactic medications (
 
 
16. Any known or suspected hypersensitivity to any of the IMPs 
5.4 Recruitment and screening 
All patients will be treated at CCIT, Herlev Hospital, Denmark. Potential patients will also be 
identified at hospitals in other Scandinavian countries and referred to Herlev Hospital for 
screening and study participation. Prior to any testing under the study protocol, including 
screening procedures and assessments, written informed consent will be obtained from the 
patient in accordance with Danish practice and applicable guidelines/regulations. If the 
patient is included after re-screening, a new written informed consent will be obtained from 
the patient. 
5.5 Patient withdrawal 
Patients will be informed that they have the right to withdraw from the study at any time for 
any reason, without prejudice to their medical care. The Investigator also has the right to 
withdraw patients from the study. 
Patients meeting any of the following criteria must be discontinued from the study: 
• The patient withdraws consent. The consequence of withdrawal of all consent by a 
patient will be that no new information will be collected from that patient and added to 
the existing data or database. However, every effort will be made to follow all patients 
for safety. 
• 
The Investigator can withdraw the patient due to safety or any other issues 
• 
Initiation of a new systemic anticancer treatment 
• 
The patient becomes pregnant or fails to use adequate birth control (for those 
patients who are able to conceive) in the treatment period 
• 
Intercurrent medical illness that, in the judgement of the Investigator, would make 
continued intervention dangerous for the patient 
• 
The patient is not eligible to continue to Step 2, based on judgement of the 
Investigator 
If a patient is withdrawn prior to the scheduled EoT visit, they should complete the Early 
Termination (ET) visit assessments as listed in table 6.1 and 6.2, if at all possible. 
The reason(s) for a patient’s withdrawal from the study are to be recorded in the patient’s 
records and in the electronic case report form (eCRF). 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 48 of 96 
 
TILs, IL-2, cyclophosphamide and fludarabine phosphate will be labelled and packed 
according to Herlev Hospital pharmacy requirements. 
IL-2 Injections for self-administration will be labelled by the cytostatica unit, Herlev Hospital, 
in accordance with Annex 13 of the GMP guidelines. 
6.1.2 Storage and handling 
LTX-315 must be stored according to the storage conditions specified on the label in a 
limited access location. The drug allocated to the study may not be used for any purpose 
other than the present study. 
IL-2, cyclophosamide and fludarabine phosphate must be stored and handled according to 
the SmPCs and in a limited access location. Mixing and storage of the products is carried out 
according to existing standard guidelines at the Department of Oncology. 
After the study is completed, all unused LTX-315 products must be destroyed or returned to 
the Sponsor or the Sponsor’s agent upon agreement with Sponsor. 
The Investigator will be responsible for the storage, dispensing, inventory, and accountability 
of all clinical supplies. An accurate and timely record of the inventory of all clinical supplies 
must be maintained. The supplies and inventory must be available for inspection by 
designated representatives of the Sponsor on request, and must include the information 
below: 
• 
Receipt of all products from clinical supplier or Herlev Pharmacy 
• 
The identification of the patient to whom the drug was dispensed 
• 
The date(s), number of injections/infusions/oral administration and quantity (volume, 
amount) of the drug dispensed to the patient 
• 
The product batch number 
The preparation of each IMP and non-IMP must be documented on a ‘Drug Preparation and 
Dispensing Log Form’. 
A copy of the inventory record and a record of any IMP that have been destroyed must be 
submitted by the Investigator to the Sponsor. This form must include the information below: 
• 
The number of administered units 
• 
The number of unused units 
• 
For self-administration, the number of units provided to the patient and the number of 
units returned by the patient. Patients are supplied with a diary to report IL-2 self-
administration if discharged prior to D13. 
• 
The number of units destroyed at the end of the study 
• 
The date and method of destruction and the location 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 50 of 96 
 
The supplied amount of IL-2 injections for self-administration will be registered by use of 
batch number, so that the total amount of administed IL-2 can be determined. 
6.2.6 Pegfilgrastim 
Is an analog of human granulocyte colony stimulatory factor. It works by stimulating the bone 
marrow into producing white blood cells and increasing the peripheral blood count. It is 
usually given to cancer patients who suffer from low blood counts following chemotherapy 
(32). 
Pegfilgrastim is administered as a single dose of 6 mg s.c. at 2 hours after TIL infusion to 
help patients recover from the lymphodepleting chemotherapy. 
6.2.7 Sulfamethizole with trimethoprime 
To prevent opportunistic infections, sulfamethizole with trimethoprime, 400/80 mg, 1 tablet is 
given daily from Step 2, Day -7 and 6 months ahead. 
6.2.8 Aciclovir 
To prevent opportunistic infections, aciclovir, 400 mg x 2 daily on Step 2, Day 1 and 6 
months ahead. 
6.2.9 Chlorpheniramine 
LTX-315 prophylaxis. Chlorpheniramine 4 mg or equivalent histamine H1-antagonist will be 
given orally 10-12 hours (self-administration) and 1 hour before the first injection each day of 
LTX-315 injection (or i.v. equivalent) 
6.2.10 
Ranitidine 
LTX-315 prophylaxis. Ranitidine 150 mg (or equivalent H2-antagonist) orally 1 hour before 
the first injection each day of LTX-315 injection (or i.v. equivalent) 
6.2.11 
Montelukast 
LTX-315 prophylaxis. Montelukast 10 mg orally 10-12 hours (self-administration) and 1 hour 
prior to the first LTX-315 injection on each planned day of administration 
6.3 Treatments administered 
Supportive care and resuscitation equipment should always be available when study drug is 
administered. 
LTX-315 Prophylactic measures will be initiated in all patients with the use of 
 
 as described in Section 6.2.9, 6.2.10, and 6.2.11. Additional 
requirements for prophylaxis will be evaluated by the Investigator and may be instituted 
based on emerging safety data. Anaphylaxis treatment guideline will be described in a 
separate document. 
For the T-cell therapy, prophylactic treatment includes fluid therapy during cyclophosphamide 
treatment as well as supportive treatment. 
6.3.1 LTX-315 injection schedule 
Detailed instructions for intra-tumoural LTX-315 injections are provided in a separate manual. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 53 of 96 
 
10 mg daily prednisolone or equivalent). No specific studies of interactions between LTX-315 
and other agents have been conducted. 
Any non-prohibited medication (prescription as well as non-prescription drugs including 
herbal medicine and natural health remedies) necessary for the patient’s wellbeing which are 
not listed among the exclusion criteria and which do not interfere with the study evaluations, 
are permitted given that they are carefully followed by the Investigator and documented on 
the applicable eCRF page. 
All concomitant medication and therapies used within 28 days prior to day 1 (screening) and 
up to the EoT visit are to be recorded in the eCRF. 
In the follow-up period and until study completion the following will be recorded in the eCRF: 
• 
concomitant medication and therapies used for soft tissue sarcoma or which may 
alter the course of the disease 
• 
concomitant medication and therapies used for events related to the LTX-315 and 
adoptive T-cell therapy 
The drug name or generic name, reason for the treatment, and the start and stop dates of 
administration are to be noted if possible. Any changes in the dose or frequency of 
administration of concomitant medications should be recorded in the eCRF. Treatments 
initiated due to AEs that occur during the study need to be documented in the eCRF, and in 
such cases the medication use will be documented until end of follow-up period for the AE. 
6.5 Method of assigning patients 
Patients are to be registered and assigned to treatment after written informed consent has 
been obtained and all pre-study evaluations have been completed. Patient eligibility should 
be documented on the patient eligibility eCRF page and in source documents. 
The study site will be required to complete a Screening Log of all screened patients, 
regardless of whether the patient is registered in the study. Registered patients will be 
assigned a unique patient number. If a patient is withdrawn and replaced, the patient 
identifier number will not be reused. Patient numbers will be allocated sequentially by the 
Electronic Data Capture (EDC) system. This study will not employ randomisation. 
6.6 Blinding (not applicable) 
This is an open labelled study. 
6.7 Emergency unblinding procedures (not applicable) 
This is an open labelled study. 
 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 54 of 96 
 
7 VISIT SCHEDULE AND ASSESMENTS 
7.1 Visit schedule 
Table 6.1 Visit Schedule from Screening to Step 1 
 
 
Step 1 - LTX-315 treatment 
 
Visit (V) number 
1 
2 
3 
4 
5 
61 
6A1, 15 
6B1, 15 
6C1 
6D 
6E 
6F 
 
Time (weeks) 
Screening 
 
 
 
 
 
 
 
 
 
ET 2 
Time (days) 
-28 to 
Step 1 
 
 
 
 
 
 
 
- 
- 
- 
- 
- 
Visit window (days) 
 
 
+ 1 
+ 1 
± 1 
- 
± 1 
± 1 
- 
- 
- 
- 
- 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Demography 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination 5 
X 
X 
X 
X 
X 
 
X 
X 
 
 
 
 
X 
Height and weight 6 
i ht 6
X 
 
 
 
 
 
 
 
 
 
 
 
X 
ECOG performance status 
X 
X 
 
 
 
 
 
 
 
 
 
 
X 
Vital signs 7 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
12-lead ECG 8 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Blood pressure monitoring 9 
 
X 
X 
X 
X 
 
X 
X 
 
 
 
 
 
Pregnancy test 10 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Blood for clinical safety laboratory tests 11 
X 
X 
 
X 
 
 
 
 
 
 
 
 
X 
Coagulation 11 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
Serology 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Urinalysis 11 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Full tumour assessment (by CT/MRI scan) 12 
X 
 
 
 
 
 
 
 
 
X 
X 
X 
 
Immunological blood sample (for PBMC) 13 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Immunological blood sample (for serum) 13 
X 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 55 of 96 
 
 
 
 
 
 
 
