A Phase I Trial of Vaccination With CT7, MAGE-A3, and WT1 mRNA-electroporated Autologous Langerhans-type Dendritic Cells as Consolidation for Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation
Phase: PHASE1
Conditions: Multiple Myeloma
Sponsor: Memorial Sloan Kettering Cancer Center

Memorial Sloan Kettering Cancer Center 
Page 1 of 35 
 
 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
A phase I randomized trial of vaccination with CT7, MAGE-A3, and W 
autologous Langerhans-type dendritic cells as consolidation for multipl 
undergoing autologous stem cell transplantation 
PROTOCOL FACE PAGE FOR 
MSKCC THERAPEUTIC/DIAGNOSTIC PROT 
Principal Investigator/Department: 
David J. Chung, MD, PhD 
T1 mRNA-electroporated 
myeloma patients 
OCOL 
Medicine, Adult BMT Service 
Co-Principal 
James W. Y 
Investigator(s)/Department: 
Sergio Giral 
oung, MD 
t, MD 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Investigator(s)/Department: 
Juliet Barker, MBBS 
Hugo Castro-Malaspina, MD 
Christina Cho, MD 
Parastoo Dahi, MD 
Boglarka Gyurkocza, MD 
Alan Hanash, MD 
Hani Hassoun, MD 
Katharine Hsu, MD, PhD 
Ann Jakubowski, MD, PhD 
Scott James, MD, PhD 
Neha S. Korde, MD 
Oscar Lahoud, MD 
Heather Landau, MD 
C. Ola Landgren, MD, PhD 
Nikoletta Lendvai, MD, PhD 
Alexander Lesokhin, MD 
Sham Mailankody, MBBS 
Esperanza Papadopoulos, MD 
Jonathan Peled, MD 
Miguel-Angel Perales, MD 
Ioannis Politikos, MD 
Elaina Preston, PA 
Doris Ponce, MD 
Craig Sauter, MD 
Michael Scordo, MD 
Brian C. Shaffer, MD 
Gunjan Shah, MD 
Eric Smith, MD, PhD 
Melody Smith, MD 
Roni Tamari, MD 
Marcel van den Brink, MD,PhD 
Glenn Heller, PhD 
Achim Jungbluth, MD 
Richard Meagher, PhD 
Marci Andreijko, NP 
Jason Batalha, NP 
Ewa Chauvin, NP 
Abigail Cohen, NP 
Melissa Cortes, NP 
Carter Hibbs, NP 
Shani Irby, NP 
Stefanie Kelly, NP 
Sheila Kenny, NP 
Maesa Koeber, NP, PhD 
Nicole Lestrange,NP 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Myeloma Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Myeloma Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Myeloma Service 
Medicine, Myeloma Service 
Medicine, Myeloma Service 
Medicine, Myeloma Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine,Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Myeloma Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Epidemiology & Biostatistics 
Pathology 
Laboratory Medicine 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
Nursing 
 

Page 2 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
 
 
Chelsea Mintz, NP 
Nursing 
Dayna Palumbo, NP 
Nursing 
Emily Patterson, NP 
Nursing 
Allison Sams, NP 
Nursing 
Megan Heavey Scott, NP 
Nursing 
Allison Tucker, NP 
Nursing 
Tara Wolff, NP 
Nursing 
 
 
Consenting  Professional(s)/Department: 
David J. Chung, MD, PhD 
Medicine, Adult BMT Service 
James W. Young, MD 
Medicine, Adult BMT Service 
Sergio Giralt, MD 
Medicine, Adult BMT Service 
Juliet Barker, MBBS 
Medicine, Adult BMT Service 
Hugo Castro-Malaspina, MD 
Medicine, Adult BMT Service 
Christina Cho, MD 
Medicine, Adult BMT 
Parastoo Dahi, MD 
ServiceMedicine, Adult BMT 
Boglarka Gyurkocza, MD 
Service 
Alan Hanash, MD 
Medicine, Adult BMT Service 
Hani Hassoun, MD 
Medicine, Adult BMT Service 
Katharine Hsu, MD, PhD 
Medicine, Myeloma Service 
Ann Jakubowski, MD, PhD 
Medicine, Adult BMT Service 
Scott James, MD, PhDNeha S. 
Medicine, Adult BMT 
Korde, MD 
ServiceMedicine, Adult BMT 
Oscar Lahoud, MD 
Service 
Heather Landau, MD 
Medicine, Myeloma Service 
C. Ola Landgren, MD, PhD 
Medicine, Adult BMT Service 
Nikoletta Lendvai, MD, PhD 
Medicine, Myeloma Service 
Alexander Lesokhin, MD 
Medicine, Myeloma Service 
Sham Mailankody, MBBS 
Medicine, Myeloma Service 
Esperanza Papadopoulos, MD 
Medicine, Myeloma Service 
Jonathan Peled, MD 
Medicine, Myeloma Service 
Miguel-Angel Perales, MD 
Medicine, Adult BMT Service 
Ioannis Politikos, MD 
Medicine, Adult BMT Service 
Doris Ponce, MD 
Medicine, Adult BMT Service 
Craig Sauter, MD 
Medicine, Adult BMT Service 
Michael Scordo, MD 
Medicine, Adult BMT Service 
Brian C. Shaffer, MD 
Medicine, Adult BMT Service 
Gunjan Shah, MD 
Medicine, Adult BMT Service 
Eric Smith, MD, PhD 
Medicine, Adult BMT Service 
Melody Smith, MD 
Medicine, Adult BMT Service 
Roni Tamari, MD 
Medicine, Myeloma Service 
Marcel van den Brink, MD, PhD 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
Medicine, Adult BMT Service 
 
 
 
Participating  Institution(s): 
PI's Name 
Site's Role 
The Rockefeller University/Center for 
Clinical & Translational Science, 1230 York 
A venue, New York, NY 10065 
David J. Chung, MD, PhD 
Data Collection 
The Rockefeller University/Center for 
Clinical & Translational Science, 1230 York 
A venue, New York, NY 10065 
James W. Young, MD (co-PI) 
Data Collection 

Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
Page 3 of 35 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please Note: A Consenting Professional must have completed the mandatory Human 
Subjects Education and Certification Program. 
 
 
 
Memorial Sloan-Kettering Cancer Center 
1275 York Avenue 
New York, New York 10065 

Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
Page 4 of 35 
 
 
 
Table of Contents 
 
 
Contents 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA ........................................................................... 6 
  
SCHEMA................................................................................................................................. 7 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS .................................................................................... 8 
Primary Objectives ....................................................................................................................... 8 
Evaluation of safety and toxicity ................................................................................................ 8 
Immune response monitoring ....................................................................................................... 8 
3.0 
BACKGROUND AND RATIONALE ......................................................................................... 8 
4.0 
OVERVIEW OF STUDY DESIGN/INTERVENTION ...................................................................... 10 
4.1 
Design ............................................................................................................................ 10 
4.2 
Intervention .......................................................................................................................... 11 
5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS ............................................................................... 11 
5.1. 
Langerhans-type dendritic cells (a.k.a. Langerhans cells or LCs) ................................. 11 
5.2. 
Plasmid expression vectors containing full-length CT7, MAGE-A3, and WT1............... 12 
5.3. 
CT7, MAGE-A3, and WT1 mRNA ............................................................................... 13 
6.0 
CRITERIA FOR SUBJECT ELIGIBILITY ................................................................................... 13 
6.1 
Subject Inclusion Criteria ................................................................................................ 14 
6.2 
Subject Exclusion Criteria ............................................................................................... 14 
7.0 
RECRUITMENT PLAN ......................................................................................................................... 14 
8.0 
PRETREATMENT EVALUATION .......................................................................................... 14 
9.0 
TREATMENT/INTERVENTION PLAN .................................................................................... 14 
9.1. 
Leukapheresis to obtain CD34
+ precursors ................................................................. 14 
9.2. 
Laboratory methods ........................................................................................................ 15 
9.2.1. 
Processing and cryopreservation of cells and cell subpopulations ................... 15 
9.2.2. 
Generation of Langerhans cells (LCs) from CD34
+ hematopoietic progenitor 
cells (CD34+ HPCs) ....................................................................................... 15 
9.2.3. 
Plasmid expression vectors containing full-length CT7, MAGE-A3, and WT1, 
and mRNA transcription .................................................................................... 16 
9.2.4. 
Electroporation of CD34+  HPC-derived LCs with mRNA encoding full-length 
CT7, MAGE-A3, and WT1 ............................................................................. 16 
9.2.5. 
Cytokines ................................................................................................................ 17 
9.2.6. 
Autologous, or heterologous, human plasma .................................................. 17 
9.2.7. 
Antibiotic supplements ...................................................................................... 17 
9.2.8. 
Release criteria for mature LC progeny ................................................................ 17 
9.2.9. 
Peripheral blood and bone marrow mononuclear cells (PBMC) and T 
lymphocytes ........................................................................................................... 18 
9.3. 
Langerhans cell vaccination protocol ........................................................................... 18 
10.0 EVALUATION DURING TREATMENT/INTERVENTION ........................................................ 18 

Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
Page 5 of 35 
 
 
11.0 TOXICITIES/SIDE EFFECTS.......................................................................................................... 21 
12.0 CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT ............................ 22 
Note:  12.2 and 12.4 only apply to patients on the vaccine arm of the study ................. 22 
12.1. In vitro lymphocyte responses............................................................................. 22 
12.2. Clinical - DTH responses .................................................................................... 22 
12.3. Clinical monitoring of patients during and after treatment ................................... 22 
12.4. Long-term follow-up of patients receiving mRNA-electroporated LCs ................ 22 
13.0 CRITERIA FOR REMOVAL FROM STUDY ........................................................................... 22 
13.1. 
Autoimmunity ....................................................................................................................... 22 
13.2. 
Anaphylaxis .......................................................................................................................... 23 
13.3. 
Disease progression ............................................................................................................ 23 
13.4. 
Other............................................................................................................................... 23 
14.0 BIOSTATISTICS ................................................................................................................... 23 
14.1. 
Patient enrollment and stopping rules .......................................................................... 23 
14.2. 
Inevaluable patients and/or removal from study ............................................................. 24 
15.0 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES ..... 24 
15.1 
Research Participant Registration ................................................................................... 24 
15.2 
Randomization ................................................................................................................ 24 
16.0 DAT A M ANAGEMENT ISSUES ............................................................................................ 25 
16.1 
Quality Assurance .......................................................................................................... 25 
16.2 
Data and Safety Monitoring ................................................................................................. 25 
17.0 PROTECTION OF HUMAN SUBJECTS ................................................................................ 26 
17.1 
Privacy ............................................................................................................................ 26 
17.2 
Serious Adverse Event (SAE) Reporting ............................................................................ 26 
17.2.1 .............................................................................. Error! Bookmark not defined. 
17.3 
Potential Risks ............................................................................................................ 27 
17.4 
Potential Benefits ............................................................................................................ 27 
17.5 
Reduction of Potential Risks ....................................................................................... 27 
17.6 
Alternatives to Therapy Under This Protocol .................................................................. 29 
17.7 
Financial Costs of Participation....................................................................................... 29 
18.0 INFORMED CONSENT PROCEDURES ........................................................................................ 29 
19.0 REFERENCES ........................................................................................................................... 30 
20.0 APPENDICES ....................................................................................................................... 34 

Page 6 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
1.0 
PROTOCOL SUMMARY AND/OR SCHEMA 
 