 
1. 
The time period from end of Step 1 to start of Step 2 will vary between patients, with a maximum of  
 weeks from surgery (W3, Step 1) until admission at W-2, Step 2 for patient with PD at enrollment. 
Visit 61 is only for these patients. Patients with SD at enrollment will have optional visits at Visit 6A1 and Visit 6B1 and mandatory visit at Visit 6C1. They will enter W-2 Step 2 after confirmed PD during 
the study  
2. 
Patients who withdraw from the study before EoT visit must be seen for an ET visit. The visit is performed as soon as possible after withdrawal 
5. 
Full physical examination to be performed at screening and on D1, Step 1 prior to LTX-315 injection. Only examination of respiratory and cardiovascular systems are required at visits thereafter, if 
clinically indicated 
6. 
Height only to be measured at screening  
7. 
Includes blood pressure, heart rate and temperature 
8. 
On Step 1, Week 1, Day 1, 12-lead ECG must be performed prior to and if indicated repeated after the LTX-315 injection(s) 
9. 
Blood pressure is to be monitored from just prior to LTX-315 injection, at 1, 3 and 5 minutes after each injection and then every 5 minutes until 30 minutes post last dose of the day, using an automated 
cuff system. At Week 2, Step 1, only pre-injection readings will be recorded unless there is an AE 
10. Urine or serum sample (only for women with child-bearing potential) must be repeated at Day 1,Step 1, if more than 7 days after last pregnancy test 
11. Safety laboratory samples are to be collected and analysed prior to LTX-315 injection on 
 and 
 (Step 1)  
12. Tumour assessments by CT-scans of chest/abdomen/pelvis (head and neck if target tumours are in this area) are to be done according to RECIST 1.1. The screening scan is to be done within 28 days 
prior Day 1, Step 1  
13. Blood samples will be collected once during screening to achieve baseline. A window of minus 3 days applies at later visits, and only one sample is sufficient. Should consist of 100 mL heparinized 
blood for isolation of PBMC and 10 mL blood in dry glass for collection of serum. 
 Sample will be collected just prior to hospital discharge 
14. AEs severity graded according to CTCAE, version 4.0 
15. See intra-tumoural injection manual for details. Day 
 and 
 are optional. 
16. Baseline biopsies must be taken prior to LTX-315 injection on D1, Step 1 
Concomitant medication/therapy 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Adverse events 14 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
X 
LTX-315 Prophylactic treatment  
 
X 
X 
X 
X 
 
X 
X 
 
 
 
 
 
LTX-315 administration 15 
 
X 
X 
X 
X 
 
X 
X 
 
 
 
 
 
LTX-315 Injected lesion biopsies 16 
 
X 
 
 
 
X 
 
 
X 
 
 
 
 
Untreated lesion biopsies (optional) 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Surgical removing of LTX-315 injected lesion 
 
 
 
 
 
X 
 
 
X 
 
 
 
 
Hospital admission 
 
 
 
 
 
 
X 
 
 
 
 
 
 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 58 of 96 
 
Table 7. Visit Schedule in Follow-up Period 
Visit 
V26 
V27 
V28 
V29 
V30 
ET 
Time (weeks) 
 
 
Time (months) 
 
 
 
 
 
 
Adverse events 1 
X 
X 
X 
X 
X 
X 
Concomitant medication/therapy 
X 
X 
X 
X 
X 
X 
Vital signs 2 
X 
X 
X 
X 
X 
 
Dispensing of Sulfamethizole with trimethoprime and Aciclovir 
X 
X 
 
 
 
 
Physical examination 3 
X 
X 
X 
X 
X 
X 
Weight 
X 
X 
 
 
 
X 
ECOG performance status 
X 
X 
X 
X 
X 
X 
Vital signs 
 
 
 
 
 
X 
Blood for clinical safety laboratory tests 4 
X 
X 
X 
X 
X 
X 
Coagulation 
X 
X 
X 
X 
X 
X 
CT/MRI scan 
 
 
 
 
 
X 
Immunological blood sample (for PBMC) 5 
X 
X 
X 
X 
X 
 
Immunological blood sample (for serum)5 
X 
X 
X 
X 
X 
 
Full tumour assessment (by CT/MRI scan)6  
X 
X 
X 
X 
X 
 
End of study 
 
 
 
 
 
X 
1. 
AEs severity graded according to CTCAE, version 4.0 
2. 
Includes blood pressure, heart rate and temperature 
3. 
Only respiratory and cardiovascular systems 
4. 
See Section 7.5.3 
5. 
Should consist of 100 mL heparinized blood for isolation of PBMC and 10 mL blood in dry glass for collection of serum 
6. 
CT, MR, PET-CT or PET-MR scan can be used. A PET-CT-scan is preferred 
 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 59 of 96 
 
7.2 Study procedures 
7.2.1 Guidelines for supportive care and treatment 
Supportive treatment is given on ordinary medical indications estimated by the Investigator 
responsible for the treatment. Any measures should be specified in the patient chart and flow 
sheet. The following is meant as guidance and other medications can be administered as it is 
seen fit. One exception is systemic corticosteroid which cannot be administered during LTX-
315 treatment (see Appendix I). 
7.2.2 Supportive treatment 
T-cell therapy: During the infusion with T-cells the patient can experience shivering which 
can be relieved with the administration of subcutaneous Pethidine in a dose of 25 mg max x 
4 if needed. 
Also, light breathing difficulties can be observed with a possible decrease in saturation which 
can be treated with oxygen by nasal catheter. 
Neutropenia: If simultaneous neutropenia and fever occurs it will be treated in accordance 
with Appendix III. 
Diarrhea: Diarrhea will be treated immediately with the necessary supportive care and 
treatment, including Loperamide. Loperamide is to be withdrawn if blood or slime is observed 
in the faeces during the diarrhea. If this occurs, suitable diagnostic microbiological samples 
should be collected to exclude an infectious cause. Patients should also be instructed in the 
intake of plentiful amounts of fluids to prevent dehydration following the diarrhea. 
Anemia: Transfusions with blood should be administered if haemaglobin < 6.0 mmol/L or if it 
is otherwise clinically indicated. Radiated and filtered blood may be given from Step 2, Day -
7 and 6 months ahead. 
Thrombocytopenia: Transfusion with platelets is indicated if platelets < 20/μl or if it is 
otherwise clinically indicated. 
7.2.3 Local radiotherapy 
Local radiotherapy can be prescribed for bone pains, wounds or if otherwise clinically 
indicated. Radiotherapy is preferably to be avoided within the first 3 weeks of Step 2 where 
the adoptive T-cell therapy treatment takes place for the interest of the patient. Radiated 
areas cannot be used as parameters in the assessment of treatment response. If possible, 
not all evaluable areas should be included in the radiated area. If this is not possible it is no 
longer possible to evaluate a response to treatment and the patient is withdrawn from the 
study. 
7.3 End of treatment and follow-up 
7.3.1 Normal end of treatment 
The EoT visit will be performed 6 weeks after TIL infusion. If a patient is withdrawn prior to 
the scheduled EoT visit, they should complete the ET visit assessments as list in table 6.1 
and 6.2. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 60 of 96 
 
All serious AEs (SAEs) and AEs considered related to study treatment that are ongoing at 
the EoT visit will be followed up until resolution or until clearly determined due to a patient’s 
stable or chronic condition or intercurrent illness(s) or deemed irreversible. The reason(s) for 
a patient’s withdrawal from the study are to be recorded in the patient’s records and in the 
eCRF. 
7.3.2 Follow-up 
Patients will be followed with visits and diagnostic imaging at 12 weeks after TIL infusion 
(Step 2, Day 1) and every 3 months hereafter for up to 15 months. 
In case of progression of the cancer, the patient will be referred back to the department in 
which they were followed before enrolment in the study. This department will be responsible 
for further treatment and follow up according to their local guidelines. 
7.3.3 Standard care following study completion 
After completion of the study, the patient will be treated at the Investigator’s discretion or 
referred back to other physician according to standard practice. 
7.4 Efficacy assessments 
7.4.1 Local inflammatory responses 
7.4.1.1 
Biopsies 
Biopsy and tumour resection samples will be collected and prepared for histological and 
immunohistochemical evaluation for verification of diagnosis. 
The pathology interpretations will be done by a central laboratory. 
All mandatory biopsies must include up to 3 (
gauge) core biopsies. 
Biopsies of the tumour lesion planned for injection with LTX-315 will be done at: 
• 
Baseline (pre-LTX-315 treatment) to assess T-cell infiltration (including CD8+) 
• 
At the time of and as part of the excision of the injected lesion 
• 
6 weeks after TIL infusion if the whole tumour is not resected 
A part of the resected lesion will be used for TIL production and another part for verification 
of diagnosis. 
The remaining part of the excised tumour will be stored for future research on immune 
responses. 
If an additional lesion is present and feasible for biopsy, this will be used as a bystander 
lesion. The optional lesion will not be injected and will allow a comparison (by biopsy) with 
the injected lesion. 
In this scenario a patient would have 3 tumour lesions: 
• 
One for LTX-315 injection 
• 
A second to be followed by CT-scan for RECIST 1.1 response assessment 
(measurable, non-injected lesion) 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 61 of 96 
 
• 
A third that is a “bystander” lesion (no LTX-315 injection) but available to biopsy to 
compare with biopsy of the injected lesion 
If a >30% reduction in a non-injected lesion is observed by CT-scan any time after treatment, 
an optional biopsy can be taken from this lesion. 
7.4.2 Systemic inflammatory responses 
7.4.2.1 
Blood samples for immunological analysis 
A total of 510 ml of blood will be collected for research purposes in the period from screening 
until EoT (Step 2, Week 7). These blood samples are taken to assess the effect of treatment 
on the immune system for research purposes. The amount of blood taken during the course 
of the study does not exceed what the body itself is capable of producing between each test. 
Blood samples for research purposes will only be taken if the haemoglobin level is 
acceptable (≥ 6 mmol/L). Summaries of the immunological response parameters will be 
presented in a separate immunological report. 
7.4.2.2 
Identification of somatic mutations in the tumour 
A PBMC sample will be collected as a source for normal cells for comparison of the DNA and 
RNA sequence in normal cells to the sequence in the tumour tissue. The sample will be 
collected at screening and will enable identification of somatic mutations in the tumour. 
7.4.3 Immune monitoring 
Change in immune biomarkers (in both peripheral blood and tumour samples) 2 weeks after 
LTX-315 treatment in patients with transdermally accessible tumours will be assessed. 
PBMC will be isolated from blood samples at screening, before and after T-cell therapy. 
The following parameters may be monitored in biopsies and PBMCs in order to investigate 
and characterise the immune status of the patients and the nature of anti-tumour immune 
responses: 
The immune biomarkers may include but is not limited to CD3, CD4, CD8, CD11, CD14, 
CD19, CD27, CD56, CD68, Ki67 and Granzyme B. T-cell receptor sequencing may be 
performed to monitor changes in the T-cell repertoire induced by treatment. 
7.4.3.1 
Identification of tumour-antigen specific T-cells 
To generate a clinical effective T-cell response it is important that LTX-315 generates 
tumour-antigen specific T-cells. To identify sarcoma tumour-antigens in LTX-315 patients, 
next-generation sequencing and epitope prediction may be used. Tumour tissue DNA and 
RNA will be compared with data from matched normal tissue (PBMC) in order to identify 
tumour-unique (“somatic”) mutations. Patients will be HLA typed, and algorithms will then be 
used to predict which tumour-epitopes the patient’s tumour cells will express. Peptides 
corresponding to predicted tumour-epitopes will be synthesized and used to identify tumour-
antigen specific T-cells in freshly expanded TILs as well as in PBMCs using MHC multimer–
based screens. The effector functions of the tumour-antigen specific T-cells may be analysed 
by ELISPOT which will reveal whether cytokines such as IFNγ and or TNFα is produced by 
peptide stimulation. Tumour reactive T-cells may be identified in PBMC and expanded TILs 
by co-culturing with autologous/ allogenic tumour cells followed by flowcytometry analysis of 
IFNγ and TNFα. Details are described in a separate immunology protocol. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 62 of 96 
 