This is a prospective, two-arm phase I randomized trial for patients with symptomatic multiple 
myeloma (MM), ISS stages I-III, within 12 months of starting induction chemotherapy resulting in 
a very good partial response or better by International Myeloma Working Group (IMWG) criteria 
and eligible for high-dose chemotherapy with autologous stem cell transplantation (ASCT) by 
standard institutional criteria.  Ten patients will receive autologous Langerhans-type dendritic 
cells (CD34
+ hematopoietic progenitor cell (HPC)-derived Langerhans cells, or LCs) 
electroporated with mRNA encoding the full-length cancer-testis antigens, CT7 and MAGE- 
A3, and the self-differentiation tumor antigen, Wilms‟ tumor 1 (WT1).  An additional cohort of 
ten patients will be randomly assigned to receive the same with regard to cytoreduction, 
ASCT, and standard supportive care but will NOT receive any LC vaccines.  All patients will 
receive lenalidomide maintenance therapy beginning at approximately day +90 after ASCT1,2. 
Enriched populations of LCs will be generated and expanded ex vivo from CD34+ progenitors 
using defined recombinant cytokines that specifically support LC developm ent3-7.  One-day 
matured LCs will be electroporated separately with each of CT7, MAGE-A3, or WT1 mRNA 
before final maturation.  Mature electroporated LCs will then be combined in equal parts into 
a single vaccine for intradermal administration.  The vaccine dose will be 9x10
6 LCs per 
vaccine (i.e., combination of 3x106  CT7 mRNA-electroporated LCs + 3x106  MAGE-A3 
mRNA-electroporated LCs + 3x10
6  WT1 mRNA-electroporated LCs). 
We will define safety and toxicity in vivo after administration of CT7, MAGE-A3, and WT1 
mRNA-electroporated LC vaccines.  Patients will receive a total of three vaccines (initial 
priming vaccine plus two boosters) after ASCT on days +12, +30, and +90.  Safety and lack 
of dose-limiting toxicity for peptide-pulsed LC vaccines up to 30x106  LCs/vaccine were 
established in a previous phase I trial for melanoma at MSKCC (IRB #98-0988). 
Beyond safety and toxicity, the principal outcome assessments will be T cell immune 
responses measured in vitro, after stimulation in vivo by LCs presenting full-length CT7, 
MAGE-A3, and WT1 encoded by mRNA.  Post-vaccination immune responses within 
individual patients in the vaccine-treated group and between the two cohorts of the study will 
include intracellular cytokine secretion assays, CTL responses, and immune reconstitution 
analyses, including TCR repertoire diversity. 
We expect to accrue up to 30 patients to this trial, with only 20 to receive protocol treatment. 
Accrual should complete within 24 months and will account for additional patients accrued, 
should any patients be enrolled and then taken off study prior to receiving any protocol- 
related treatments. 
Treatment-related toxicity will be assessed according to standard NCI/CTEP Common 
Terminology Criteria for Adverse Events (CTCAE, v4.0).  Patients will also be monitored for 
immune response adverse events9.  No additional clinical measurements or outcome 
assessments will be required as part of this research study beyond those that already 
constitute standard care for patients with this malignancy and stages of disease. 

Page 7 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
SCHEMA 
 
T cells viably 
cryopreserved 
to compare with 
post-vaccine T 
cell responses 
Aliquot of collected 
product used to 
select CD34+ HPCs 
by MACS for LC 
generation. 
Buffy coat & 
marrow asp. for 
pre-Rx baseline 
 
 
 
G-CSF +/- plerixafor 
primed 
autologous HSCT 
leukopheresis 
 
Melphalan 
Melphalan 
100mg/m2 OR 
200mg/m2 
Days -3, -2 
Day -2; 
Rest Day -1 
Rest Day -1 
 
Autologous HSCT reinfusion 
Day 0 
 
Neulasta 
Day +1 
 
N=10 
N=10 
 
Day +12  
Day +30  
Day +90 
 
 
 
 
Day +120 
 
Day +180 
Vaccine #1 
 
Vaccine #2 
 
Vaccine #3* 
 
Post-vaccine 
steady-state 
leukopheresis 
& marrow asp. 
#1 
 
#2 
NO vaccine 
NO vaccine 
NO vaccine* 
Post-NO vaccine 
buffy coat 
 
 
#1 
 
#2 
 
*start lenalidomide maintenance 
 
Eligible patients with multiple myeloma will receive high-dose melphalan (200mg/m2) on day - 
2 (or day -3 and -2 if given over two days).  Autologous stem cells will be reinfused on day 0. 
Neulasta (pegfilgrastim) will be administered on day +1.  Patients will have been randomized 
to one of two arms of the study (i.e., vaccine or non-vaccine).  Patients on the vaccine arm 
will receive a total of three vaccinations (priming vaccine followed by two boosters) with 
autologous LCs electroporated with CT7, MAGE-A3, and WT1 mRNA.  Vaccines will be 
administered on days +12, +30, and +90.  Patients on the non-vaccine arm will receive the 
same treatment as those on the vaccine arm, with the exception of the vaccine.  Patients in 
both arms of the study will start lenalidomide maintenance therapy at approximately day +90, 
as deemed clinically appropriate.  Lenalidomide will be administered at a dose of 10 mg per 
day on a 21- or 28-day schedule until disease progression/relapse or unacceptable toxicity. 
Lenalidomide dose adjustments for toxicity will be at the discretion of the treating physician. 

Page 8 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
2.0 
OBJECTIVES AND SCIENTIFIC AIMS 
 
Primar y Objective s: 
Evaluation of safety and toxicity 
The primary goal is to evaluate the safety and toxicity of immunizing patients with autologous 
LCs presenting full-length CT7, MAGE-A3, and WT1 after electroporation with CT7, MAGE- 
A3, and WT1 mRNA, respectively.  Patients will receive a dose of 9x10
6  LCs/vaccine (i.e., 
combination of 3x106  CT7 mRNA-electroporated LCs + 3x106  MAGE-A3 mRNA- 
electroporated LCs + 3x10
6  WT1 mRNA-electroporated LCs).  Safety and lack of dose- 
limiting toxicity for peptide-pulsed LC (and blood moDC) vaccines up to 30x106  LCs/vaccine 
were established in IRB #98-098
8. 
Immune response monitoring 
The secondary goal of the study is to monitor and compare changes in T cell responses 
(e.g., intracellular cytokine secretion assays, CTL responses, and immune reconstitution 
analyses) stimulated by the CT7, MAGE-A3, and WT1 mRNA-electroporated LCs relative to 
pre-vaccine baselines and to the untreated cohort of the study. 
Secondary Objective: 
Descriptive and preliminary progression free survival data will be collected only to assist in 
the design of a follow-up study, if the LC vaccines prove successful for the principal 
endpoints of safety and immune responses. 
3.0 
BACKGROUND AND RATIONALE 
 
Multiple myeloma (MM) is a plasma cell malignancy that causes bone lesions, renal 
dysfunction, immunodeficiency, and marrow failure.  It is the second most common 
hematologic malignancy in the United States with an estimated 21,700 new diagnoses and 
10,710 deaths in 201210.  The mean age of affected individuals is 61 years for women and 62 
years for men.  Over the past decade, the advent of more effective treatment options, 
including thalidomide analogues and proteasome inhibitors, has dramatically improved 
response rates and survival of MM patients
11,12.  For the majority of patients, however, MM 
remains an incurable disease. 
Attempts to cure MM with high-dose chemotherapy followed by autologous or allogeneic 
stem cell transplantation (SCT) have been successful in only a small fraction of patients.  For 
most patients, relapse is inevitable with a median progression free survival after autologous 
SCT (ASCT) of only about 2 years and a median overall survival of 7-8 years.  The addition 
of lenalidomide maintenance therapy after ASCT improves progression free survival
1,2, but 
relapse remains the primary cause of treatment failure.  The identification of relevant 
myeloma antigen targets, including the cancer-testis antigens, CT7 and MAGE-A3, and the 
self-differentiation antigen, Wilms‟ tumor 1 (WT1) protein, has spurred interest in 
incorporating immune-based therapies into treatment regimens to improve patient outcomes. 
A number of observations support the concept that restoring immunity against MM antigens 
can improve therapeutic outcomes.  Plasma cells in MM and MGUS (the premalignant 
condition) are genetically very similar, suggesting that evolution to MM involves interactions 
with the host tumor stroma
13,14.  Studies also implicate host immunity as a mechanism of 
disease control.  Bone marrow of patients with MGUS, but not those with progression to MM, 
contains T cells that can mount robust immune responses against MM antigens 
15.  Loss of 
immunity to the embryonal stem cell marker, SOX2, correlates with progression from MGUS 
to MM; and the presence of anti-SOX2 T cells in patients with asymptomatic MM predicts a 
better overall outcome16.  Further underscoring the hypothesis that MM evolution involves 
active mechanisms of immune evasion was a study showing that malignant plasma cells 
shed increasing amounts of soluble MHC I-related chain A (sMICA), as MGUS progresses to 

Page 9 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
MM17.  s MICA in turn triggers the down-regulation of the lymphocyte activating receptor, 
NKG2D, by natural killer (NK) cells and CD8+ effector T cells17. 
Cancer-testis (CT) antigens have emerged as important targets for immunotherapy in MM. 
CT antigens, which are normally restricted to immune-privileged tissues like developing germ 
cells and placenta, are over-expressed in a number of cancers, including MM18.  CT7 and 
MAGE-A3 are the most commonly expressed CT antigens in MM19,20.  In one study, ≥70% of 
bone marrow specimens from myeloma patients were positive for CT7 (82%) and MAGE-A3 
(70%) by immunohistochemistry, and there was a positive correlation between the  
expression of these antigens and advanced stage of disease19.  Higher percentages of CT7 
and MAGE-A3-positive tumor cells also had higher percentages of proliferating plasma cells 
based on Ki-67 expression19.  CT7 promotes the survival of myeloma cells and clonogenic 
precursors by reducing the rate of spontaneous and chemotherapy-induced apoptosis21.  In 
addition, silencing CT7 expression in vitro more than doubled their sensitivity to bortezomib21. 
MAGE-A3 inhibits apoptosis of myeloma cells and correlates with relapsed disease
22.  These 
observations indicate a biological role for CT7 and MAGE-A3 in MM and their relevance as 
antigen targets.  MM disease control also temporally coincides with the expansion of CT7- 
specific T cells following reinfusion of donor lymphocytes after T cell-depleted allogeneic SCT 
(Dr. Guenther Koehne, MSKCC, personal communication).  In addition, antibodies       
against multiple CT antigens, including MAGE-A3, were detected in MM patients after 
allogeneic SCT
23.  Collectively, these findings provide compelling rationale for developing CT 
antigen-directed immunotherapies for MM to improve treatment outcomes. 
The Wilms‟ tumor 1 (WT1) protein, a strongly conserved self-differentiation antigen 
expressed by many tumors, is expressed in MM and may play an important role in its 
pathogenesis.  In one study, increased WT1 expression in the bone marrow of myeloma 
patients correlated with advanced disease stage, higher monoclonal protein spike, and 
higher beta-2 microglobulin levels
24.  MM cells are recognized and lysed by WT1-specific 
cytotoxic T lymphocytes (CTLs)25.  A significant decrease in disease burden in the bone 
marrow and urine was associated with the expansion of functional WT1-specific CTLs and 
their migration to the bone marrow in a patient treated with a peptide-based WT1 vaccine26. 
A recent study showed a positive correlation between WT1 expression in the bone marrow 
with disease burden, as well as an association between the emergence of WT1-specific T 
cells and graft-versus-myeloma effect in patients treated for relapsed MM following 
allogeneic T cell-depleted transplantation and donor leukocyte infusions27. 
Numerous studies have demonstrated the feasibility of dendritic cell (DC)-based immunization 
to induce host responses against tumors28.  DCs comprise a complex system of bone marrow- 
derived leukocytes that are critical to the onset and modulation of immunity.  DCs prime T 
cell responses by coupling antigen to all the requisite co-stimulatory, cytokine, and 
chemokine signals required for the activation of naive and resting T cells 
29.  Certain DC 
subtypes also provide cytokines and activating ligands for resting natural killer (NK) cells30,31. 
The ability to stimulate both the adaptive (T cell) and innate (NK cell) arms of the immune 
response makes DCs attractive candidates for vaccine-based therapies. 
Almost all previous DC vaccine trials have used monocyte-derived DCs (moDCs) in large 
part because monocyte precursors are easier to obtain and culture in vitro than CD34+- 
derived subsets, including Langerhans-type DCs (LCs).  Studies in mice and recent studies 
in humans, however, highlight the phenotypic and functional heterogeneity of DC subsets  
and underscore the importance of subset diversity in determining the outcome of 
immunization.  LCs are superior to moDCs and other conventional DC subsets at inducing 
antigen-specific CTLs against viral and tumor antigens in vitro
3,32.  When compared with 
moDCs, LCs secrete more IL153,31,32, which in turn reduces IL2-induced T cell apoptosis and 
decreases regulatory T cell expansion during LC-mediated CTL generation
33.  LCs can break 
tolerance against WT1 by an IL15R/IL15/pSTAT5-dependent mechanism33.  Clinical trial 
data have demonstrated greater efficacy of DC vaccines that contain LCs
34, as well as 