7.4.4 Anti-tumour effects in measurable tumours 
A preliminary assessment on systemic anti-tumour activity will be done for selected 
measurable tumours according to RECIST 1.1 (16). 
Tumour assessments by CT-scans (or MRI) of chest/abdomen/pelvis are to be done 
according to the hospital procedure as outlined in Appendix IV. 
Additional CT-scans should be taken as clinically indicated in order to assess the total 
tumour burden of a patient. The baseline scan is to be done within 28 days prior to first LTX-
315 treatment. 
The RECIST 1.1 criteria for anti-tumour activity for measurable lesions will be used 
(Appendix IV). 
7.4.5 Storage of biological samples for future research 
Samples that are not used in the study will be transferred to a biobank at CCIT for future 
biomedical research for up to 15 years and is accepted by the Danish Data Protection 
Agency. If additional studies in other research areas are to be performed on any samples 
obtained during the conduct of this study/samples that are transferred to a new biobank, a 
request to do so will be submitted to the Scientific Ethics Committee, Capital Region of 
Denmark, as per the ‘Act of Processing of Personal Data’ § 5 and § 10, paragraph 2 and 3. 
After 15 years, any remaining tissue samples will be disposed of according to the local 
guidelines for destruction of biohazardous waste. 
If a patient withdraws his/her informed consent, all biological material is to be destroyed if the 
patient wishes so. 
7.5 Safety assessments 
A full medical history of ongoing medical conditions or symptoms must be completed during 
the screening period (up to 28 period days prior to first LTX-315 dosing). Ongoing medical 
conditions will be graded according to CTCAE v. 4.0 at the time of screening. Abnormal 
laboratory values or vital signs at screening will be entered as a medical condition if viewed 
as clinical significant by the Investigator in which case a CTCAE v 4.0 grade should be 
assigned. AEs identified during the screening or based on screening tests, will be captured 
as Medical History 
The patient’s demographics, diagnosis and disease status/stage at screening must be 
recorded. The history of the cancer, including date of initial diagnosis, primary cancer site 
and the cancer type confirmed by histology must be recorded. Information should be 
collected on previous treatments for the malignant disease and concomitant non-malignant 
diseases.  Recording of concomitant medication, see Section 6.4. 
A pregnancy test (urine or serum) for women with child-bearing potential is to be done within 
7 days prior to the start of LTX-315 dosing and within 7 days prior to start of chemotherapy 
(Step 2, Week -1, Day -7). The result is to be documented. 
7.5.1 Vital signs, physical examinations and ECOG performance status 
Vital signs (resting blood pressure, heart rate and body temperature) will be recorded. 
Blood pressure should be monitored from prior to each LTX-315 injection, 
 
. Blood pressure measurement should continue at a minimum of 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 63 of 96 
 
 or as clinically indicated. The 
blood pressure readings pre-dose, at 1, 3 and 5 minutes will be entered in the eCRF during 
Week 1, Step 1. At Week 2, Step 1, only pre-injection readings will be recorded unless there 
is an AE. 
The patient will be observed for minimum one hour post last daily LTX-315 injection or longer 
at the Investigator’s discretion. 
A complete, physical examinations required at screening and Week 1, D1 in Step 1. 
Thereafter, only the respiratory and cardiovascular body systems need to be examined at 
other visits, if clinically indicated. The physical examination findings and relevant parameters 
are to be documented in the medical source documents and the eCRF. Any clinically 
significant abnormal findings observed and recorded during the treatment period will be 
recorded as AE. 
The patient’s height (without shoes) and weight will be recorded (indoor clothing, without 
shoes). 
ECOG performance status will be scored in accordance with the ECOG performance scale 
(see Appendix V). 
7.5.2 Electrocardiogram (ECG) 
12-lead ECG will be evaluated locally at the study site prior to LTX-315 administration. Any 
clinically significant abnormal findings observed and recorded during the treatment period 
(Step 1 and Step 2) will be recorded as AEs. The same method of assessment should be 
used throughout the study. 
7.5.3 Local clinical safety laboratory evaluations 
Blood and urine samples will be collected for clinical safety laboratory tests. The parameters 
to be analysed during screening, Step 1, Step 2 and T-cell follow-up are listed in Table 8. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 65 of 96 
 
day as collected. Urine samples will be collected at the study site, and will be analysed 
immediately by trained study personnel. 
7.5.4 Pregnancy test 
Urine or serum hCG test will be performed at specified timepoints. 
7.5.5 Total blood volume 
Blood samples will be drawn for clinical safety laboratory evaluations and immune 
monitoring. 
From screening until EoT visit, the estimated volumes of blood to be drawn per patient are: 
• 
Clinical Safety Laboratory: 485 ml to 685 ml dependent on day of discharge from 
hospital. If additional blood samples for safety are required; a total of 20-25 ml blood 
will be taken per day 
• 
Immune monitoring for PBMC and serum: 510 ml 
At each follow-up visit the total volume of blood drawn from each patient will be 130 mL. 
The amount of blood taken during the course of the study does not exceed what the body 
itself is capable of producing between each test. Blood samples for research purposes will 
only be taken if the haemoglobin level is acceptable (≥ 6 mmol/L). 
7.6 Adverse events and serious adverse events 
7.6.1 Definitions 
Adverse Events: any untoward medical occurrence in a subject or clinical study subject 
administered a medicinal product and which does not necessarily have a causal relationship 
with this treatment. This includes clinically significant laboratory abnormalities as judged by 
the Investigator. 
Serious Adverse Events: A SAE is an AE which results in one of the 6 outcomes described 
below (International Conference of Harmonisation (ICH) serious criteria). A SAE can occur 
during any phase of the study and at any dose of the investigational product. This is 
particularly true for an AE that: 
• 
results in death 
• 
is immediately life-threatening 
• 
requires patient hospitalisation or prolongation of existing hospitalisation 
• 
results in persistent or significant disability/incapacity 
• 
is a congenital anomaly/birth defect 
• 
is an important medical event that may have jeopardised the patient or may have 
required medical intervention to prevent one of the outcomes listed above 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 66 of 96 
 
Medical and scientific judgement is to be exercised in deciding on the seriousness of a case. 
Important medical events may not be immediately life-threatening or result in death or 
hospitalisation, but may jeopardise the patient or may require intervention to prevent one of 
the listed outcomes in the definitions above. In such situations, or in doubtful cases, the case 
should be considered as serious. Drug misuse and drug overdose should be regarded as 
serious, even if they may not result in the above mentioned outcomes. 
Hospitalisation at the Investigator’s discretion is allowed and if this is for observation or social 
reasons this would not qualify as serious unless there is an associated AE warranting 
hospitalisation. 
Treatment emergent AEs (TEAEs): AEs/SAEs occurring during or  after administration of the 
IMP. AEs occurring before administration of the IMP are considered as non-treatment 
emergent and recorded as Medical history. Non-treatment emergent AEs/SAEs which are 
worsened after treatment with IMP will be added as new event and assessed as treatment 
emergent. 
Severity 
The term "severe" is often used to describe the intensity (severity) of a specific event (as in 
mild, moderate, or severe myocardial infarction); the event itself, however, may be of 
relatively minor medical significance (such as severe headache). This is not the same as 
"serious," which is based on patient/event outcome or action criteria usually associated with 
events that pose a threat to a patient's life or functioning. Seriousness (not severity) serves 
as a guide for defining regulatory reporting obligations 
Severity will be evaluated by Investigator using the CTCAE v. 4.0: 
• 
Grade 1: Mild: the AE is asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
• 
Grade 2: Moderate: minimal, local or noninvasive intervention indicated; limiting age-
appropriate instrumental Activities of Daily Living (ADL) 
• 
Grade 3: Severe: Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self care 
ADL. 
• 
Grade 4: Life-threatening: the AE has life-threatening consequences OR urgent 
intervention indicated. 
o Note, a grade 4 event is not always life-threatening. The ICH serious criterion 
“life-threatening” is used for reporting purposes. 
Grade 5: Death related to AE. 
7.6.2 Reporting of adverse events 
All AEs are to be recorded in the eCRF, however: 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 67 of 96 
 
• AEs with onset in the screening period or based on a screening procedure, will be 
recoded in the Medical History form 
• AEs with onset in the treatment period will be recorded on the AE form 
• AEs with onset In the follow-up period, only AEs considered related to either LTX-315 
or TIL treatment are to be recorded on the AE form. No other AE collection  will be 
done. 
 
AEs will be recorded in response to asking the patient if they have experienced any unusual 
events since last visit at the site. 
AEs will be collected from the time the patient signs the informed consent form. All AEs must 
be recorded in the patient’s medical record and in the eCRF, defining relationship to study 
medication and severity. 
Conditions that existed before screening and inclusion in the study, as well as planned 
hospital admissions, including hospital admissions as part of the study visit schedule, or 
surgical procedures for a pre-existing condition, are not to be considered as AE unless there 
is significant worsening during the study period. 
All SAEs and AEs leading to discontinuation of IMP either observed by the Investigator or 
patient must be reported by the Investigator and evaluated. 
The Investigator should report the diagnosis, if available. If no diagnosis is available, the 
Investigator should record each sign and symptom as individual AEs using separate AE 
forms. 
Signs and symptoms of the treated cancer which, according to the investigator are expected 
and well known both in intensity and frequency, should not be reported as AEs or SAEs. Any 
unexpected change in the intensity or frequency should be reported as an AE or SAE as 
applicable. In addition, all deaths (including death caused by progession of disease) and 
secondary cancers must be reported as SAE 
 
Timelines for initial reporting of AEs: 
The investigator must complete the AE form in the eCRF: 
• For SAEs within 24 hours of the Investigator’s first knowledge of the SAE 
• For all other AEs on an ongoing basis 
If the eCRF is unavailable, the concerned SAE information must be reported on a paper SAE 
form and sent to KLIFO by fax or e-mail within the same timelines as stated above. When the 
eCRF becomes available again, the Investigator must enter the information on the form into 
the eCRF. 
7.6.3 Causality of AEs 
The causality of AE/SAEs (i.e., their relationship to study treatment) will be assessed by the 
Investigator at the study centre for all IMPs. Assessment of causality  is based on the 
following considerations: associative connections (time associative connections (time or 
place)), pharmacological explanations, previous knowledge of the drug, presence of 
characteristic clinical or pathological phenomena, and exclusion of other causes and/or 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 69 of 96 
 
7.6.5 AE/SAE follow-up 
All AEs that were ongoing at the EoT visit will be followed up by the Investigator until the last 
follow-up visit or until the AE has resolved, unless in the Investigator’s opinion the condition 
is unlikely to resolve due to the patient’s underlying disease. 
For patients withdrawn, AEs must be followed up for 28 days after the last dose of IMP or 
until resolution, whichever comes first. 
All SAEs must be followed up by the Investigator until resolved, unless in the Investigator’s 
opinion the condition is unlikely to resolve due to the patient’s underlying disease. 
Additional site visits to follow-up injection site reactions and AE/SAEs can be done if deemed 
necessary by the Investigator. Additional post treatment follow-up visits may be scheduled by 
the Investigator according to clinical judgement. 
Additional safety information is provided in Appendix V. 
7.6.6 Pregnancy 
Each pregnancy that occurs during the trial participation must be reported to sponsor within 
24 hours of learning of its occurrence using the pregnancy form. The pregnancy must be 
followed up to determine outcome and status of mother and child. The child must be followed 
at least to the age of one month. Pregnancy complications and elective terminations for 
medical reasons must be reported as an AE or SAE. Spontaneous abortions must be 
reported as an SAE. 
 
 
7.7 Known adverse reactions to LTX-315 and adoptive T-cell therapy 
7.7.1 LTX-315 
Adverse reactions with LTX-315 administration are modest and predictable and include most 
commonly low grade (CTCAE v. 4.0 grade 1-2) allergy-like AEs including symptoms and 
signs of flushing, paraesthesia, pruritis, rash and asymptomatic hypotension. These allergy-
like AEs emerge quickly (seconds to minutes) and resolve quickly (minutes). For additional 
information please see current IB (28). 
7.7.2 Chemotherapy 
The adverse reactions to chemotherapy described in the following are all general adverse 
reactions seen when the drugs are given as the primary treatment for oncological and 
haematological diseases. 
In these cases the treatment is often given over several series. In this study, the treatment 
will be given as a single dose, why a milder adverse reaction profile is expected. 
7.7.3 Cyclophosphamide 
The adverse reactions are myelosuppression (neutropenia, thrombocytopenia and anemia) 
and urotoxicity (cystitis, haematuria and haemorrhagic cystitis). Sufficient treatment with 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 70 of 96 
 
Mesna alongside rehydration markedly reduces the frequency and severity of the urotoxicity. 
Other common adverse reactions are alopecia, nausea and vomiting. 
Patients receiving treatment with cyclophosphamide can experience the following adverse 
reactions described in the current version of the summary of product characteristics (42). 
7.7.4 Fludarabine phosphate 
The adverse reactions are myelosuppression (neutropenia, thrombocytopenia and anemia), 
infection including pneumonia, coughing, fatigue, limpness, nausea, vomiting and diarrhea. 
Other common adverse reactions are shivering, edema, malaise, peripheral neuropathy, 
visual disturbances, anorexia, mucositis, stomatitis and rash. Severe opportunistic infections 
have occurred in patients receiving treatment with fludarabine phosphate. Deaths have been 
recorded as a cause of severe adverse reactions. 
Patients receiving treatment with fludarabine phosphate can experience the following 
adverse reactions described in the current version of the summary of product characteristics 
(19). 
7.7.5 TILs 
No SAEs are expected due to TIL infusion. The patients might experience transient fever, 
shivering and mild dyspnoea with a few cases of an observed light decrease in oxygen 
saturation. There is a theoretical risk of the development of allergic reactions/anaphylactic 
shock. This has not yet been observed according to literature. See the IMPD for more details 
on previous human exposure and anticipated risks (TIL IMPD 2017). 
7.7.6 Interleukin-2 
Frequency and severity of adverse reactions to IL-2 has generally shown to be related to the 
route of administration, dose and frequency of treatment. Most adverse reactions are self-
limiting and will disappear within 1-2 days after cessation of treatment. Subcutaneous IL-2 
administration can cause a local inflammatory reaction with reddening and induration at the 
site of injection. World Health Organization (WHO) grade 1 toxicity characterised by flu-like 
symptoms with muscle soreness, joint pains, malaise and a slight increase in temperature 
with a duration of 12-18 hours has been observed when administering IL-2 locally. 
Experience shows that fatigue is the most common AE when administering the IL-2 dose 
used in this study. Detailed information on adverse reactions are described in the current 
version of the summary of product characteristics (37). 
Any other adverse effects will be treated according to local guidelines. 
7.8 Safety monitoring and precautions 
7.8.1 Haematological parameters 
Careful haematological monitoring of blood counts is indicated for all patients during 
treatment. Leukocyte count, platelet count and haemoglobin values will be controlled at fixed 
intervals. Measurements will be made before start of chemotherapy, IL-2 and daily during 
treatment until neutrophile counts is > 500/μl and leukocyte count is > 1000/μl. 
Chemotherapy will not be given to patients with a leukocyte count < 500/μl and/or platelet 
number < 50.000/ μl before the start of chemotherapy. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 71 of 96 
 
7.8.2 Kidney and urine infections 
Any obstruction of the efferent urinary tracts, cystitis or infection will be resolved before start 
of treatment. Patients will be treated with Mesna and fluid therapy to decrease the frequency 
and severity of bladder toxicity. Treatment will be terminated if cystitis associated with micro- 
or macroscopic haematuria occurs during treatment with cyclophosphamide. The patients’ 
urine will be controlled for the presence of microscopic haematuria before start of treatment 
with cyclophosphamide. 
7.8.3 Cardiotoxicity 
Cardiotoxicity is especially seen when administrating high doses of cyclophosphamide (120-
240 mg/kg body weight). An electrocardiogram will be performed before the start of 
treatment. Patients with known heart disease will not be included in the study. Necessary 
investigational procedures will be performed if the patients experiences symptoms from the 
cardiovascular system (e.g. chest pains, shortness of breath). 
7.8.4 Infertility 
Women receiving chemotherapeutic treatment have a risk of affecting their fertility in the 
future. 
7.8.5 Interactions 
Cyclophosphamide inhibits cholinesterase activity which increases the effect of depolarizing 
muscle relaxants such as suxamethoniumchloride. This can results in prolonged apnea when 
anesthetized. The anesthesiologist is to be informed if the patient has received treatment 
with cyclophosphamide within 10 days before treatment with suxamethoniumchloride. The 
combination should be avoided. 
The patient is to avoid eating grapefruit or drinking grapefruit juice since grapefruit contains a 
substance that can impair the activation of cyclophosphamide and thereby its effect. 
Transfusion related graft-versus-host reactions have been observed in patients receiving 
treatment with fludarabine phosphate after transfusion with non-radiated/non-filtered blood. 
Patients requiring blood transfusion within 6 months from treatment with fludarabine 
phosphate is therefore to receive only irradiated or filtered blood. An agreement with the 
blood bank at Herlev Hospital has been made so that there will be ordered irradiated blood 
only for these patients for 6 months after treatment. All blood in the Capital Region is filtered. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 72 of 96 
 
 
8 DATA HANDLING AND QUALITY ASSURANCE 
8.1  Data collection 
The main objective is to obtain those data required by the study protocol in a complete, 
accurate, legible and timely fashion. EDC will be used for recording data from each patient, 
into an eCRF. The eCRF is based on the EDC system IBM Clinical Development, which is a 
Software as a Service (SaaS) application compliant with 21 CFR Part 11 regulation provided 
by IBM. The data in the eCRFs should be consistent with the relevant source documents. It 
is the responsibility of the Investigator to ensure that these eCRFs are properly completed. 
The Investigator will sign the eCRF screen/pages to confirm that the information on each 
screen is accurate and complete. 
All people involved in the study will get appropriate training to handle the EDC system. 
The Investigator and authorised staff at the clinical site can add data to the eCRF and must 
keep the eCRF current to reflect patient status during the study. 
Only authorised access to the eCRF will be possible using encrypted username and 
password. Roles in the system are given according to functions. All tasks performed in the 
eCRF are logged in an audit trail. 
The eCRF will contain data ranges and validation checks to maintain an ongoing quality 
check of data entered. All data validation will be performed as part of the eCRF system. 
Medical history data and AEs will be coded according to Medical Dictionary for Regulatory 
Activities (MedDRA), and concomitant medication will be coded according to WHO drug 
dictionary. 
The data will be monitored electronically and source data verification (a comparison of the 
data in the eCRFs with the patients’ records at the hospital or practice, and other records 
relevant to the study) will take place at the site where all information within safety, tolerability 
and efficacy will be verified against the hospital patient records and other source documents. 
For patients who fail to meet eligibility criteria at screening the following must be collected in 
the eCRF: demographics, reason for not continuing in the study, SAE and AEs. 
8.2 Clinical data management 
Data management will be provided by 
 
Denmark. Clinical data management will be performed in accordance with applicable 
standards and data cleaning procedures and will comply with regulatory guidelines. 
8.3 Data analysis and reporting 
After the last patient has completed EoT (Step 2, Week 7), all data pertaining up to EoT 
period will be verified and locked for reporting of the results including preparation of a Clinical 
Study Report. The study will continue according to the protocol in the 15 months follow-up 
period until study completion.  