Page 10 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
greater tetramer reactivity stimulated by LCs when compared with moDCs8.  LC-based 
vaccines therefore merit further investigation in clinical trials. 
Electroporation of DCs with mRNA encoding specific tumor-associated antigens is an 
effective non-viral method to stimulate T cell responses both in vitro and in vivo35-42.  Antigen 
loading by electroporation is more efficient than peptide pulsing and less problematic than 
using retroviral transgenes, which carry the risk of genome integration43.  Another important 
advantage of tumor antigens expressed by mRNA-electroporated DCs is that the DCs can 
process and present a diverse array of multiple peptides tailored to their own class I and II 
MHC molecules over a sustained period of time.  This should stimulate more robust  
antitumor immunity than achieved by alternative methods of loading antigen onto DCs (e.g., 
single class I MHC-peptide pulsing).  MoDCs electroporated with tumor-derived RNA have 
induced myeloma-specific CTLs, but this was only in vitro and required supplemental IL2 that 
could promote apoptosis and expansion of regulatory T cells41. 
The majority of vaccine studies have been limited to single antigen and restricted epitope 
targets.  Simultaneously targeting more than one antigen, however, should improve the 
breadth of immune responses, leading to improved clinical response rates.  This concept 
was tested in a prostate cancer animal model in which adenovirus vector-based 
immunization with both prostate-specific antigen (PSA) and prostate stem cell antigen 
(PSCA) induced the expansion of anti-PSA and anti-PSCA CTLs and inhibited the growth of 
established tumors in mice44.  More recently, therapeutic vaccination for renal cell carcinoma 
with multiple tumor-associated peptides was associated with enhanced T cell responses and 
longer patient survival45.  Concurrent vaccination with more than one full-length antigen has 
not been evaluated for MM. 
Post-transplant vaccination to control or eliminate residual disease is one strategy to improve 
outcomes after ASCT for MM.  In addition to minimal disease burden, the early post- 
transplant period is marked by a phase of immune reconstitution during which immune- 
suppressive factors, like regulatory T cells, are markedly reduced, thus providing an 
opportune time to introduce vaccines to induce antitumor immune responses.  The timing of 
immunization, therefore, may be as critical to obtaining meaningful therapeutic responses as 
the choice of antigen or mode of delivery. 
We have developed procedures for reproducibly generating LCs in vitro, have completed a 
phase I trial with peptide-pulsed DCs for melanoma (MSKCC IRB #98-0988), and have a 
phase I clinical trial for melanoma (MSKCC IRB #10-229) using mRNA-electroporated LCs 
presenting the full-length melanoma antigen, murine tyrosinase-related protein 2 (mTRP2). 
In this study, we will assess the safety and immunogenicity of LCs electroporated with CT7, 
MAGE-A3, and WT1 mRNA in a phase I clinical trial for MM after ASCT. 
 
4.1 
OVERVIEW OF STUDY DESIGN/INTERVENTION 
 
4.2 
Design 
This is a prospective, two-arm phase I randomized trial.  Patients will be accrued only 
from MSKCC and treated at MSKCC and The Rockefeller University/Center for Clinical 
& Translational Science.  The study will assess autologous LCs presenting CT7, 
MAGE-A3, and WT1 after electroporation with CT7, MAGE-A3, and WT1 mRNA.  Up to 
thirty patients will accrue to the study to allow for drop-out of patients who are 
subsequently unable to proceed with treatment.  A total of twenty patients will receive 
treatment, with ten receiving vaccines at 9x10
6  LCs per dose (i.e., combination of 3x10
6 
CT7 mRNA-electroporated LCs + 3x106  MAGE-A3 mRNA-electroporated LCs +  
3x106  WT1 mRNA-electroporated LCs), and another ten who will not receive any LC 
vaccines but will otherwise undergo identical cytoreduction, ASCT, and standard 
supportive care.  At approximately 3 months after ASCT and as deemed clinically 

Page 11 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
appropriate, patients will start lenalidomide maintenance therapy, which is now 
standard to delay disease progression1,2. 
 
4.3 
Intervention 
Autologous LCs will be generated ex vivo from CD34+ hematopoietic progenitor cells 
(HPCs) under the aegis of defined cytokines.  LCs will be electroporated with CT7, 
MAGE-A3, and WT1 mRNA encoding full-length CT7, MAGE-A3, and WT1.  The fully 
mature, antigen-loaded LCs will be injected intradermally into eligible patients.  Patients 
on the vaccine arm of the study will receive a total of 3 vaccinations, comprising a 
primary immunization on day +12 after ASCT followed by two boosters at days +30 and 
+90.  Vaccines will be dosed at 9x106  LCs per vaccine x 3. 
 
5.0 
THERAPEUTIC/DIAGNOSTIC AGENTS 
 
5.1. 
Langerhans-type dendritic cells (a.k.a. Langerhans cells or LCs) 
 
5.1.1. Formulation: Derived from CD34+ HPCs as per Section 9.2 and laboratory 
standard operating procedures (SOPs). 
 
5.1.2. Preparation: As per Section 9.2 and the respective SOPs. 
 
5.1.3. Storage: LCs will be cryopreserved as outlined in the respective SOPs. 
Optimal cryopreservation duration of cells for clinical use is thought to be 
approximately two years maximum, but this has not been conclusively established. 
 
5.1.4. Route of Administration: Intradermal. 
 
5.1.5. Toxicities: Minimal erythema and induration at injection sites, and rarely 
pruritus, have been noted after administration of peptide-pulsed DC vaccines (46-49 
and MSKCC IRB #98-0988) and mRNA-electroporated DC vaccines50,51.  These 
toxicities have not been dose limiting. 
Observed toxicities of DC-based vaccines 
DC 
subtype 
Melanoma 
antigen(s) 
Dose & schedule 
Toxicity 
Reference 
moDC 
Mage-3 
3x106 id + 3x106 sc x 3, 
then 6x106 iv x 1, then 
12x106 iv x 1 (vaccine 
interval: q14d) 
• Local reactions (erythema, 
induration, pruritus) at 
injection site 
• Transient fever (grade I-II) 
Thurner B et al. 1999, 
J.Exp.Med 190:1669 
moDC 
Mage-3 
6x106 sc x 3, then 
6x106 iv x 1, then 12x106 
iv x 1 
(vaccine interval: q14d) 
• Local reactions (erythema, 
induration, pruritus) at 
injection site 
• Transient fever (grade I-II) 
Schuler-Thurner B et 
al. 2000, J. Immunol. 
165:3492 
LC/DDC- 
IDC mix 
(CD34+ HPC 
derived) 
MelanA/ 
MART-1 
tyrosinase 
Mage-3 
gp100 
Up to 1x106 
DC/kg/injection q14d x 4 
• Local DTH reactions at 
injection site 
• Mild progressive vitiligo in 
2 pts with pre-existing 
vitiligo 
Banchereau J et al. 
2001, 
Cancer Res. 61:6451 
moDC 
Mage-3 
2x106 sc biw eekly x 5 
• Local DTH reactions at 
injection site 
• Transient fever (grade I) 
Schuler-Thurner B et 
al. 2002, J.Exp.Med. 
195:1279 
moDC 
MART-1 
5x106 q3w ks x 4 
• Local DTH reactions at 
injection site 
Markovic SN et al. 
2006, J. Transl. Med. 
4: 35 
moDC 
vs LC 
tyrosinase 
gp100 
3x106, 10x106, or 30x106 
~q4w ks x 3 
• Local DTH reactions at 
injection site 
Romano E et al. 2011, 
Clin Cancer Res. 
17:1984 (MSKCC IRB 
#98-098) 
 
5.1.6. Special Handling:  Standard universal precautions. 

Page 12 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
 
5.2. 
Plasmid expression vectors containing full-length CT7, MAGE-A3, and WT1 
 
5.2.1. Formulation: 
CT7 plasmid: The vector contains the following elements: a T7 promoter and 
transcription initiation site, a pUC origin for high copy replication and maintenance of 
the plasmid in E. coli, and a gene conferring ampicillin resistance for selection in 
E.coli.  All gene segments were amplified by polymerase chain reaction (PCR).  The 
role of each segment is as follows: the T7 promoter to drive the expression of the CT7 
antigen cDNA, and that cDNA is cloned in the polylinker region.  To propagate the 
plasmid in E. coli, the pUC replicon and the ampicillin cassette are included.  The 
ampicillin resistance gene is cloned in the opposite orientation from the CT7 cDNA to 
limit transcription from the T7 promoter in human cells. 
 
MAGE- A3 plasmid: The vector contains the following elements: a T7 
promoter/priming site, a polylinker region to facilitate cloning of a variety of DNA 
fragments, attR1 and attR2 recombinational cloning sites, a Herpes Simplex Virus 
Thymidine Kinase (TK) polyadenylation signal for efficient transcription termination 
and polyadenylation of mRNA, a pUC origin for high copy replication and 
maintenance of the plasmid in E. coli, and a gene conferring ampicillin resistance for 
selection in E.coli.  All gene segments were amplified by polymerase chain reaction 
(PCR).  The role of each segment is as follows: the T7 promoter to drive the 
expression of the MAGE-A3 antigen cDNA, and that cDNA is cloned in the polylinker 
region.  The resulting mRNA is processed and polyadenylated using the attR1 and 
attR2 sites and polyadenylation signals.  To propagate the plasmid in E. coli, the pUC 
replicon and the ampicillin cassette are included.  The ampicillin resistance gene is 
cloned in the opposite orientation from the MAGE-A3 cDNA to limit transcription from 
the T7 promoter in human cells. 
 
W T1 plasmid: The vector contains the following elements: an SP6 promoter 
and transcription initiation site, a pUC origin for high copy replication and 
maintenance of the plasmid in E. coli, and a gene conferring ampicillin resistance for 
selection in E.coli.  All gene segments were amplified by polymerase chain reaction 
(PCR).  The role of each segment is as follows: the SP6 promoter to drive the 
expression of the WT1 antigen cDNA, and that cDNA is cloned in the polylinker 
region.  To propagate the plasmid in E. coli, the pUC replicon and the ampicillin 
cassette are included.  The ampicillin resistance gene is cloned in the opposite 
orientation from the WT1 cDNA to limit transcription from the SP6 promoter in human 
cells. 
 
5.2.2. Preparation: Each lot of plasmid DNA will be completely sequenced to 
ensure fidelity with the sequence on record in our laboratory.  Each lot will be tested 
for endotoxin, which is of particular concern given that DNA will be purified from E. 
Coli.  Each lot will be in full compliance with FDA regulations regarding endotoxin 
content. 
 
5.2.3. Storage: Aliquots of the vectors are stored at -80°C until needed for 
electroporation. 
 
5.2.4. Route of Administration: Not applicable.  Patients will not directly receive 
the plasmids in this study. 
5.2.5. Toxicities: Not applicable.  Patients will not directly receive the plasmids in 
this study. 

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IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
5.3. 
CT7, MAGE-A3, and WT1 mRNA 
 
5.3.1. Formulation: CT7, MAGE-A3, and WT1 mRNA are produced from plasmid 
expression vectors containing the respective genes under the control of either an SP6 
or T7 promoter. 
 
5.3.2. Preparation: 
For CT7 mRNA in vitro transcription, an insert encoding human CT7 cDNA 
has been cloned into a pGEM®-T Easy Vector (Promega; Madison, WI).  To select 
for an expression clone, the plasmid is transformed in One Shot® TOP10 Chemically 
Competent E.coli (Invitrogen; Carlsbad, CA), propagated, and purified using QIA filter 
Maxi Cartridges and the Plasmid Maxi Kit (Qiagen; Hilden, Germany).  The CT7- 
pGEM-T plasmid DNA is linearized with the restriction enzyme, NdeI (New England 
Biolabs, Ipswich, MA), before mRNA transcription in vitro, which is performed with T7 
RNA polymerase according to the manufacturer‟s instructions (mMESSAGE 
mMACHINE® T7 Ultra Kit; Ambion; Austin, TX).  The production of full-length, 
capped and tailed mRNA is confirmed by agarose gel electrophoresis, and mRNA 
concentration and purity (A260/A280) are measured by spectrophotometry. 
 