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 73 of 96 
 
An addendum to the Clinical Study Report reporting the results from the 15 months follow-up 
period will be prepared after the data generated during that period has been entered into the 
study database and the data has been verified and locked. 
8.4 Archiving 
The eCRFs and all medical records upon which the eCRFs are based (source data) must be 
kept for at least 15 years after completion of the study. Image carriers or other data carriers 
may be used for this purpose. 
The Investigator has to keep a written or electronic patient file for every patient participating 
in the study. 
8.5 Study monitoring 
Before the initiation of the study, a representative for Sponsor will visit the investigational site 
to: 
• 
Determine the adequacy of the facilities 
• 
Discuss with the Investigator(s) (and other personnel involved with the study) their 
responsibilities with regard to protocol adherence, and the responsibilities of Sponsor 
or its representatives 
During the study, a monitor will have regular contacts with the investigational site, including 
visits to: 
• 
Provide information and support to the Investigator(s) and discuss findings and any 
other relevant issues with the Investigator and his/her personnel 
• 
Confirm that facilities remain acceptable 
• 
Confirm that the investigational team is adhering to the protocol, that data are being 
accurately recorded in the eCRFs, and that investigational product accountability 
checks are being performed 
• 
Perform source data verification. Incorrect or missing entries into the eCRFs will be 
queried electronically and must be corrected immediately 
8.6 Source Data 
For all data recorded, the source document must be defined in a source document 
agreement or similar document at the study centre. There must only be one source defined 
at any time for any data element. Source data verification will require direct access to all 
original records for each patient (e.g. medical records). 
The following should as a minimum be added to the patient’s medical record: 
• 
Date(s) of conducting the informed consent process (date of enrolment) including 
date of provision of information 
• 
Eligibility criteria is met 
• 
Patient number 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 74 of 96 
 
• 
The fact that the patient is participating in a clinical study in soft tissue sarcoma 
including treatment with LTX-315 and adoptive T-cell therapy for up to 26 weeks and 
15 months follow-up period 
• 
Specification of the patient’s cessation in the study (e.g. premature withdrawal) 
• 
Other relevant medical information 
8.7 Audit and inspection 
During or after the study is completed, Sponsor representatives, regulatory authority 
representatives or Independent Ethics Committee (IEC) or Institutional Review Board (IRB) 
may wish to carry out an audit or inspection. These representatives must have the same 
access to study data and patient source data as the monitor. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 75 of 96 
 
 
9 STATISTICAL METHODS AND PLANNED ANALYSIS 
This section presents the principal features of the statistical analysis of this study. Further 
details will be given in a separate statistical analysis plan (SAP). 
Summary statistics of continuous variables will include: n, mean, median, standard deviation, 
minimum and maximum. Summary statistics of categorical variables will include number and 
percentage of patients, and, where applicable, the number of events in the corresponding 
group. 
Baseline is used as reference to Step 1, Week 1, Day 1, End of Step 1 as reference to Step 
2, Week 1  and EoT as reference to Step 2, Week 7 in the following. 
9.1 Analysis data sets and populations 
9.1.1 Full analysis set 
Patients will be included in the full analysis set (FAS) if they receive at least one injection of 
LTX-315. The FAS is by this definition also the safety analysis set. FAS will be used for 
evaluation of all efficacy and safety endpoints. The analyses and presentations will be 
performed for the FAS population unless specified otherwise. 
9.1.2 Per protocol analysis set 
Patients will be included in the per protocol (PP) analysis set, if they have followed the study 
protocol without any major violations which may affect the assessment of the efficacy 
endpoints. This will be used as supportive for evaluation of all efficacy endpoints. 
9.2 Randomisation (not applicable) 
This study will not employ randomisation as this a one armed study. 
9.3 Primary analyses 
9.3.1 Primary efficacy endpoint 
The primary efficacy endpoint is change in total T-cell level in tumour tissues from Baseline 
to end of Step 1  and will be presented by descriptive statistics using both FAS and PP 
analysis set. 
9.3.2 Primary safety endpoint 
The primary safety endpoint is  AEs related to LTX-315 or to the combination of LTX-315 and 
adoptive T-cell therapy from Baseline to EoT. 
Number of related events and number and percentage of patients reporting these events will 
be summarized by IMP relation, system organ class (SOC) and preferred term (PT), and by 
SOC and PT. 
AEs will be coded using the MedDRA dictionary, latest version at time of first patient first 
visit. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 76 of 96 
 
Number of events and number and percentage of patients reporting these events will be 
summarized and in addition by SOC and PT for: 
• 
TEAEs 
• 
SAEs 
• 
AEs leading to withdrawal 
• 
AEs leading to death 
• 
Severity of AEs by CTCAE grade 
All data will be listed by patient. 
9.4 Secondary analyses 
9.4.1 Total T-cell level in tumour tissues 
The change in total T-cell level in tumour tissues from Baseline to EoT will be presented by 
descriptive statistics using both FAS and PP analysis set. 
9.4.2 Total CD8+ T-cell level 
The change in the numbers of CD8+ T-cells in tumour tissues from Baseline to end of Step 1 
and EoT will be presented by descriptive statistics using both FAS and PP analysis set. 
9.4.3 Anti-tumour effect 
The anti-tumour effect is assessed by 
• 
Objective Response Rate (ORR) 
• 
Clinical Benefit Rate (CBR) 
• 
Progression free survival (PFS) 
and will be presented using both FAS and PP analysis set as described below. 
9.4.3.1 
Objective response rate 
ORR is defined as proportion of patients who according to RECIST 1.1 criteria (see Appendix 
IV) have acheived CR or PR. ORR at EoT and up to 15 months  after EoT will be presented 
by descriptive statistics. 
The objective tumour response (CR, PR, SD, PD) according to RECIST 1.1 criteria verified 
by imaging technique will be listed by patient and summarized by visit. 
In addition, the best overall tumour response according to RECIST 1.1 criteria from 
screening until PD, death, or 15 months  after EoT, whichever comes first will be listed and 
summarized. 
9.4.3.2 
Clinical benefit rate 
CBR is defined as proportion of patients who according to RECISIT 1.1 criteria have 
achieved CR, PR or SD. CBR at EoT and up to 15 months  after EoT will be presented by 
descriptive statistics. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 77 of 96 
 
9.4.3.3 
Progression free survival 
PFS is defined as the time in days from Baseline until PD or death. PFS will be estimated 
using the Kaplan-Meier method. A patient who leaves the study without evidence of 
progression or death will be censored at the last tumour assessment date. Progression free 
patients will be censored 15 months  after EoT. Plots including the Kaplan-Meier curve and 
median survival time will be presented. 
9.5 Exploratory analyses 
The immunological response parameters are described in Section 7.4.3 Details will be 
described in a separate immunology protocol. 
9.5.1 Tumour-antigen specific T-cells 
Identification of tumour-antigen specific T-cells in tumour tissue and PBMCs by MHC 
multimer–based screens, ELISPOT and flowcytometry analysis of cytokines including IFNγ 
and TNF⍺, will be described in a separate immunological report. 
9.5.2 Changes in immunologicical parameters 
Changes in immunological parameters from Baseline to 15 months  after EoT will be 
described in a separate immunological report. 
9.6 Other assessments 
The following assessments will be listed or presented by descriptive statistics: ECG, vital 
signs, blood and urine clinical safety laboratory tests, serology, BAS test, physical 
examination, height, weight, ECOG performance status, full tumour assessment, renal 
function evaluation. 
The overall survival 15 months  after EoT will be estimated and presented using the Kaplan-
Meier method as described for PFS. 
9.7 Sample size determination 
This is a one armed study without sample size calculation. 6 patients completing Step 1 are 
planned to be enrolled in the study. 
9.8 Handling of missing values 
Missing data for time to event endpoints is handled by time to event methods. No imputation 
of missing data is planned for other endpoints. 
10 REGULATORY AND ADMINISTRATIVE PROCEDURES 
10.1 
Ethics Committee and good clinical practice 
This study has been designed in accordance with the Declaration of Helsinki (52). 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 78 of 96 
 
The study will be managed and conducted according to the study protocol, the latest 
international (ICH) guidelines for Good Clinical Practice (GCP) (24) and applicable regulatory 
requirements. A copy of these guidelines can be found in the Investigator’s Site File. 
10.1.1 
Ethics committee and regulatory authority review 
The final study protocol, including the final version of the written patient information sheet 
and informed consent form, must be approved or given a favourable opinion in writing by an 
IEC or IRB as appropriate. The Investigator must submit a copy of the written approval to the 
Sponsor before he or she can enrol any patient into the study. 
The appropriate regulatory authority must be notified of/approve the clinical study as 
required. 
10.2 
Changes to the conduct of the study or protocol 
10.2.1 
Protocol amendments 
Changes in the study protocol must take the form of written study protocol amendments. 
These will require the approval of all signatories of the final protocol. Any amendments to the 
protocol which affect the patient, e.g. changes in procedures/assessments or matters relating 
to patient safety, require a favourable opinion approval from the IEC for the study centre 
concerned, prior to implementation. Changes of a purely administrative nature should be 
notified to the IEC, but do not require formal approval. Any amendment affecting the patient 
requires further informed consent from each patient before implementation. 
10.2.2 
Protocol deviations 
Deviations from the study protocol, especially the prescription of doses not scheduled in the 
study protocol, other modes of administration, other indications, and longer treatment periods 
are not permissible (except in an emergency). 
10.3 
Informed consent process 
The consent of the patient to participate in the study has to be given in writing prior to 
enrolment. The patient must be given sufficient time to consider the study before deciding 
whether to participate. Each patient must be informed that participation in the study is 
voluntary and that he/she may withdraw from the study at any time and that withdrawal of 
consent will not affect his/her subsequent medical treatment or relationship with the 
Investigator. 
The consent must be signed and personally dated by the patient and by the Investigator or a 
sub-Investigator designated by the Investigator to conduct the informed consent discussion. 
The signed and dated declaration of informed consent will remain at the investigator’s site 
and must be safely archived by the investigators so that the forms can be retrieved at any 
time for monitoring, auditing and inspection purposes. A copy of the signed and dated 
information and consent should be provided to the patient prior to participation and a copy 
maintained in the patient’s source documents if there is a separate archive file for the 
informed consent documents for the study. 
After review of a patient information sheet and oral information to the patient and the 
provision of written informed consent, study specific screening procedures will be initiated. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 79 of 96 
 
10.4 
Investigator’s responsibilities 
The investigator shall be responsible for ensuring that the study is performed in accordance 
with the protocol and the current revision of the Declaration of Helsinki (52), as well as with 
the Note for Guidance on Good Clinical Practice (24) and applicable regulatory requirements. 
These documents state that the informed consent of the patients is an essential precondition 
for participation in the clinical study. 
10.4.1 
Training of staff 
The Investigator must maintain a record of all individuals involved in the study (medical, 
nursing and other staff). He or she will ensure that appropriate training relevant to the study 
is given to all these staff, and that they will receive any new information of relevance to the 
performance of this study. 
10.5 
Patient privacy 
The Investigator must ensure that patient’s confidentiality will be maintained. eCRFs or other 
documents submitted to the Sponsor should only identify patients by their patient number 
and study number. The Investigator should keep a separate log of patient codes and 
names. Documents not for submission to the Sponsor, e.g. patient’s completed informed 
concent form, should be retained by the Investigator in strict confidence. 
The Investigator is required to record primary efficacy and safety data, concomitant 
medication and patient progress in the patient’s file/notes/medical record. 
The patient’s medical records will be reviewed by the study monitor and possibly by other 
Sponsor personnel or regulatory authorities, to verify adequate source documentation, 
accuracy and completeness of eCRFs. The review will be conducted with strict adherence to 
professional standards of confidentiality. 
All patients screened for the study will be entered chronologically on the Patient Screening 
Log at the initial visit. An explanation for exclusion from admission to the protocol is to be 
provided on the Patient Screening Log. 
10.6 
Insurance and liability 
Lytix Biopharma has implemented No Fault Compensation Insurance for Clinical Trials with 
Howden Insurance Brokers Inc. Liability for study induced injury will be covered according to 
local requirements.  
10.7 
Premature study termination criteria 
The study centre or the whole study may be discontinued at the discretion of the Principal 
Investigator or the Sponsor in the event of any of the following: 
• 
Occurrence of either SUSAR or an increase in known adverse drug reactions which 
impose an unacceptable safety concern 
• 
Medical or ethical reasons affecting the continued performance of the study 
• 
Difficulties in the recruitment of patients 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 80 of 96 
 