For MAGE-A3 mRNA in vitro transcription, an insert encoding human MAGE- 
A3 cDNA has been cloned into a pcDNA™6.2/V5-DEST Gateway® Vector 
(Invitrogen; Carlsbad, CA).  To select for an expression clone, the plasmid is 
transformed in One Shot® TOP10 Chemically Competent E.coli (Invitrogen; 
Carlsbad, CA), propagated, and purified using QIA filter Maxi Cartridges and the 
Plasmid Maxi Kit (Qiagen; Hilden, Germany).  The MAGE-A3-pcDNA6.2 plasmid DNA 
is linearized with the restriction enzyme, XbaI (New England Biolabs, Ipswich, MA), 
before mRNA transcription in vitro, which is performed with T7 RNA polymerase 
according to the manufacturer‟s instructions (mMESSAGE mMACHINE® T7 Ultra Kit; 
Ambion; Austin, TX).  The production of full-length, capped and tailed mRNA is 
confirmed by agarose gel electrophoresis, and mRNA concentration and purity (A260/A2 
80) are measured by spectrophotometry. 
 
For W T1 mRNA in vitro transcription, an insert encoding human WT1 cDNA, 
derived from the pUC119 plasmid (Riken Bioresource; Tokyo, Japan), has been 
cloned into a pGEM-4Z vector (Promega; Madison, WI).  To select for an expression 
clone, the plasmid is transformed in One Shot® TOP10 Chemically Competent E.coli 
(Invitrogen; Carlsbad, CA), propagated, and purified using QIA filter Maxi Cartridges 
and the Plasmid Maxi Kit (Qiagen; Hilden, Germany).  The WT1-pGEM-4Z plasmid is 
linearized with the restriction enzyme, HindIII (New England Biolabs, Ipswich, MA), 
before mRNA transcription in vitro, which is performed with SP6 RNA polymerase 
(mMESSAGE mMACHINE® SP6 Kit and Poly(A) Tailing Kit; Ambion; Austin, TX). 
The production of full-length, capped and tailed mRNA is confirmed by agarose gel 
electrophoresis, and mRNA concentration and purity (A260 /A280) are measured by 
spectrophotometry. 
 
5.3.3. Storage: mRNA can be frozen and stored prior to use for in vitro transcription 
for electroporation. 
 
5.3.4. Route of Administration: Not applicable.  Patients will not directly receive 
mRNA in this study. 
 
5.3.5. Toxicities: Not applicable.  Patients will not directly receive mRNA in this 
study. 
 
6.1 
CRITERIA FOR SUBJECT ELIGIBILITY 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
6.2 
Subject Inclusion Criteria 
1. Symptomatic multiple myeloma, ISS stages I-III, within 12 months of starting 
therapy. 
2. Completion of induction therapy with Very Good Partial Response (VGPR), or 
better, by International Myeloma Working Group (IMWG) criteria. 
3. Deemed eligible for ASCT by standard institutional criteria. 
4. Age ≥18 years. 
5. Documentation of CT7, MAGE-A3, or WT1 expression in the bone marrow and/or 
bone marrow aspirate. 
6.3 
Subject Exclusion Criteria 
1. Prior autologous or allogeneic SCT. 
2. Previous immunization against CT7, MAGE-A3, other cancer-testis antigens, or 
WT1. 
3. Known immunodeficiency, HIV positivity, hepatitis B, or hepatitis C. 
4. Clinically active  autoimmune disease (e.g., rheumatoid arthritis, SLE) requiring 
treatment. Vitiligo, diabetes, or treated thyroiditis are allowed. 
5. History of severe allergic reactions to vaccines or unknown allergens. 
6. Participation in any other clinical trial involving another investigational agent within 
4 weeks prior to first immunization. 
7. Lenalidomide-related toxicities before ASCT necessitating its discontinuation as 
part of treatment. 
 
7.0 
RECRUITMENT PLAN 
 
Patients meeting the eligibility criteria above will be recruited from the Adult BMT Service, 
Division of Hematologic Oncology, Department of Medicine.  Information regarding this study 
will be made available on the MSKCC web site, and the trial will be listed on 
www.clinicaltrials.gov.  This study will be offered to eligible patients regardless of gender, 
race, or ethnicity.  Physicians will discuss with the patient his/her diagnosis, prognosis, risks 
and benefits of study participation, as well as treatment alternatives which will include 
standard treatment options and may include other investigational options.  All patients will be 
required to sign an IRB approved informed consent prior to enrollment on study. 
 
8.0 
PRETREATMENT EVALUATION 
 
8.1 
SCREENING 
Confirmation of protocol eligibility as described in Section 6. 
 
 
8.2 
PRE-VACCINATION 
Pre-treatment blood samples will be from the buffy coat (leukocyte concentrate) of an 
autologous unit of blood.  These blood samples will be used for pre-treatment in vitro 
assays (baseline T cell responses against tumor antigens) and for cryopreservation of 
cells and/or plasma for future use. 
 
9.0 
TREATMENT/INTERVENTION PLAN 
 
9.1. 
Leukapheresis to obtain CD34+  precursors 
 
All patients on the study will undergo stem cell mobilization followed by leukapheresis for 
stem cell collection for ASCT per Adult BMT Service guidelines.  An aliquot of the 

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Approval date: 15-Feb-2018 
 
 
 
leukapheresis product will be used to isolate CD34+ precursors according to laboratory 
SOPs.  Sufficient cell yields to generate the primary and booster LC vaccinations are 
expected.  If yields from a patient are insufficient to provide enough cells for the initial 
vaccine plus two boosters after cryopreservation and thawing (see laboratory SOPs), 
then the patient will be deemed inevaluable, and will be replaced by a new patient. 
Excess, unused cells and/or cell subpopulations may be cryopreserved for future use for 
this protocol or may be used for other research purposes. The latter requires 
documentation of both the disposition of the excess cells and the approval of the PI. 
 
9.2. 
Laboratory methods 
 
All laboratory methods will be conducted under Good Manufacturing Practice-Good 
Tissue Practice (GMP-GTP) like environment using SOPs of the Laboratory of Cellular 
Immunobiology. 
 
9.2.1. Processing and cryopreservation of cells and cell subpopulations 
G-CSF/plerixafor-elicited leukapheresis product will be obtained and handled through  
the MSKCC Blood Donor Room or comparable facility under the direction of the MSKCC 
Blood Bank and/or Cell Therapy Laboratory, in coordination with the Laboratory of 
Cellular Immunobiology.  Patient identification, collection dates, and sample tracking will 
all adhere to SOPs.  CD34+ hematopoietic progenitor cells (HPCs) will undergo initial 
isolation by positive immunomagnetic selection over a CliniMACS column (CliniMACS® 
CD34 Reagent System, Serial Number 041, Miltenyi Biotec, cross-reference Device 
Master File on file at CBER, document no. BB MF 8061) according to manufacturer‟s 
directions and SOPs.  Isolation of total blood mononuclear cells will use Ficoll-Paque or 
comparable gradient according to SOPs.  Cryopreservation of cells and cell 
subpopulations, identification, dating, and storage, will also be performed according to 
SOPs and current GLP/GTP (Good Tissue Practice; see also 21 CFR 1271). 
 
9.2.2. Generation of Langerhans cells (LCs) from CD34
+  hematopoietic 
progenitor cells (CD34+  HPCs) 
CD34+ HPCs are positively selected from MNCs of the PBSC product, using a 
magnetic cell sorter (CliniMACS® CD34 Reagent System).  Recovered cells are never 
administered directly to patients without prior culture in vitro and expansion with 
recombinant cytokines as outlined in the respective SOPs.  Cytokines are also never 
administered directly to a patient, apart from the G-CSF used for pre-stimulation of 
leukapheresis, as LC progeny are thoroughly washed free of cytokines before in vivo 
administration. 
LCs are generated from CD34+ HPCs using defined cytokines for differentiation and 
maturation, according to published methodology3-7,52-55  and the laboratory SOPs. 
Initial culture is in KL, FL, GM-CSF, TNF-alpha, and TGF-beta-1 from day 0 to days 
+5 to +6, followed by reculture to day +11 to +12 in GM-CSF, TNF-alpha, and TGF- 
beta-1, without KL and FL.  Terminal maturation occurs over two more days by the 
additional provision of an inflammatory cytokine combination (TNF-alpha, IL-1, IL-6) 
with PGE256. 
It is expected that sufficient LCs will be generated from the leukapheresis collection of 
CD34+ HPCs, to provide adequate numbers for the initial vaccine of 9x106 cells, as 
well as for subsequent booster doses after cryopreservation and thawing.  These 
procedures are outlined in the laboratory SOPs.  If yields from a patient are 
insufficient, the patient may be deemed inevaluable and may be replaced by a new 
patient. 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
9.2.3. Plasmid expression vectors containing full-length CT7, MAGE-A3, and 
WT1, and mRNA transcription 
For CT7 mRNA in vitro transcription, an insert encoding human CT7 cDNA has been 
cloned into a pGEM®-T Easy Vector (Promega; Madison, WI).  To select for an 
expression clone, the plasmid is transformed in One Shot® TOP10 Chemically 
Competent E.coli (Invitrogen; Carlsbad, CA), propagated, and purified using QIA filter 
Maxi Cartridges and the Plasmid Maxi Kit (Qiagen; Hilden, Germany).  The CT7- 
pGEM-T plasmid DNA is linearized with the restriction enzyme, NdeI (New England 
Biolabs, Ipswich, MA), before mRNA in vitro transcription, which is performed with T7 
RNA polymerase according to the manufacturer‟s instructions (mMESSAGE 
mMACHINE® T7 Ultra Kit; Ambion, Austin, TX).  The production of full-length, 
capped and tailed mRNA is confirmed by agarose gel electrophoresis, and mRNA 
concentration and purity (A260/A280) are measured by spectrophotometry. 
 
For MAGE-A3 mRNA in vitro transcription, an insert encoding human MAGE-A3 
cDNA has been cloned into a pcDNA™6.2/V5-DEST Gateway® Vector (Invitrogen; 
Carlsbad, CA).  To select for an expression clone, the plasmid is transformed in One 
Shot® TOP10 Chemically Competent E.coli (Invitrogen; Carlsbad, CA), propagated, 
and purified using QIA filter Maxi Cartridges and the Plasmid Maxi Kit (Qiagen; 
Hilden, Germany).  The MAGE-A3-pcDNA6.2 plasmid DNA is linearized with the 
restriction enzyme, XbaI (New England Biolabs, Ipswich, MA), before mRNA in vitro 
transcription, which is performed with T7 RNA polymerase according to the 
manufacturer‟s instructions (mMESSAGE mMACHINE® T7 Ultra Kit; Ambion, Austin, 
TX).  The production of full-length, capped and tailed mRNA is confirmed by agarose 
gel electrophoresis, and mRNA concentration and purity (A260/A28 0) are measured by 
spectrophotometry. 
 
For W T1 mRNA in vitro transcription, an insert encoding human WT1 cDNA, derived 
from the pUC119 plasmid (Riken Bioresource; Tokyo, Japan), has been cloned into a 
pGEM-4Z vector (Promega; Madison, WI).  To select for an expression clone, the 
plasmid is transformed in One Shot® TOP10 Chemically Competent E.coli 
(Invitrogen; Carlsbad, CA), propagated, and purified using QIA filter Maxi Cartridges 
and the Plasmid Maxi Kit (Qiagen; Hilden, Germany).  The WT1-pGEM-4Z plasmid is 
linearized with the restriction enzyme, HindIII (New England Biolabs, Ipswich, MA), 
before mRNA transcription in vitro, which is performed with SP6 RNA polymerase 
(mMESSAGE mMACHINE® SP6 Kit and Poly(A) Tailing Kit; Ambion; Austin, TX). 
The production of full-length, capped and tailed mRNA is confirmed by agarose gel 
electrophoresis, and mRNA concentration and purity (A260 /A280) are measured by 
spectrophotometry. 
 
Aliquots of CT7, MAGE-A3, and WT1 mRNA are stored and certified, with in process 
sterility testing, as outlined in the respective laboratory SOPs. 
 
9.2.4. Electroporation of CD34+  HPC-derived LCs with mRNA encoding full- 
length CT7, MAGE-A3, and WT1 
Partially matured (i.e., one-day matured) LCs are electroporated with CT7, MAGE-A3, 
or WT1 mRNA.  Cells are washed and resuspended in OptiMEM I (Gibco, Invitrogen), 
mixed with mRNA, and then electroporated, using a BTX ECM 830 square-wave 
electroporator (BTX Harvard, Holliston, MA)
39, as outlined in the respective laboratory 
SOPs.  After electroporation, LCs are immediately returned to rest in culture 
supplemented with maturation-inducing cytokines for 24 hours prior to administration. 

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IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
9.2.5. Cytokines 
All cytokines are recombinant human cytokines, manufactured according to endotoxin- 
free GMP conditions, and used solely in vitro according to current GLP and GTP. When 
available, pharmaceutical grade cytokines, e.g., GM-CSF, are used.  Certificates of 
analysis will be maintained on file for each lot used. Cytokines are aliquotted from stock 
vials and stored frozen in accordance with manufacturer‟s recommendations.  Cytokines 
are never administered directly to a patient (apart from cytokine pre-stimulation as 
described above for G-CSF-elicited leukapheresis), and cell progeny are thoroughly 
washed free of cytokines before in vivo administration. 
 
9.2.6. Autologous, or heterologous, human plasma 
Autologous plasma is obtained via a closed, sterile system in the MSKCC Blood Bank 
and/or Cytotherapy Laboratory in conjunction with the Laboratory of Cellular 
Immunobiology as a by-product of the leukapheresis product.  Plasma may be used 
directly, or after freeze-thawing.  Autologous plasma may be replaced by heterologous 
plasma in the rare instance where autologous plasma may not be available, and only 
after meeting standard release criteria according to FDA-sanctioned and/or standard 
American Association of Blood Banking guidelines. 
Note that bovine/xenogeneic serum products will not be used for the final LC expansion 
cultures.  See also laboratory SOPs. 
 
9.2.7. Antibiotic supplements 
Antibiotic supplements will not be used in order not to (a) suppress any bacterial growth 
that would alert the investigators not to proceed with administration of the cellular 
product; or (b) interfere with mycoplasma detection. 
 
9.2.8. Release criteria for mature LC progeny 
• 
Approximately 70% or greater viability based on negative DAPI (4',6-diamidino-2- 
phenylindole) staining of the large forward scatter cells as detected by 
cytofluorography, or by trypan blue exclusion by direct hemacytometer count. 
• 
Approximately 50% or greater expression of CD83 and CD86 by the class II 
MHC+, CD14negativ e  large forward scatter cells as detected by cytofluorography. 
Exact dosing of LCs will be calculated based on the mean percentage of large 
FSC, class II MHC+, CD14neg  cells that co-express CD83 and CD86. 
• 
No detectable undifferentiated progenitors based on expression of CD34. 
• 
Detectable CT7, MAGE-A3, and WT1 in electroporated LCs by standard assays 
(see laboratory SOPs). 
• 
Sterility based on an approximately 48 hrs “no growth” result from a 
bacterial/fungal culture taken in-process after the last refeeding and culture 
manipulation. 
• 
Negative gram stain of the final vaccine product. 
• 
Endotoxin level less than 5 EU per kg of recipient weight in the final cell vaccine 
product (endotoxin level is based on recipient weight, since cell concentration in 
the vaccine can vary with the dose level) as measured by gel clot method using 
the limulus amebocyte lysate assay (LAL assay, BioWhittaker, CBER/FDA 
biologic license number 709). 
• 
See also Section 17.0 Protection of Human Subjects/Section 17.3 Reduction of 
Potential Risks, which further outlines (a) testing for bacteria, fungi, mycoplasma, 
and endotoxin, both in-process and in final product, as well as for reagents 
handled in open systems; and (b) plan of action if a sample tests positive after the 
product has been administered to a patient. 

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Approval date: 15-Feb-2018 
 
 
 
Specific data supporting release of product for patient administration will become part 
of the file.  These are detailed in the SOPs, batch record, and certificate of analysis 
for the final vaccine product. 
 
9.2.9. Peripheral blood and bone marrow mononuclear cells (PBMC) and T 
lymphocytes 
These will be obtained from all patients on the study and are required for the in vitro 
response assessments.  Either bulk PBMC or marrow MNCs or enriched populations of 
T cells may be obtained as a by-product of the above separation procedures, or directly 
from a leukapheresis, phlebotomy product, or marrow aspiration.  This trial is not 
designed to stimulate T cells ex vivo for in vivo administration.  It is preferred that 
assessments of T cell responses pre- and post- vaccination not use T cells obtained as 
a by-product of G-CSF elicited leukapheresis because of the potential effect of G-CSF 
on altering T cell responses in vitro. 
 
9.3. 
Langerhans cell vaccination protocol 
 
Cells are harvested after maturation as above and assessed per the release criteria as 
outlined.  Cells are then washed free of culture medium, medium reagents, and 
cytokines.  The wash fluid and diluent for the injections will be sterile, endotoxin-free, 
clinical grade normal saline (Normosol, or Isolyte, for injection, supplemented with 1% 
human serum albumin). 
Route of administration will be intradermal, with a usual volume of 0.1 ml and a 
maximum volume of 0.2ml injected at any one site. This usually entails 10 separate 
injections per vaccine administration.  Sites of injection should drain to an intact 
lymphatic bed, and not to an area of prior surgery, such as lymph node dissection. 
Injection sites will be rotated randomly and may be split between preferably no more 
than two areas, e.g., right upper inner arm (draining to right axillary nodes) and left 
upper inner thigh (draining to left inguinal nodes); or bilateral upper inner arms (draining 
to bilateral axillary nodes); or right upper inner arm and inner thigh (draining to right 
axillary and inguinal nodes). 
All patients will receive 9x106 LCs per vaccine x 3.  Concentration of the cellular 
vaccines will be adjusted so that each dose is split between as many as ~10 fractions 
with ~3x105 to ~1x106 LCs per 100-200 µl per injection. 
Dosing is based on actual LC counts derived from direct hemacytometer counts and 
flow cytometry analysis as specified in the batch record and SOPs.  These cell doses 
are actual/final and do not represent a cell number per kg of recipient weight.  All 
patients will receive an initial vaccine and two booster vaccinations. 
 
Vaccines will be administered at MSKCC or at The Rockefeller University/Center for 
Clinical & Translational Science.  Only MSKCC physicians with a dual appointment at 
The Rockefeller University will administer vaccines at The Rockefeller University. 
 
10.0 
EVALUATION DURING TREATMENT/INTERVENTION 
 
For disease status monitoring, patients will be clinically monitored according to MSKCC 
standards of care for multiple myeloma (ISS stages I-III), which are consistent with NCCN 
Guidelines for multiple myeloma. 
 
In addition to standard clinical care for multiple myeloma, patients receiving the vaccine will 
be evaluated for post-vaccine safety and toxicity, as well as measurement of delayed type 
hypersensitivity (DTH) reactions, at each vaccine-related clinic visit after the initial vaccine 
(e.g., day +30, day +30+2d, day +90, day +90+2d).  Vaccine administration dates include a 

Page 19 of 35 
Memorial Sloan Kettering Cancer Center 
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Approval date: 15-Feb-2018 
 
 
 
window of ±4 days for the first vaccine and ±7 days for the last two vaccines. The day +120, 
day +180, and day +365 follow-up visits and assessments include a window of ±7 days. For 
additional details, see Sections 11 and 12 of the protocol. 
 
For patients on the vaccine arm of the study, in vitro lymphocyte responses by 
mononuclear cells or T cells enriched from peripheral blood and bone marrow will be 
determined using peripheral blood mononuclear cells (PBMCs) and bone marrow 
mononuclear cells (MNCs) collected pre-transplant before the start of vaccination, as well as 
PBMCs and bone marrow MNCs collected at one month (day +120 post-transplant) and 
three months (day +180 post-transplant) after the last vaccine given on day +90 post- 
transplant, and PBMCs on day +365 post-transplant.  Blood will be collected by steady-state 
leukapheresis on day +120, with the option of substituting leukapheresis with a buffy coat 
(leukocyte concentrate) of an autologous unit of blood if the patient has inadequate venous 
access.  Blood will also be collected from a buffy coat on day +180, and from a peripheral 
blood draw on day +365.  Post-vaccine bone marrow samples, as well as additional studies 
as clinically indicated, will be obtained at days +120 and +180, as part of vaccine response 
evaluation.  An additional bone marrow evaluation at day +365 will be performed as clinically 
indicated at the discretion of the treating physician.  Post-vaccination lymphocyte responses 
will be compared with pre-immunization baseline values. 
 
For patients on the control arm of the study, no steady-state leukapheresis will be required. 
For these patients, in vitro lymphocyte responses by mononuclear cells or T cells enriched 
from peripheral blood will be determined using peripheral blood mononuclear cells (PBMCs) 
collected pre-transplant, as well as PBMCs collected at four months (day +120) and six 
months (day +180) after transplant from the buffy coat (leukocyte concentrate) of an 
autologous unit of blood, and PBMCs collected at 12 months (day +365) from a peripheral 
blood draw.  A bone marrow sample, as well as additional studies as clinically indicated, will 
be obtained at day +180.  A day +120 bone marrow evaluation is optional for the control 
group.  A day +365 bone marrow evaluation will be performed as clinically indicated at the 
discretion of the treating physician.  Post-transplant lymphocyte responses will be compared 
with pre-transplant baseline values. 
 
 
 
 
 
 
 
 
 
Clinic visits, tests, and vaccine schedule will be as follows: 
 
ASCT 
Vaccination schedule1 
Post-treatment 
assessments 
Prior 
to 
ASCT2 
Day 
-2 
Day 
0 
Day 
+12 
Day 
+30 
Day 
+32 
Day 
+90 
Day 
+92 
Day 
+120 
Day 
+180 
Day 
+365 
Window (days) 
±4 
±7 
±7 
±7 
±7 
±7 
±7 
±7 
Clinic visit 
x 
x3 
x3 
x3 
x 
x 
x 
x 
x 
Demographics 
x 
Medical history 
x 
Physical exam 
x 
Vital signs 
x 
HLA high-res typing (A, B, C, DR, DQ) 
x 
HIV, Hep B, Hep C testing 
x 
Complete blood count 
x 
x 
x 
x 
x 
x 
Comprehensive  panel 
x 
x 
x 
x 
x 
x 
Myeloma serum analyses4 
x 
x 
x 
x 
x 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
Myeloma 24-hr urine analyses5 
x 
x 
x6 
x6 
x6 
Research blood 
x 
x 
x 
x 
x 
x 
x 
Bone marrow aspiration and/or 
biopsy 
x 
x 
x7,8 
x7 
x13 
Research bone marrow aspiration 
x 
x 
x8 
x 
x13 
Leukocyte concentrate (buffy coat) 
x9 
x11 
x 
Stem cell mobilization & collection 
(per MSKCC standard of care) 
x 
Leukapheresis (G-CSF +/- plerixafor- 
primed) 
x 
High-dose melphalan 
x10 
Stem cell reinfusion 
x 
Vaccine administration 
x 
x 
x 
Lenalidomide maintenance therapy 
x12 
Leukapheresis   (steady-state) 
x11 
DTH check 
x 
x 
Post-vaccine safety & toxicity check 
x 
x 
x 
x 
 
1Vaccines #2 (day +30) and #3 (day +90) to be administered only on Mon/Tue/Wed to avoid DTH checks (day + 32 and day +92) falling 
on a Sat/Sun. 
2Pre-transplant tests may be repeated as clinically indicated. 
3Clinic visit or in hospital if still admitted for ASCT. 
4Myeloma serum analyses include: LDH, phosphorus, serum protein electrophoresis, serum immunofixation, serum free light chains, 
quantitative immunoglobulins. 
5Myeloma 24-hr urine analyses include: Urine protein electrophoresis, urine immunofixation, total protein. 
6Myeloma 24-hr urine analyses optional. 
7Bone marrows on day +120 and +180 only require a research aspirate, with additional samples/tests performed as clinically indicated. 
8Day +120 bone marrow aspiration is optional for patients on the control arm. 
9Pre-ASCT buffy coat collection should be performed prior to exposure to stem cell mobilization agents (e.g., G-CSF +/- Mozobil) or at 
least 7 days after completion of stem cell collection to allow an adequate G-CSF +/- Mozobil w ashout period. 
10High-dose melphalan may be given over two days (day -3 and -2). 
11At day +120, patients on the vaccine arm of the study will undergo steady-state leukapheresis with the option of having a buffy coat 
collection instead if venous access is deemed inadequate. Patients on the control arm of the study will have a buffy coat collection. 
12Lenalidomide maintenance to start at approximately day +90 without a definedw indow , as deemed clinically appropriate. 
13 Day +365 bone marrow aspiration and/or biopsy will be performed as clinically indicated at the discretion of the treating physician. 
NOTE: Vaccination schedule, vaccine administration, day +32 and day +92 clinic visits for DTH check, and post-vaccine safety and 
toxicity checks only apply to patients on the vaccine arm of the study. 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
11.1 TOXICITIES/SIDE EFFECTS 
 
Toxicity will be graded according to standard NCI/CTEP toxicity criteria.  The only toxicities 
captured outside of the SAEs reported will be all grade 1-5 toxicites deemed definitely, 
probably, or possibly related to the vaccine portion of the study. This protocol will use the 
Common Terminology Criteria for Adverse Events (CTCAE) v4.0 for toxicity and adverse 
event reporting to the Food and Drug Administration.  Copies of Adverse Event Reports will also 
be sent to Chief, RAB, CTEP, EPN/718, Bethesda, MD 20892.  A copy of the CTCAE version 
4.0 can be downloaded from the internet (http://evs.nci.nih.gov/ftp1/CTCAE/About.html).  All 
treatment areas at MSKCC have internet access to a copy of the CTCAE version 4.0. 
 