• 
Cancellation of drug development 
10.8 
End of study 
The end of the study is defined as the last visit of the last patient included in the study. The 
competent authorities and IEC/IRB will be notified about the end of the study. 
10.9 
Publication of results 
All data generated from the conduct of this study is the sole property of Lytix Biopharma. 
Regulatory agencies and authorities will have unrestricted access to the data as required by 
applicable guidance, regulation and law. Lytix Biopharma retains the exclusive right to decide 
when to publish data from this study. When Lytix Biopharma decides to publish the results of 
this study in a scientific journal and/or at a scientific meeting then the following stipulations 
will apply:  
• 
The authorship of this publication will include the Principal Investigator and her/his 
team, and representatives for Lytix Biopharma. 
The published international guidelines for authorship (25) will be adhered to; i.e., ‘All persons 
designated as authors should qualify for authorship. Each author should have participated 
sufficiently in the work to take public responsibility for the content.’ 
All draft publications, including abstracts or detailed summaries of any proposed 
presentations, must be submitted to the Sponsor at the earliest practicable time for review, 
but at any event not less than 30 days before submission or presentation unless otherwise 
set forth in the clinical trial agreement. Sponsor shall have the right to delete any confidential 
or proprietary information contained in any proposed presentation or abstract and may delay 
publication for up to 60 days for purposes of filing a patent application. 
The information developed during the conduct of this clinical study is confidential and may 
only be disclosed as authorised in writing by Lytix Biopharma. 
After the conclusion of the study, a report will be written which will include a descriptive 
statistical analysis and an appraisal of the results from a medical viewpoint. This report will 
be based on the items listed in this study protocol. Any publication of the results, either in 
part or in total (articles in journals or newspapers, oral presentation, etc.) by the 
Investigators, requires the approval of Lytix Biopharma. 
Sponsor commits to communicate and make available for public disclosure, the results of the 
clinical study regardless of outcome. Public disclosure implies publication in scientific 
journals, abstract submission for scientific meetings and other types of disclosure (e.g. via 
cinicaltrials.gov). 
10.10 Confidentiality 
The investigator must agree to maintain the confidentiality of the study at all times and must 
not reveal information relating to the Investigator’s Brochure, protocol, eCRFs or associated 
documents to unauthorised third parties. 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 81 of 96 
 
11 REFERENCES 
1 
Adams-Graves P, Kedar A, Koshy M, Steinberg M, Veith R, Ward D, et al. RheothRx 
(poloxamer 188) injection for the acute painful episode of sickle cell disease: a pilot 
study. Blood. 1997 Sep;90(5):2041–6.  
2 
Andersen RS, Thrue CA, Junker N, Lyngaa R, Donia M, Ellebæk E, et al. Dissection 
of T-cell antigen specificity in human melanoma. Cancer Res. 2012 Apr;72(7):1642–
50. 
3 
Andersen R et al. Long-Lasting Complete Responses in Patients with Metastatic 
Melanoma after Adoptive Cell Therapy with Tumor-Infiltrating Lymphocytes and an 
Attenuated IL2 Regimen. CCR 2016; 22(15):3734-45 
4 
Antony, P. et al. CD8+ T-cell immunity against a tumor/self-antigen is augmented by 
CD4+ T helper cells and hindered by naturally occurring T regulatory cells. J. 
Immunol. 174, 2591–601 (2005). 
5 
Besser, M. J. et al. Minimally cultured or selected autologous tumor-infiltrating 
lymphocytes after a lympho-depleting chemotherapy regimen in metastatic melanoma 
patients. J. Immunother. 32, 415–23 (2009) 
6 
Besser MJ, Shapira-Frommer R, Itzhaki O, Treves AJ, Zippel D, Levy D, et al. 
Adoptive Transfer of Tumor Infiltrating Lymphocytes in Metastatic Melanoma 
Patients: Intent-to-Treat Analysis and Efficacy after Failure to Prior Immunotherapies. 
Clin cancer Res. 2013 May 
7 
D’Angelo SP, Shoushtari AN, Agaram NP, Kuk D, Qin L, Carvajal RD, et al. 
Prevalence of tumor-infiltrating lymphocytes and PD-L1 expression in the soft tissue 
sarcoma microenvironment. Hum Pathol. Elsevier Inc.; 2015;46(3):357–65  
8 
Danish Sarcoma Database. Annual report. 2013 
9 
Dong H, Strome SE, Salomao DR, Tamura H, Hirano F, Flies DB, et al. Tumor-
associated B7-H1 promotes T-cell apoptosis: a potential mechanism of immune 
evasion. Nat Med. 2002;8(8):793–800 
10 Donia, M. et al. Characterization and comparison of ‘Standard’ and ‘Young’ tumor 
infiltrating lymphocytes for adoptive cell therapy at a Danish Translational Research 
Institution. Scand. J. Immunol. 157–167 (2011) 
11 Donia, M. et al. Methods to Improve Adoptive T-Cell Therapy for Melanoma: IFN-γ 
Enhances Anticancer Responses of Cell Products for Infusion. J. Invest. Dermatol. 
(2012). doi:10.1038/jid.2012.336 
12 Donia M, Andersen R, Ellebaek E, Iversen TZ, Andersen MH, Straten PT, et al. 
Adoptive T-cell therapy (ACT) with TILs for metastatic melanoma: Clinical responses 
and durable persistence of anticancer responses in peripheral blood. J Clin Oncol. 
2013;31:suppl; abstr 3028. 
13 Dudley, M. E. et al. A phase I study of nonmyeloablative chemotherapy and adoptive 
transfer of autologous tumor antigen-specific T lymphocytes in patients with 
metastatic melanoma. J. Immunother. 25, 243–51 (2002) 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 82 of 96 
 
14 Dudley, M. E. et al. CD8+ enriched ‘young’ tumor infiltrating lymphocytes can mediate 
regression of metastatic melanoma. Clin. cancer Res. 16, 6122–31 (2010) 
15 Eike et al, Zhou et al Oncotarget 2016 
16 Eisenhauer, E.A. et al. New response evaluation criteria in solid tumours: Revised 
RECIST guidelines (version 1.1). European Journal of Cancer. 2009; 45: 228-47 
17 Ellebaek, E. et al. Adoptive cell therapy with autologous tumor infiltrating lymphocytes 
and low-dose Interleukin-2 in metastatic melanoma patients. J. Transl. Med. 10, 169 
(2012) 
18 ESMO / The European Sarcoma Network Working Group. Soft tissue and visceral 
sarcomas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. 
Ann Oncol (2014) 25 (suppl 3): iii102-iii112. 
19 Fludara® SmPC 2011 
 
20 Gattinoni, L. et al. Removal of homeostatic cytokine sinks by lymphodepletion 
enhances the efficacy of adoptively transferred tumor-specific CD8+ T-cells. J. Exp. 
Med. 202, 907–12 (2005) 
21 Gattinoni L, Powell DJ, Rosenberg S a, Restifo NP. Adoptive immunotherapy for 
cancer: building on success. Nat Rev Immunol. 2006 May;6(5):383–93 
22 Goff, S. L. et al. Tumor infiltrating lymphocyte therapy for metastatic melanoma: 
analysis of tumors resected for TIL. J. Immunother. 33, 840–7 (2010) 
23 Hancock, R. Cationic peptides: effectors in innate immunity and novel antimicrobials. 
Lancet Infectious Diseases. 2001; 1:156-64. 
24 ICH-GCP. Integrated Addendum to ICH E6(R1): Guideline for Good Clinical Practice 
E6(R2). 2016. 
25 ICMJE. International Committee of Medical Journal Editors. Uniform requirements for 
manuscripts submitted to biomedical journals. JAMA.1997 Mar 19;277(11):927-34. 
26 Joseph, R. W. et al. Impact of clinical and pathologic features on tumor-infiltrating 
lymphocyte expansion from surgically excised melanoma metastases for adoptive T-
cell therapy. Clin. cancer Res. 17, 4882–91 (2011) 
27 Keilholz, U. et al. Interferon alfa-2a and interleukin-2 with or without cisplatin in 
metastatic melanoma: a randomized trial of the European Organization for Research 
and Treatment of Cancer Melanoma Cooperative Group. J. Clin. Oncol. 15, 2579–88 
(1997)  
28 LTX-315 Investigator’s Brochure, version 13.0 2020 
29 Marabelle, A., et al. Intratumoral immunization: a new paradigm for cancer. Therap. 
Clin. Cancer Res. 2014; 20:1747-56 
30 Ngok FK, Mitsuyasu RT, Macpherson JL, Boyd MP, Symonds GP, Amado RG. 
Clinical gene therapy research utilizing ribozymes: application to the treatment of 
HIV/AIDS. Methods Mol Biol. 2004 Jan;252:581–98. 
31 Nelson, B. H. & Willerford, D. M. Biology of the interleukin-2 receptor. Adv. Immunol. 
70, 1–81 (1998)  