The safety of the vaccine will be monitored and graded according to the CTCAE v4.0 for 
toxicity and adverse event reporting to the Food and Drug Administration.  Dose limiting 
toxicity (DLT) is defined as grade 3 or higher toxicity.  The observation period for a DLT will 
continue for one month after the last vaccine.  Patients will also be monitored for immune 
response adverse events9. 
 
Toxicities of LCs, the plasmid expression vectors, and CT7, MAGE-A3, and WT1 mRNA are 
listed in detail in Section 5 of the protocol.  Additional potential toxicities related to the 
protocol include: 
• 
Autoimmune or hypersensitivity reactions to autologous LCs are theoretical possibilities. 
• 
Autoimmunity to CT antigens is a potential side effect of vaccination.  One advantage of 
targeting CT antigens for MM is that their expression is limited to tumor cells and not 
normal tissue, except the testis
18.  The expression in testis is unlikely to result in 
autoimmune-mediated damage because the only normal cells in the testis that express 
CT antigens are germ cells, which lack expression of HLA molecules on their surface, 
rendering them unable to present antigens to the adaptive immune system.  CT antigen- 
directed immunotherapies have been well-tolerated by patients in numerous clinical 
trials57-60. 
• 
Because WT1 is expressed at low levels by normal kidney and bone marrow stem cells, 
there is a potential risk for inducing nephritis or marrow suppression, respectively.  This 
risk, however, is expected to be extremely low.  Patients with AML in remission often 
have detectable levels of WT1-specific CTLs61  but do not develop renal impairment or 
marrow suppression.  Also, WT1 antigen-directed immunotherapies have been well- 
tolerated by patients in numerous clinical trials42,62-64. 
• 
WT1 is also expressed at low levels in the normal ovary and testis.  In normal individuals, 
it is therefore possible that WT1-sensitized T cells could cause sterility.  Patients eligible 
for this trial, however, will have already received chemotherapy and myeloablative 
conditioning at doses expected to induce sterility prior to their initial vaccine.  As a result, 
the potential incremental risk of WT1-sensitized T cells reacting against gonadal cells is 
expected to be limited. 
• 
Mild local inflammation, swelling, and pruritus (positive DTH response) at the injection site 
are possible.  Due to the nature of this treatment and expected mild reaction(s), only grade 
3-4 toxicities will be evaluated. 
• 
Infection is a possible risk associated with any injection, particularly the injection of biologics. 
Precautions are taken to ensure sterility, which is confirmed by both in-process and final 
product cultures for bacterial and fungal contaminants, negative gram stain of final product, 
negative testing for mycoplasma, and absence of significant levels of endotoxin. 
• 
There are no anticipated risks of other uses of recombinant human cytokines in vitro, as 
none of these will be administered directly in vivo to the patients.  All cells are washed free 
of these cytokines before administration of the cellular vaccines. 
• 
Safety and toxicity are primary endpoints of this phase I study, especially with respect to 
the administration of LCs that have undergone electroporation with mRNA.  Patients in 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
this trial will not receive direct injections of the plasmid expression vector used to produce 
mRNA. 
 
12.0 
CRITERIA FOR THERAPEUTIC RESPONSE/OUTCOME ASSESSMENT 
 
Note:  12.2 and 12.4 only apply to patients on the vaccine arm of the study 
 
12.1. 
In vitro lymphocyte responses 
Studies will include measurements of T cell responses, e.g., intracellular cytokine 
secretion assays, CTL responses, and T cell immune reconstitution (e.g., TCR 
repertoire diversity), determined before and after LC vaccinations, by rechallenging 
lymphocytes in vitro with the immunizing antigens overnight and for 6-7 days, but 
without exogenous cytokines or repeated restimulations.  Control patients will have 
samples taken at the identical time points and assayed in the same way. 
See also Biostatistics (Section 14) for analysis of response assessments. 
 
12.2. 
Clinical - DTH responses 
DTH responses to intradermally injected, LC vaccinations will be evaluated after each 
booster dose whenever possible, limited only by patient availability and compliance. 
If a patient cannot return to the Center for evaluation, he/she will be instructed how to 
take correct measurements.  Injection sites will be monitored clinically for DTH at 
approximately 48 hrs, with measurements of erythema and induration.  There is an 
option to biopsy DTH sites with pathologic review. 
 
12.3. 
Clinical monitoring of patients during and after treatment 
Patients will be clinically monitored according to MSKCC standards of care for  
multiple myeloma (ISS stages I-III), which are consistent with NCCN Guidelines for 
multiple myeloma.  The guidelines for multiple myeloma include specific response criteria 
as defined by the International Myeloma Working Group (IMWG) in Appendix A.  Clinical 
data will be monitored as secondary endpoints for correlation with T cell responses in 
vitro.  These comprise descriptive and preliminary progression-free survival data to 
assist in the design of a follow-up study, if the LC vaccines prove successful for the 
principal endpoints of safety and immune responses. 
 
12.4. 
Long-term follow-up of patients receiving mRNA-electroporated LCs 
Blood draws will be performed at one and three months after the last vaccine to 
monitor immune responses.  There will be no additional follow-up beyond that which 
is standard because mRNA is extremely labile, has a short half-life, and poses no risk 
of genome integration
39.  In addition, patients will not directly receive mRNA in this 
study.  As mentioned above, patients will be clinically monitored according to MSKCC 
standards of care for multiple myeloma. 
 
13.0 
CRITERIA FOR REMOVAL FROM STUDY 
 
13.1. 
Autoimmunity 
Treatment will be discontinued if evidence of unacceptable grade 3 (NCI/CTEP 
Common Terminology Criteria for Adverse Events (CTCAE) v4.0: 
http://evs.nci.nih.gov/ftp1/CTCAE/About.html)  autoimmunity develops. 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
13.2. 
Anaphylaxis 
Treatment will be discontinued for anaphylactic reactions (grade 4 NCI/CTEP Common 
Terminology Criteria for Adverse Events (CTCAE) v4.0: 
http://evs.nci.nih.gov/ftp1/CTCAE/About.html). 
 
13.3. 
Disease progression 
Treatment will be discontinued if the patient develops progression of disease. 
 
13.4. 
Other 
Treatment will be discontinued according to a patient‟s expressed wishes, or at the 
discretion of the responsible or treating physician of record.  This may include currently 
unanticipated toxicities from administration of mRNA-electroporated LCs.  Patients may 
also be removed from study for failure of compliance. 
 
14.0 
BIOSTATISTICS 
 
This is a phase I study designed to assess the safety and efficacy of Langerhans cells (LCs) 
bearing CT7, MAGE-A3, and WT1 expressed after electroporation with CT7, MAGE-A3, and 
WT1 mRNA when administered as a cell-based vaccine to patients with ISS stage I-III MM. 
 
14.1. 
Patient enrollment and stopping rules 
Ten patients will be randomly assigned to receive CT7, MAGE-A3, and WT1 mRNA- 
electroporated LCs on days +12, +30, and +90 after ASCT, after standard melphalan 
200mg/m2 cytoreduction.  A separate cohort of ten patients will be randomly  
assigned to exactly the same cytoreduction, ASCT, and standard supportive care but 
will NOT receive any LC vaccines.  All patients will receive post-transplant 
lenalidomide maintenance therapy beginning at approximately day +90 after ASCT
1,2. 
 
The safety of the vaccine will be monitored and graded according to the Common 
Terminology Criteria for Adverse Events (CTCAE) v4.0 for toxicity and adverse event 
reporting to the Food and Drug Administration.  Dose limiting toxicity (DLT) is defined 
as grade 3 or higher toxicity.  The observation period for a DLT will continue for one 
month after the last vaccine.  The study will be stopped if at any time during accrual 
three DLTs occur.  This decision is based on the calculation that if at least three of 
ten DLTs were observed, the 90% lower confidence bound on the probability of a 
dose limiting toxicity is greater than 0.10. 
 
Another objective of the study is to compare changes in phenotypic and  
polyfunctional antigen-specific CD4+  and CD8+  T cell responses (intracellular cytokine 
secretion assays), cytolytic T lymphocyte (CTL) responses, and TCR repertoire 
diversity.  T cell responses will be evaluated within a given patient at one and three 
months after the third and final vaccine, compared against that patient‟s pretreatment 
baseline.  The antigen that maximizes this change for each patient will be used for  
the comparison between the vaccine and control groups. The rank sum test statistic 
will be used to compare the maximum change in T cell response between groups. 
Phenotypic T cell immune reconstitution will be evaluated descriptively by flow 
cytometry for both groups and analyzed separately from the above. 
 
A power function for the rank sum test statistic, based on the Lehmann alternative, 
may be computed using a single parameter; the odds a patient in the vaccine group 
has a maximum T cell response that is larger than a patient in the control group. 
Using 10 patients per group, the power function for a one-sided .05 level test is 
provided in the table below.  Note that an odds of 1:1 corresponds to the null 

Page 24 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
hypothesis of no difference between groups.  Assuming the odds are 4:1 that a 
patient in the vaccine group has a greater T cell response, the power of this test is 
0.78. 
 
Odds 
1.0 
2.0 
3.0 
4.0 
5.0 
6.0 
Power 
0.04 
0.34 
0.61 
0.78 
0.87 
0.92 
 
At the conclusion of the study, if a clear superiority is demonstrated for the vaccine 
group, a single arm phase 2 clinical trial study will be initiated using a time to 
progression endpoint.  If the study is stopped due to toxicity, an exploratory analysis 
of the immunogenicity will be undertaken rather than the comparative analyses. 
 
The clinical responses use only descriptive statistics, including the DTH 
measurements and preliminary determinations of PFS as per the consensus 
recommendations from the International Myeloma Workshop Consensus Panel I65. 
These data will only assist in the design of a followup study, if the LC vaccines prove 
successful for the principal endpoints of safety and immune responses. 
 
14.2. 
Inevaluable patients and/or removal from study 
Patients will be deemed inevaluable if they go off study for any reason other than 
dose-limiting or treatment-related toxicity (e.g., leave or refuse treatment, experience 
progression of disease, are non-compliant, etc.), or if they have not yet received all 
three vaccinations (primary immunization plus two boosters) and provided follow-up 
blood samples with sufficient yields for post-vaccination response testing in vitro.  A 
new patient will replace such an inevaluable patient.  Patients that discontinue 
treatment for any toxicity will not be replaced.  Patient replacement will not occur until 
evaluation determines that a patient left the study for reasons other than toxicity.  All 
patients who have received at least one vaccination, including those deemed 
inevaluable and/or removed from study, will continue to be monitored for safety. 
 
15.1 
RESEARCH PARTICIPANT REGISTRATION AND RANDOMIZATION PROCEDURES 
 
15.2 
Research Participant Registration 
Confirm eligibility as defined in the section entitled Inclusion/Exclusion Criteria. 
Obtain inform ed consent, by following procedures defined in section entitled 
Informed Consent Procedures. During the registration process registering 
individuals will be required to complete a protocol specific Eligibility Checklist. The 
individual signing the Eligibility Checklist is confirming whether or not the 
participant is eligible to enroll in the study. Study staff are responsible for ensuring 
that all institutional requirem ents necessary to enroll a participant to the study 
have been completed. See related Clinical Research Policy and Proc edure # 401 
(Protocol Participant Registration). 
 
 
 
15.3 
Randomization 
Patients will be randomized prior to stem cell collection to receive the LC vaccines after 
ASCT or to receive no vaccine.  All patients will receive the same cytoreduction, ASCT, 
standard supportive care, and post-transplant lenalidomide maintenance therapy 
beginning at day approximately +90 after ASCT.  After eligibility is established and 
immediately after consent is obtained, patients will be registered in the Protocol 
Participant Registration (PPR) system and randomized using the Clinical Research 
Database (CRDB), by calling the MSKCC PPR Office at 646-735-8000 between the 

Page 25 of 35 
Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
hours of 8:30 am and 5:30 pm, Monday - Friday.  Randomization will be 
accomplished by the method of random permuted block. 
 