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 83 of 96 
 
32 Neulasta. European public assessment report (EPAR) summary for the public. 2011 
33 Nielsen M, et al. Preclinical development of tumor-infiltrating lymphocyte (TIL) based 
adoptive cell transfer (ACT) immunotherapy for patients with sarcoma and the 
potential benefit of anti-CD137 stimulation. Journal of Clinical Oncology 2017 
35:15_suppl, e14545-e14545 
34 Orringer EP, Casella JF, Ataga KI, Koshy M, Adams-Graves P, Luchtman-Jones L, et 
al. Purified poloxamer 188 for treatment of acute vaso-occlusive crisis of sickle cell 
disease: A randomized controlled trial. JAMA. 2001 Nov;286(17):2099–106  
35 Papo, N. and Shai, Y. Host defense peptides as new weapons in cancer treatment. 
Cell Mol Life Sci. 2005 Apr;62(7-8):784-90 
36 Pilon-Thomas S, Kuhn L, Ellwanger S, Janssen W, Royster E, Marzban S, et al. 
Efficacy of adoptive cell transfer of tumor-infiltrating lymphocytes after lymphopenia 
induction for metastatic melanoma. J Immunother. 2012;35(8):615–20 
37 Proleukin® SmPC 2017 
38 Radvanyi LG, Bernatchez C, Zhang M, Fox PS, Miller P, Chacon J, et al. Specific 
Lymphocyte Subsets Predict Response to Adoptive Cell Therapy Using Expanded 
Autologous Tumor-Infiltrating Lymphocytes in Metastatic Melanoma Patients. Clin 
Cancer Res. 2012 Oct;18(24):6758–70.  
39 Robbins, P. F. et al. A Pilot Trial Using Lymphocytes Genetically Engineered with an 
NY-ESO-1-Reactive T-cell Receptor: Long-term Follow-up and Correlates with 
Response. Clin. Cancer Res. 21, 1019–1027 (2015).  
40 Rosenberg, S. a et al. Durable complete responses in heavily pretreated patients with 
metastatic melanoma using T-cell transfer immunotherapy. Clin. cancer Res. 17, 
4550–7 (2011) 
41 Schwinger W, Klass V, Benesch M, Lackner H, Dornbusch HJ, Sovinz P, et al. 
Feasibility of high-dose interleukin-2 in heavily pretreated pediatric cancer patients. 
Ann Oncol. 2005;16(7):1199–206  
42 Sendoxan® SmPC 2016 
43 Somerville, R. P. T., Devillier, L., Parkhurst, M. R., Rosenberg, S. a & Dudley, M. E. 
Clinical scale rapid expansion of lymphocytes for adoptive cell transfer therapy in the 
WAVE® bioreactor. J. Transl. Med. 10, 69 (2012)  
44 Sorbye, S. W. et al. Prognostic impact of lymphocytes in soft tissue Sarcomas. PLoS 
One 6, 1–10 (2011) 
45 Stiller CA, Trama A, Serraino D et al. Descriptive epidemiology of sarcomas in 
Europe: report from the RARECARE project. Eur J Cancer 2013; 49: 684–695 
46 Tap w et al. Olaratumab and doxorubicin versus doxorubicin alone for treatment of 
soft-tissue sarcoma: an open-label phase 1b and randomised phase 2 trial. 2016 
Lancet; 388: 448-497. 
47 Tumour Infiltrating Lymphocytes (TILs) Investigational Medicinal Product Dossier. 
Version 1.0. 2017 

 
 
Protocol C17-315-04 
 
Protocol Version 3.0, 31-Mar-2020 
Page 84 of 96 
 
48 Tran, K. Q. et al. Minimally cultured tumor-infiltrating lymphocytes display optimal 
characteristics for adoptive cell therapy. J. Immunother. 31, 742–51 (2008) 
49 Wick D, Webb JR, Nielsen JS, Martin SD, Kroeger DR, Milne K, et al. Surveillance of 
the tumor mutanome by T-cells during progression from primary to recurrent ovarian 
cancer. Clin cancer Res. 2014 Mar;20(5):1125–34 
50 Wiemann B, Starnes CO. Coley’s toxins, tumor necrosis factor and cancer research: 
A historical perspective. Pharmacology & Therapeutics. 1994. p. 529–64  
51 E.A. Eisenhauera, P. Therasseb, et al. New response evaluation criteria in solid 
tumours: revices RECIST guideline (version 1.1). Eur J of Cancer 45. 2009: 228-247 
52 WMA. World Medical Association. Declaration of Helsinki - Ethical Principles for 
Medical Research Involving Human Subjects. 2013. Adopted by the WMA General 
Assembly in Helsinki (1964) and as amended by the WMA General Assembly. 
53 Zasloff, M. Antimicrobial peptides in health and disease. N Engl J Med. 2002; 
347(15):1199-200 
 
 
 
 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 85 of 96 
 
12 APPENDIX I 
PROHIBITED MEDICATIONS 
The following list is not exhaustive. When in doubt, contact the Medical Monitor. 
Immunosuppressive agents 
Glucocorticoids*, e.g. 
• 
dexamethasone 
• 
prednisone 
• 
cortisol 
Calcineurin inhibitors, e.g. 
• 
Tacrolimus 
• 
Cyclosporins 
Anti-proliferative and anti-metabolic drugs, e.g. 
• 
Sirolimus 
• 
Everolimus 
• 
Azathioprine 
• 
Mycophenolate Mofentil (CellCept®) 
• 
Glatiramer acetate 
• 
Methotrexate 
Monoclonal antibodies, e.g. 
• 
Alefacept 
• 
Basiliximab 
• 
TNF binding proteins 
* See exceptions for steroid concomitant therapy (see Section 6.4) 
 
Immunostimulants 
Levamisole 
Thalidomide 
Interferons 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 86 of 96 
 
13 APPENDIX II 
EFFECTIVE METHODS OF BIRTH CONTROL 
Acceptable methods of contraception include: 
• 
combined (oestrogen and progestogen containing) hormonal contraception 
associated with inhibition of ovulation (oral, intravaginal, transdermal) 1 
• 
progestogen-only 
hormonal 
contraception 
associated 
with 
inhibition 
of 
ovulation1(oral, injectable, implantable) 2 
• 
intrauterine device (IUD) 2 
• 
intrauterine hormone-releasing system (IUS) 2 
• 
bilateral tubal occlusion 2 
• 
vasectomised partner 2,3 
• 
sexual abstinence 4 
 
1. 
Hormonal contraception may be susceptible to interaction with the IMP, which may reduce the efficacy of 
the contraception method.  
2. 
Contraception methods in this context are considered to have low user dependency. 
3. 
Vasectomised partner provided that partner is the sole sexual partner of the WOCBP study participant 
and that the vasectomised partner has received medical assessment of the surgical success.  
4. 
Sexual abstinence is considered a high effective method if defined as refraining from heterosexual 
intercourse during the entire period of risk associated with the study treatments. The reliability of sexual 
abstinence need to be evaluated in relation to the duration of the duration of the clinical study and the 
preferred usual lifestyle of the patient.  

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 87 of 96 
 
14 APPENDIX III 
FEBRIL NEUTROPENI UNDER T-CELLE TERAPI 
Neutropeni (granulocytopeni) neutrofiltal < 0,5 mia./l 
Feber = tp > 38º C (rektalt > 38,5º C) 
OBS: Begrundet mistanke eller påvist infektion + neutropeni + feber = sepsis! 
 
Patienter der får T-celle terapi udvikler forventeligt neutropeni fra ca. dag 0 og 7 dage frem 
(kan variere betydeligt) og de udvikler forventeligt febrilia ligeledes dag 0 (efter T-celle 
infusion eller start af IL-2) indtil ca. 1 døgn efter ophør med IL-2. 
Bivirkninger til IL-2 ligner det kliniske billede ved sepsis og en eventuelt samtidig 
infektion/sepsis kan derfor maskeres under IL-2 behandlingen. Der er derfor indikation for at 
indlede empirisk behandling med antibiotika hos patienter med febril neutropeni under T-
celle terapi. 
 
Fremgangsmåde 
Diagnostik 
1. Objektiv us 
2. Dyrkning for bakterier og svamp fra 
• 
Blod (dyrkning fra CVK + evt. perifert) 
• 
Urin 
• 
Ved symptomer og/eller objektive fund endvidere: ekspektorat/svælgpodning, 
podning fra kateter, fæces for tarmpatogene og evt. clostridium difficile, 
podning fra sår 
3. Rtg thorax (på stuen; kan udelades initialt (dag 0) hvis der ikke er mistanke om 
pneumoni ) 
4. CRP, hæmatologi, kreatinin/væsketal, levertal, DIC-prøver ved svær sepsis/septisk 
shock. 
 
Behandling 
Initialt 
• 
Piperacillin+tazobactam (Tazocin) 4 g x 3 i.v. 
• 
Ved penicillin-allergi: meropenem (Meronem) 1 g x 3 i.v. 
Ved klinisk påvirket patient og/eller mistanke om infektion (septisk shock/svær sepsis) kan 
der suppleres med gentamycin (Hexamycin®) 5 mg/kg x 1 i.v. 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 88 of 96 
 
OBS forsigtighed da kombinationen af gentamicin og IL-2 kan medføre øget risiko for 
nefrotoxicitet. Der gives max 3 doser gentamicin. 
Ved nyreinsufficiens eller anden risiko for nefrotoxicitet (fx tidligere cisplatinbehandling) kan 
der i stedet anvendes ciprofloxacin (Ciproxin®) 400 mg x 2 i.v., ved svær nyreinsufficiens 
(GFR < 30 ml/min) 400 mg x 1 i.v. 
Ved positivt dyrkningsfund foretages relevant ændring jævnfør svar. Gram negativ dækning 
bør dog som regel bibeholdes neutropeniperioden ud. 
Evaluering under IL-2 behandling (dag 0-5) 
1. Ved klinisk stabil patient med forventelige bivirkninger til IL-2 fortsættes antibiotisk 
behandling uændret indtil patienten har været afebril i minimum 2 døgn og neutrofile 
er > 0,5 x 109/l. 
 
2. Ved klinisk forværring under IL-2 og mistanke om infektion (septisk shock/svær 
sepsis) foretages grundig objektiv us. og initiale undersøgelser gentages. 
 
Vigtige overvejelser: 
• 
Lungeinfiltrater: HRCT-thorax til diagnostik af evt. svampe-pneumoni. Endvidere 
evt. BAL, evt. ekspektorat til D+R og undersøgelse for Legionella (PCR) og 
Legionella antigen i urin (LUT), evt. mundskyl for pneumocyster. Evt. tillæg af 
azithromycin (Zitromax®) 500 mg x 1 i.v. alternativt ciproxin 400 mg x 2 i.v. i 7-10 
dage til dækning af Legionella/mycoplasma. 
• 
I.v. kateter-infektion: In situ med rødme ved indstikssted: Tillæg af vancomycin 1 
g x 2 i.v., dosis-reduktion ved nyreinsufficiens, hvor der endvidere bør udføres 
regelmæssige serum vancomycin koncentrationsbestemmelser. Ved tunnel-
infektion med rødme, ømhed langs tunnel og pussekretion fra indstikssted bør 
kateter endvidere fjernes. 
 
Normal obj. us: skift af initiale behandling til meropenem (Meronem) 1 g x 3 i.v. 
Evaluering ved fortsat febrilia >1 døgn efter ophør med IL-2 
Febrilia udløst af IL-2 aftager typisk indenfor det første døgn efter afsluttet IL-2 behandling. 
Ved klinisk påvirket patient, evt. med stigende tp. eller hvis tp. ikke er faldende 1-2 døgn efter 
ophør med IL-2 gentages grundig obj. us, initiale undersøgelser og vigtige overvejelser. 
Nedenstående overvejes ved langvarig febril neutropeni efter afsluttet IL-2 
• 
Fornyet 
grundig 
obj. 
us 
omfattende 
mundslimhinde 
(især 
mhp. 
svampekolonisering), genitalia externa og rektal inspektion. 
• 
Gentagelse af initiale undersøgelser suppleret med aspergillus galactomannan 
antigen (SSI - sendes via KMA), CMV-antigen (SSI- sendes via KMA) og (ved 
normal rtg. af thorax) HRCT-scanning af thorax og UL, alternativt CT af lever/milt 
(aspergillus 
i 
lunger, 
dissemineret 
candidiasis 
i 
lever/milt). 
Systemisk 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 89 of 96 
 
svampebehandling 
bør 
overvejes 
især 
ved 
påvirket 
patient 
med 
svampekolonisering af ex. mundhule. 
 