16.1 
DAT A M ANAGEMENT ISSUES 
 
16.2 
Quality Assurance 
There are several different mechanisms by which clinical trials are monitored for data, 
safety and quality.  There are institutional processes in place for quality assurance 
(e.g., protocol monitoring, compliance and data verification audits, therapeutic 
response, and staff education on clinical research QA) and departmental procedures 
for quality control, plus there are two institutional committees that are responsible for 
monitoring the activities of our clinical trials programs.  The committees: Data and 
Safety Monitoring Committee (DSMC) for Phase I and II clinical trials, and the Data 
and Safety Monitoring Board (DSMB) for Phase III clinical trials, report to the Center‟s 
Research Council and Institutional Review Board. 
A data manager will be assigned to the study.  The responsibilities of the data 
manager include project compliance, data collection, abstraction and entry, data 
reporting, regulatory monitoring, and coordination of the protocol study team.  The 
data collected for this study will be entered into a secure database (Clinical Research 
Database, CDRB). 
As described in Section 9.2, all laboratory methods will be conducted under GMP-GTP 
like environment using SOPs of the Laboratory of Cellular Immunobiology. 
 
16.3 
Data and Safety Monitoring 
The Data and Safety Monitoring (DSM) Plans at Memorial Sloan-Kettering Cancer 
Center were approved by the National Cancer Institute in September 2001.  The 
plans address the new policies set forth by the NCI in the document entitled “Policy of 
the National Cancer Institute for Data and Safety Monitoring of Clinical Trials” which 
can be found at:   http://www.cancer.gov/clinicaltrials/conducting/dsm -  
guidelines/page1. The DSM Plans at MSKCC were established and are monitored by 
the Office of Clinical Research.  The MSKCC Data and Safety Monitoring Plans can 
be found on the MSKCC Intranet at: 
 
http ://inside2 /c linre searc h/Doc ume nts/MSKCC%20Da ta%20a nd%20Sa fety%20Mo nit  
oring%20P la ns.pd f 
 
There are several different mechanisms by which clinical trials are monitored for data, 
safety and quality.  There are institutional processes in place for quality assurance 
(e.g., protocol monitoring, compliance and data verification audits, therapeutic 
response, and staff education on clinical research QA) and departmental procedures 
for quality control, plus there are two institutional committees that are responsible for 
monitoring the activities of our clinical trials programs.  The committees: Data and 
Safety Monitoring Committee (DSMC) for Phase I and II clinical trials, and the Data 
and Safety Monitoring Board (DSMB) for Phase III clinical trials, report to the Center‟s 
Research Council and Institutional Review Board. 
 
During the protocol development and review process, each protocol will be assessed 
for its level of risk and degree of monitoring required.  Every type of protocol (e.g., 
NIH sponsored, in-house sponsored, industrial sponsored, NCI cooperative group, 
etc.) will be addressed and the monitoring procedures will be established at the time 
of protocol activation. 
 
16.4 
Regulatory Documentation 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
The Rockefeller University should submit this protocol to their IRB according to local 
guidelines. Copies of any site IRB correspondence should be forwarded to MSKCC. 
 
17.1 
PROTECTION OF HUMAN SUBJECTS 
 
17.2 
Privacy 
MSKCC‟s Privacy Office may allow the use and disclosure of protected health 
information pursuant to a completed and signed Research Authorization form. The 
use and disclosure of protected health information will be limited to the individuals 
described in the Research Authorization form. A Research Authorization form must 
be completed by the Principal Investigator and approved by the IRB and Privacy 
Board (IRB/PB). 
 
17.3 
Serious Adverse Event (SAE) Reporting 
An adverse event is considered serious if it results in ANY of the following outcomes: 
• 
Death 
• 
A life-threatening adverse event 
• 
An adverse event that results in inpatient hospitalization or prolongation of existing 
hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
A congenital anomaly/birth defect 
• 
Important Medical Events (IME) that may not result in death, be life threatening, or 
require hospitalization may be considered serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition 
Note: Hospital admission for a planned procedure/disease treatment is not considered an 
SAE. 
 
SAE reporting is required as soon as the participant signs consent.  SAE reporting is 
required for 30-days after the participant‟s last investigational treatment or intervention. Any 
events that occur after the 30-day period and that are at least possibly related to protocol 
treatment must be reported. 
 
If an SAE requires submission to the IRB office per IRB SOP RR-408 „Reporting of Serious 
Adverse Events‟, the SAE report must be sent to the IRB within 5 calendar days of the event. 
The IRB requires a Clinical Research Database (CRDB) SAE report be submitted 
electronically to the SAE Office as follows: 
 
For IND/IDE trials: Reports that include a Grade 5 SAE should be sent to  
saegrade5@mskcc.org.  All other reports should be sent to saemskind@mskcc.org. 
 
For all other trials: Reports that include a Grade 5 SAE should be sent to  
saegrade5@mskcc.org.  All other reports should be sent to sae@mskcc.org. 
The report should contain the following information: 
Fields populated from CRDB: 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
• 
Subject‟s initials 
• 
Medical record number 
• 
Disease/histology (if applicable) 
• 
Protocol number and title 
Data needing to be entered: 
• 
The date the adverse event occurred 
• 
The adverse event 
• 
The grade of the event 
• 
Relationship of the adverse event to the treatment (drug, device, or intervention) 
• 
If the AE was expected 
• 
The severity of the AE 
• 
The intervention 
• 
Detailed text that includes the following 
o A explanation of how the AE was handled 
o A description of the subject‟s condition 
o Indication if the subject remains on the study 
• 
If an amendment will need to be made to the protocol and/or consent form 
• 
If the SAE is an Unanticipated Problem 
The PI‟s signature and the date it was signed are required on the completed report. 
For IND/IDE protocols: 
The CRDB SAE report should be completed as per above instructions.  If appropriate, the 
report will be forwarded to the FDA by the SAE staff through the IND 
 
 
17.4 
Potential Risks 
Potential risks and toxicities associated with the therapeutic agents used in this study 
are described in detail in Section 5 and Section 11. 
 
17.5 
Potential Benefits 
There are no inducements to participation, implied or expressed.  There is no financial 
remuneration for participation.  There is no promise or guarantee of a positive response. 
The potential benefit to individual participants is a positive laboratory response to 
immunization with autologous LCs and peptide, which may or may not have an effect on 
the clinical course of the primary disease.  Otherwise, the investigators anticipate at 
least an improved understanding of the immunologic mechanisms underlying human 
cellular responses to malignancy, which may provide the basis for improved 
therapeutics for future patients. 
 
17.6 
Reduction of Potential Risks 
A dedicated GMP Facility will be used for tissue culture involving cells that will be used 
in vaccines for human administration. 
There will be no mixing of samples between patients/study participants in the same 
biosafety hood or incubator section at the same time. 
All samples in culture, in process, or in cryopreserved storage will be clearly identified 
using the SOP for labeling of samples. 

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Memorial Sloan Kettering Cancer Center 
IRB Number: 13-009 A(14) 
Approval date: 15-Feb-2018 
 
 
 
Sterile or aseptic technique will be followed in all patient contacts and in all contacts with 
blood or blood products using universal precautions. 
Aseptic technique in laminar airflow hoods will be used in all manipulations of cells, 
peptides, and associated reagents that will be returned to patients in the form of 
vaccines. 
Cultures will be monitored daily in process for any microscopically visible evidence of 
bacterial or fungal contamination. 
Sterility testing for detection of bacterial and fungal contaminants will be performed in 
the MSKCC Clinical Microbiology Laboratory, which is a New York State licensed and 
JCAHO accredited clinical laboratory.  The MSKCC Clinical Microbiology Laboratory 
cultures and reports results of our experimental products for sterility, based on 14 day 
cultures in thioglycollate broth at 35oC and tryptic soy broth at 25oC.  These cultures 
are monitored on day 3, 4, or 5, on day 7 or 8, and finally on day 14.  Negative 
cultures are monitored for a total of fourteen days before a final report of no growth is 
issued.  These procedures comply with 21 CFR 610.12.  Positive cultures are 
subcultured to other media as required to identify the contaminating organism(s) and 
determine antibiotic sensitivities. Any update to the culture system in the Clinical 
Microbiology Laboratory will adhere to these processes and criteria at a minimum. 
Acceptance criteria for release of the LCs for vaccination require no growth of bacteria 
or fungus at the time of administration, based on cultures in-process (aerobic and 
anaerobic) taken after the last culture manipulation and cytokine feeding which will have 
been at least approximately 48 hrs before final product administration.  A negative gram 
stain of the final product at the time of administration is also required.  A final set of 
aerobic and anaerobic cultures will be taken from the final product, and assessed as 
above; these results will be available after administration but will become part of the file 
or protocol patient record. 
In the event of a pre-release sterility test failure (i.e., microbial contamination detected 
during in‐process sterility testing), all activities related to the production of the product 
will be suspended until the source of contamination has been identified by 
systematically checking all reagents, consumables, equipment, and facility used in  
the manufacturing process.  GMP facility managers and the QA/QC group will be 
notified.  Vaccination will resume on a revised schedule that closely approximates the 
original one only after the contamination issue has been thoroughly 
investigated/resolved, and any necessary corrective and preventive actions 
implemented. 
In the event of a post-release sterility test failure (i.e., positive bacterial or fungal 
culture result after vaccine administration), the patient and physician will be notified 
immediately, the patient will be medically evaluated, and surveillance blood cultures 
will be drawn and sent to the lab.  Other evaluation and care will follow good clinical 
practice.  Patients are also advised to report any unusual symptoms or fever (100.5oF 
or 38.0oC).  There is 24hr/7d physician coverage by telephone and on-site at Memorial 
Hospital, MSKCC.  The local IRB and the FDA will be notified within 15 calendar days. 
In addition, all activities related to the production and administration of the product will 
be suspended until the source of contamination has been identified by systematically 
checking all reagents, consumables, and equipment used in the manufacturing 
process.  Once a cause has been identified, corrective actions will be taken to  
prevent a recurrence of the incident.  Mycoplasma testing is performed in the 
Monoclonal Antibody Core Facility at Sloan-Kettering Institute using a validated assay 
covered by the IND for this trial.  Mycoplasma testing will be performed on a cell-free 
sample of the culture medium from the final product.  Due to turnaround time for the 
mycoplasma test, test results for the final product will not be known prior to vaccine 
administration.  In the case of a positive result for mycoplasma after administration of 

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Memorial Sloan Kettering Cancer Center 
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the vaccine product, the patient will be contacted to return for clinical evaluation. 
Serial antibody titers against mycoplasma will also be drawn at that visit and 2 
additional times at approximately 3 week intervals.  A significant or positive serologic 
response would require a four-fold rise from the baseline titer.  Any symptomatic 
patient at the time of clinical evaluation (e.g., fever, cough, etc.) would be further 
investigated as appropriate to the presenting symptoms and treated empirically with 
azithromycin 500 mg orally on the first day, followed by 250 mg orally on days 2-5. 
Patients allergic to or intolerant of macrolide antibiotics would be alternatively treated 
with an oral fluoroquinolone. 
Patients will be closely monitored for anaphylaxis or less severe allergic reactions after 
each injection, and treated according to standard clinical measures.  Patients are also 
advised to report any unusual symptoms or fever (100.5oF or 38.0oC).  There is 
24hr/24hr physician coverage by telephone and on-site at Memorial Hospital, MSKCC. 
 
17.7 
Alternatives to Therapy Under This Protocol 
Patients may elect to pursue standard of care therapy appropriate to their 
clinicopathologic stage of multiple myeloma.  Patients may also elect to pursue other 
vaccine trials, other immunotherapy, or other chemotherapy available to them.  A 
patient‟s decision to decline participation in this study, either before or after initial 
enrollment, would in no way prejudice or jeopardize future care at this institution. 
 
17.8 
Financial Costs of Participation 
Patients and/or their third party coverage are expected to pay for all tests that are part 
of the clinical practice standards for managing similar patients as are eligible for this 
study.  Patients are not charged for the generation of LCs in vitro, including the cost 
of isolating the progenitors, cytokines, mRNA production, peptides, or the final 
preparation and administration of the vaccines. 
 