Behandlingsophør 
Antibiotika fortsættes indtil patienten har været afebril i minimum 2 døgn og neutrofile er > 
0,5 x 109/l. Dog gives altid minimum 7 døgns behandling. 
Er granulocyt-tallet stigende og patienten afebril kan behandlingen evt. ændres til peroral 
antibiotika, fx tabl. Penicillin 1MIE x 3 p.o. + tabl. Ciprofloxacin 500 mg x 2 peroralt. Ved 
penicillinallergi erstattes penicillin af Roxithromycin-dosis: 150 mg x 2 peroralt. 
Tilpasning af antibiotika ved positive dyrkningsfund 
Pseudomonas aeruginosa: Tazocin® 4 g x 3 i.v. i kombination med gentamycin i.v. 5 mg/kg x 
1 til granulocyttal > 0,5 mia./l. Ved nyrefunktionsnedsættelse erstattes gentamycin af 
ciprofloxacin 400 mg x 2 i.v., se ovenfor. 
Koagulase negative stafylokokker (overvej dog evt. forurening, ex. ved påvisning i 1 af 5 
bloddyrkningskolber eller i ekspektorat hos patient uden pneumoni-symptomer): Vancomycin 
(Vancomycin®) 1 g x 2 i.v. 
Clostridium difficile: Vancomycin® 125 mg x 4 p.o. i 10-14 dage (min. 10 dage). Ved påvirket 
patient (sepsis/ileus) Vancomycin® 500 mg x 4 kombineret med metronidazol (Metronidazol®) 
500 mg x 3 i.v., samt evt. rektal indhældning af 500 mg vancomycin i 100 ml 
saltvandsopløsning hver 4.-12. time. 
ESBL: gram negativ bakterie med extended spectrum beta-laktamase: Meropenem 
(Meronem®) 1 g x 3 i.v. Ved tidligere dokumenteret ESBL bærerskab bør patienten 
behandles initialt med Meropenem ved feber såfremt der ikke er andet oplagt fokus hvor 
ESBL producerende stamme er usandsynlig. 
Stafylokokkus aureus: Dicloxacillin (Diclocil®) 1 g x 4 i.v. Patient bør vurderes for evt. 
endocarditis. 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 90 of 96 
 
15 APPENDIX IV 
TUMOUR ASSESSMENT CRITERIA BY RECIST  
Anti-tumour activity measured as shrinkage of the tumours is a secondary endpoint in this 
study. The Response Evaluation Criteria in Solid Tumors (RECIST)  will be used to evaluate 
tumour response. (51). 
 
Baseline documentation of “Target” and “Non-Target” lesions 
• 
All measurable lesions up to a maximum of five lesions per organ and 10 lesions in total, 
representative of all involved organs should be identified as target lesions and recorded 
and measured at baseline.  
• 
Target lesions should be selected on the basis of their size (lesions with the longest 
diameter) and their suitability for accurate repeated measurements (either by imaging 
techniques or clinically).  
• 
A sum of the longest diameter (LD) for all target lesions will be calculated and reported as 
the baseline sum LD. The baseline sum LD will be used as reference by which to 
characterize the objective tumor. 
• 
All other lesions (or sites of disease) should be identified as non-target lesions and 
should also be recorded at baseline. Measurements of these lesions are not required, but 
the presence or absence of each should be noted throughout follow-up.  
Definition of Measurable lesions 
 - Lesions that can be accurately measured in at least one dimension with longest diameter  
≥10 mm with CT scan. 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. 
Definition of Non-measurable lesions 
 - All other lesions, including small lesions (longest diameter <10 mm with CT scan), 
 
Evaluation of target lesions 
* Complete Response (CR): 
Disappearance of all target lesions 
* Partial Response (PR): 
At least a 30% decrease in the sum of the LD of target lesions, 
taking as reference the baseline sum LD 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 91 of 96 
 
Evaluation of non-target lesions 
* Complete Response (CR): 
Disappearance of all non-target lesions and normalization of tumor 
marker level 
* Incomplete Response/          
Stable Disease (SD):  
Persistence of one or more non-target lesion(s) or/and maintenance of 
tumor marker level above the normal limits 
* Progressive Disease (PD): 
Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions (1)  
(1) Although a clear progression of “non target” lesions only is exceptional, in such 
circumstances, the opinion of the treating physician should prevail.  
 
 
Evaluation of best overall response 
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for PD the smallest measurements 
recorded since the treatment started). In general, the patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria  
 
 
 
 
 
 
 
 
 
 
* Progressive Disease (PD): 
At least a 20% increase in the sum of the LD of target lesions, 
taking as reference the smallest sum LD recorded since the 
treatment started or the appearance of one or more new lesions 
* Stable Disease (SD): 
Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum 
LD since the treatment started 
Target lesions 
Non-Target lesions 
New Lesions 
Overall response 
CR 
CR 
No 
CR 
CR 
Incomplete 
response/SD 
No 
PR 
PR 
Non-PD 
No 
PR 
SD 
Non-PD 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 92 of 96 
 
 
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be classified as having 
“symptomatic deterioration”. Every effort should be made to document the objective 
progression even after discontinuation of treatment.  
In some circumstances it may be difficult to distinguish residual disease from normal tissue. 
When the evaluation of complete response depends on this determination, it is 
recommended that the residual lesion be investigated (fine needle aspirate/biopsy) to confirm 
the complete response status. 
 
Duration of overall response 
The duration of overall response is measured from the time measurement criteria are met for 
CR or PR (whichever status is recorded first) until the first date that recurrence or PD is 
objectively documented, taking as reference for PD the smallest measurements recorded 
since the treatment started. 
 
Duration of stable disease 
SD is measured from the start of the treatment until the criteria for disease progression are 
met, taking as reference the smallest measurements recorded since the treatment started.  
 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 93 of 96 
 
16 APPENDIX V 
ECOG PERFORMANCE STATUS 
 
ECOG PERFORMANCE STATUS 
Grade 
Performance Status 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light house work, office work 
2 
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 
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours 
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or 
chair 
5 
Dead 
 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 94 of 96 
 
17 APPENDIX VI 
FURTHER GUIDANCE ON THE DEFINITION OF A SERIOUS ADVERSE EVENT, 
CAUSALITY AND OUTCOME 
Life-threatening 
‘Life-threatening’ means that the subject was at immediate risk of death from the AE as it 
occurred or it is suspected that use or continued use of the product would result in the 
subject’s death. ‘Life-threatening’ does not mean that had an AE occurred in a more severe 
form it might have caused death (i.e. hepatitis that resolved without hepatic failure). 
Hospitalisation 
Out-subject treatment in an emergency room is not in itself a SAE, although the reasons for it 
may be (e.g. bronchospasm, laryngeal oedema). Hospital admissions and/or surgical 
operations planned before or during a study are not considered AEs if the illness or disease 
existed before the subject was enrolled in the study, provided that it did not deteriorate in an 
unexpected way during the study. 
Important medical event or medical intervention 
Medical and scientific judgement should be exercised in deciding whether a case is serious 
in a situation where important medical events may not be immediately life-threatening or 
result in death, hospitalisation, disability or incapacity, but may jeopardise the subject or may 
require medical intervention to prevent one or more outcomes listed in the definition of 
serious. These should usually be considered as serious. Examples of such events are: 
• 
Angio-oedema not severe enough to require intubation but requiring iv. 
hydrocortisone treatment 
• 
Hepatotoxicity caused by paracetamol (acetaminophen) overdose requiring treatment 
with N-acetylcysteine 
• 
Intensive treatment in an emergency room or at home for allergic bronchospasm 
• 
Blood dyscrasias (e.g. neutropenia or anemia requiring blood transfusion, etc) or 
convulsions that do not result in hospitalisation 
• 
Development of drug dependency or drug abuse 
Causality 
Not related: There is probably no relationship to the study medication or there is a 
reasonable alternative explanation. AEs assessed as “Unlikely related” is categorised as not 
related. 
Related: Anything that does not fall into the “not related” category. Any event for which a 
causal relationship cannot be excluded should be considered as related. 
The following factors should be considered when deciding if there is a “reasonable 
possibility” that an AE may have been caused by the investigational product: 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 95 of 96 
 
• 
Time course of events and exposure to suspect drug. Has the patient actually 
received the suspect drug? Did the AE occur in a reasonable temporal relationship to 
the administration of suspect drug? 
• 
Consistency with known drug profile. Was the AE consistent with the previous 
knowledge of the suspect drug (pharmacology and toxicology) or drugs of the same 
pharmacological class? OR could the AE be anticipated from its pharmacological 
properties? 
• 
Dechallenge experience. Did the AE resolve or improve on stopping or reducing the 
dose of the suspect drug? 
• 
No alternative cause. The AE cannot be reasonably explained by another aetiology, 
such as the underlying disease, other drugs, other host or environmental factors. 
• 
Re-challenge experience. Did the AE reoccur if the suspected drug was 
reintroduced after having been stopped? 
• 
Laboratory tests. Has a specific laboratory investigation confirmed the relationship? 
A “reasonable possibility” could be considered to exist for an AE where one or more of these 
factors exist. 
In contrast, there would not be a “reasonable possibility” of causality if none of the above 
criteria apply or where there is evidence of exposure and a reasonable time course but any 
dechallenge (if performed) is negative or ambiguous or there is another more likely cause of 
the AE. 
In difficult cases, other factors could be considered such as: 
• 
Is this a recognised feature of overdose of the drug? 
• 
Is there a known mechanism? 
Ambiguous cases should be considered as being a “reasonable possibility” of a causal 
relationship unless further evidence becomes available to refute this. 
Outcome 
The outcome of the event will be described in terms of: 
Recovered/resolved: ‘SAE/AE stop date’ should be provided 
Recovering/resolving: Can be used in cases where subject is known to be clearly 
recovering from an event. The event is however not resolved yet. A follow-up is required. ‘AE 
stop date’ should be left blank. 
Not recovered/not resolved: Event is ongoing. A follow-up is required. ‘AE stop date’ 
should be left blank. 
Recovered with sequelae: Used only with persistent incapacity/lifelong condition. ‘SAE/AE 
stop date’ should be entered. 

 
 
Protocol C17-315-04 
 
 
Protocol Version 3.0, 31-Mar-2020 
Page 96 of 96 
 
Resolved with sequelae: E.g. like blindness after diabetes mellitus. ‘SAE stop date’ should 
be provided. 
Fatal: SAE stop date’ (date of death) should be provided only for the events leading to death 
Unknown/unknown to Investigator: E.g. subject is lost to follow-up