18.1 
INFORMED CONSENT PROCEDURES 
 
Before protocol-specified procedures are carried out, consenting professionals will explain  
full details of the protocol and study procedures as well as the risks involved to participants 
prior to their inclusion in the study. Participants will also be informed that they are free to 
withdraw from the study at any time. All participants must sign an IRB/PB-approved consent 
form indicating their consent to participate. This consent form meets the requirements of the 
Code of Federal Regulations and the Institutional Review Board/Privacy Board of this Center. 
The consent form will include the following: 
1. The nature and objectives, potential risks and benefits of the intended study. 
2. The length of study and the likely follow-up required. 
3. Alternatives to the proposed study. (This will include available standard and 
investigational therapies. In addition, patients will be offered an option of supportive care 
for therapeutic studies.) 
4. The name of the investigator(s) responsible for the protocol. 
5. The right of the participant to accept or refuse study interventions/interactions and to 
withdraw from participation at any time. 
Before any protocol-specific procedures can be carried out, the consenting professional will 
fully explain the aspects of patient privacy concerning research specific information.  In 
addition to signing the IRB Informed Consent, all patients must agree to the Research 
Authorization component of the informed consent form. 
Each participant and consenting professional will sign the consent form. The participant must 
receive a copy of the signed informed consent form. 

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19.0 
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highly sensitive to the granule exocytosis pathway mediated by WT1-specific cytotoxic T 
lymphocytes. Clin Cancer Res. 2004;10(21):7402-7412. 
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induced a minimal response in a patient with advanced therapy-resistant multiple myeloma. 
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Tyler EM, Jungbluth AA, O‟Reilly RJ, Koehne G. Wilms‟ tumor 1 protein-specific T-cell 
responses in high-risk multiple myeloma patients undergoing T-cell depleted allogeneic 
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121(2):308-317.. 
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2004;172(3):1333-1339. 
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Munz C, Dao T, Ferlazzo G, de Cos MA, Goodman K, Young JW. Mature myeloid dendritic 
cell subsets have distinct roles for activation and viability of circulating human natural killer 
cells. Blood. 2005;105(1):266-273. 
32. 
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Langerhans cells and CD14+ dermal dendritic cells. Immunity. 2008;29(3):497-510. 
33. 
Romano E, Cotari JW, Barreira da Silva R, et al. Human Langerhans cells use an IL15- 
alpha/IL15/pSTAT5-dependent mechanism to break T cell tolerance against the self- 
differentiation antigen, WT1. Submitted for publication. 
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Banchereau J, Palucka AK, Dhodapkar M, et al. Immune and clinical responses in patients 
with metastatic melanoma to CD34(+) progenitor-derived dendritic cell vaccine. Cancer Res. 
2001;61(17):6451-6458. 
35. 
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carcinoembryonic antigen (CEA)-specific cytotoxic T lymphocytes in vitro using human 
dendritic cells transfected with RNA. Nat Biotechnol. 1998;16(4):364-369. 
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prostate-specific antigen stimulate prostate-specific CTL responses in vitro. J Immunol. 
2000;164(10):5508-5514. 
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transfected with renal tumor RNA stimulate polyclonal T-cell responses against antigens 
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38. 
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specific antigen RNA stimulate CTL responses against metastatic prostate tumors. J Clin 
Invest. 2002;109(3):409-417. 
39. 
Van Tendeloo VF, Ponsaerts P, Lardon F, et al. Highly efficient gene delivery by mRNA 
electroporation in human hematopoietic cells: superiority to lipofection and passive pulsing of 
mRNA and to electroporation of plasmid cDNA for tumor antigen loading of dendritic cells. 
Blood. 2001;98(1):49-56. 
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specific T lymphocytes in vitro using mRNA-electroporated dendritic cells. Cancer Gene 
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41. 
Milazzo C, Reichardt VL, Muller MR, Grunebach F, Brossart P. Induction of myeloma-specific 
cytotoxic T cells using dendritic cells transfected with tumor-derived RNA. Blood. 
2003;101(3):977-982. 
42. 
Van Tendeloo VF, Van de Velde A, Van Driessche A, et al. Induction of complete and 
molecular remissions in acute myeloid leukemia by Wilms' tumor 1 antigen-targeted dendritic 
cell vaccination. Proc Natl Acad Sci U S A. 2010;107(31):13824-13829. 
43. 
Gilboa E, Vieweg J. Cancer immunotherapy with mRNA-transfected dendritic cells. Immunol 
Rev. 2004;199:251-263. 
44. 
Karan D, Dubey S, Van Veldhuizen P, Holzbeierlein JM, Tawfik O, Thrasher JB. Dual antigen 
target-based immunotherapy for prostate cancer eliminates the growth of established tumors 
in mice. Immunotherapy. 2011;3(6):735-746. 
45. 
Walter S, Weinschenk T, Stenzl A, et al. Multipeptide immune response to cancer vaccine 
IMA901 after single-dose cyclophosphamide associates with longer patient survival. Nat 
Med. 2012. 
46. 
Dhodapkar M, Steinman RM, Sapp M, et al. Rapid generation of broad T-cell immunity in 
humans after single injection of mature dendritic cells. JClinInvest. 1999;104:173-180. 
47. 
Dhodapkar MV, Krasovsky J, Steinman RM, Bhardwaj N. Mature dendritic cells boost 
functionally superior CD8(+) T-cell in humans without foreign helper epitopes [see 
comments]. J Clin Invest. 2000;105(6):R9-R14. 
48. 
Thurner B, Haendle I, Roder C, et al. Vaccination with mage-3A1 peptide-pulsed mature, 
monocyte-derived dendritic cells expands specific cytotoxic T cells and induces regression of 
some metastases in advanced stage IV melanoma. J Exp Med. 1999;190(11):1669-1678. 
49. 
Schuler-Thurner B, Dieckmann D, Keikavoussi P, et al. Mage-3 and influenza-matrix peptide- 
specific cytotoxic T cells are inducible in terminal stage HLA-A2.1+ melanoma patients by 
mature monocyte-derived dendritic cells. J Immunol. 2000;165:3492-3496. 
50. 
Su Z, Dannull J, Yang BK, et al. Telomerase mRNA-transfected dendritic cells stimulate 
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Young JW, Szabolcs P, Moore MAS. Identification of  dendritic cell colony-forming units 
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Caux C, Dezutter-Dambuyant C, Schmitt D, Banchereau J. GM-CSF and TNF- cooperate in 
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Caux C, Massacrier C, Vanbervliet B, et al. CD34+ hematopoietic progenitors from human 
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Functional analysis. Blood. 1997;90:1458-1470. 

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56. 
Jonuleit H, Kuhn U, Muller G, et al. Pro-inflammatory cytokines and prostaglandins induce 
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Kruit WH, van Ojik HH, Brichard VG, et al. Phase 1/2 study of subcutaneous and intradermal 
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Vantomme V, Dantinne C, Amrani N, et al. Immunologic analysis of a phase I/II study of 
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Cilloni D, Gottardi E, Messa F, et al. Significant correlation between the degree of WT1 
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Maslak PG, Dao T, Krug LM, et al. Vaccination with synthetic analog peptides derived from 
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20.0 
APPENDICES 
 
APPENDIX A: International Myeloma Working Group (IMWG) Uniform Response Criteria for 
Multiple Myeloma 
 
The following criteria reconcile various previously used systems for assessing response and have been universally 
adopted. 
 
Response 
IMWG criteria 
sCR 
CR as defined below plus normal FLC ratio and absence of clonal cells in bone marrow 3 by 
immunohistochemistry or immunofluorescen   
4
 
ce
CR 
Negative immunofixation on the serum and urine and disappearance of any soft tissue 
plasmacytomas and < 5% plasma cells in bone marrow3 
VGPR 
Serum and urine M-protein detectable by immunofixation but not on electrophoresis or > 
90% reduction in serum M-protein plus urine M-protein level < 100 mg/24 h 
PR 
> 50% reduction of serum M-protein and reduction in 24 hours urinary M-protein by >90% 
or to < 200 mg/24 h 
If the serum and urine M-protein are unmeasurable,5 a > 50% decrease in the difference 
between involved and uninvolved FLC levels is required in place of the M-protein criteria 
If serum and urine M-protein are not measurable, and serum free light assay is also not 
measureable, > 50% reduction in plasma cells is required in place of M-protein, provided 
baseline bone marrow plasma cell percentage was > 30% 
In addition to the above listed criteria, if present at baseline, a > 50% reduction in the size 
of soft tissue plasmacytomas is also required 
MR 
NA 
No change/Stable disease 
Not meeting criteria for CR, VGPR, PR, or progressive disease 
Plateau 
NA 
Progressive disease
5
 
Increase of > 25% from lowest response value in any one or more of the following: 
• 
Serum M-component and/or (the absolute increase must be > 0.5 g/dL)
6
 
• 
Urine M-component and/or (the absolute increase must be > 200 mg/24 h) 
• 
Only in patients without measurable serum and urine M-protein levels; the 
difference between involved and uninvolved FLC levels. The absolute increase 
must be > 10 mg/dL 
• 
Bone marrow plasma cell percentage; the absolute percentage must be > 10%7 
• 
Definite development of new bone lesions or soft tissue plasmacytomas or 
definite increase in the size of existing bone lesions or soft tissue plasmacytomas 
• 
Development of hypercalcaemia (corrected serum calcium > 11.5 mg/dL or 2.65 
mmol/L) that can be attributed solely to the plasma cell proliferative disorder 
Relapse 
Clinical relapse requires one or more of: 
Direct indicators of increasing disease and/or end organ dysfunction (CRAB features).6 It is 
not used in calculation of time to progression or progression -free survival but is listed here 
as something that can be reported optionally or for use in clinical practice 
• 
Development of new soft tissue plasmacytomas or bone lesions 
• 
Definite increase in the size of existing plasmacytomas or bone lesions. A definite 
increase is defined as a 50% (and at least 1 cm) increase as measured serially by 

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the sum of the products of the cross -diameters of the measurable lesion 
• 
Hypercalcemia (> 11.5 mg/dL) [2.65 mmol/L] 
• 
Decrease in haemoglobin of > 2 g/dL [1.25 mmol/L] 
• 
Rise in serum creatinine by 2 mg/dL or more [177 mmol/L or more] 
Relapse from CR5 (To be 
used only if the end point 
studied is DFS)8 
Any one or more of the following: 
• 
Reappearance of serum or urine M-protein by immunofixation or electrophoresis 
• 
Development of > 5% plasma cells in the bone marrow
7
 
• 
Appearance of any other sign of progression (i.e., new plasmacytoma, lytic bone 
lesion, or hypercalcaemia) 
 
 
1 BGM Durie et al. Inte rnatio nal u niform resp onse criteri a for multipl e myelom a. Leukemia (2006) 1-7.   
Adapted from Durie BGM, et al. Leukemia 2006; 20: 1467-1473; and Kyle RA, Rajkumar SV. Leukemia 2008;23:3 -9. 
Note: A clarification to IMWG criteria for coding CR and VGPR in patients in whom the only measurable disease is by 
serum FLC levels: CR in such patients is defined as a normal FLC ratio of 0.26–1.65 in addition to CR criteria listed above. 
VGPR in such patients is defined as a >90% decrease in the difference between involved and uninvolved free light chain 
(FLC) levels. 
3 Confirmation with repeat bone marrow biopsy not needed. 
4 Presence/absence of clonal cells is based upon the kappa/lambda ratio. An abnormal kappa/lambda ratio by 
immunohistochemistry and/or immunofluorescence requires a minimum of 100 plasma cells for analysis. An abnormal ratio 
reflecting presence of an abnormal clone is kappa/lambda of > 4:1 or < 1:2. 
5 All relapse categories require two consecutive assessments made at any time before classification as relapse or disease 
progression and/or the institution of any new therapy. In the IMWG criteria, CR patients must also meet the criteria for 
progressive disease shown here to be classified as progressive disease for the purposes of calculating time to progression 
and progression-free survival. The definitions of relapse, clinical relapse and relapse from CR are not to be used in 
calculation of time to progression or progression-free survival. 
6 For progressive disease, serum M-component increases of >1 gm/dL are sufficient to define relapse if starting M- 
component is >5 g/dL. 
7 Relapse from CR has the 5% cut-off versus 10% for other categories of relapse. 
8 For purposes of calculating time to progression and progression -free survival, CR patients should also be evaluated 
using criteria listed above for progressive disease.