A Randomized, Prospective, Phase II Study to Determine the Efficacy of Bacillus Calmette-Guerin (BCG) Given in Combination With PANVAC[TM] Versus BCG Given Alone in Adults With High Grade Non-Muscle Invasive Bladder Cancer (NMIBC) Who Failed at Least 1 Induction Course of BCG
Phase: PHASE2
Conditions: Bladder Cancer
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: Vaccine and BCG for bladder ca
Version Date: 05/22/2025
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Abbreviated Title: Vaccine and BCG for Bladder Ca
CC Protocol #: 14-C-0036
CTEP Protocol #: 9539
OSP#: 1310-1269
Version Date:   05/22/2025
NCT #: NCT02015104
IBC#: RD-13-X-04
Title:  A Randomized, Prospective, Phase II Study to Determine the Efficacy of Bacillus 
Calmette-Guerin (BCG) given in combination with PANVAC™ versus BCG given alone in 
Adults with High Grade Non-Muscle Invasive Bladder Cancer (NMIBC) who failed at least 1 
Induction Course of BCG
NCI Principal Investigator:
Raju Chelluri, MD
Urologic Oncology Branch (UOB)
Center for Cancer Research (CCR)
National Cancer Institute (NCI)
National Institutes of Health (NIH)
10 Center Drive, 1-5940
Bethesda, MD 20892
Phone: 240-858-3700
CTEP Supplied Investigational Agents:
Note: Study closed with CTEP as of 5/1/2019
Agent name
IND #
IND Sponsor
Manufacturer
PANVAC-V [Recombinant Vaccinia-
CEA(D609)/MUC1(L93)/TRICOM] 
NSC 727026 
IND 11660 
CTEP
Therion Biologics
PANVAC-F [Recombinant Fowlpox-
CEA(D609)/MUC1(L93)/TRICOM] 
NSC 727027
IND 11660
CTEP
Therion Biologics
Commercially available agents:
TICE Bacillus Calmette-Guerin (BCG), NSC 614388

Abbreviated Title: Vaccine and BCG for bladder ca
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PRÉCIS 
Background:
•
High grade (G3) non-muscle invasive urothelial carcinoma of the bladder (stages Ta, T1, and 
CIS) has a high rate of recurrence and progression
•
The standard of care therapeutic agent is a single induction course of bacillus Calmette-
Guerin (BCG)
•
Although a second induction course can be used in patients who fail a single induction course 
of BCG, only 35% of patients who failed an initial induction course will experience 12 
month disease-free survival after receiving a second induction course 
•
For those patients failing a second induction course, radical cystectomy with pelvic 
lymphadenectomy is the recommended treatment, although it has a high morbidity rate and a 
small but real mortality rate
•
Therefore, there is an unmet need for localized treatment for patients who fail an initial 
induction course of BCG that can potentially improve upon the poor results of a second 
induction course of BCG
•
Recently, a unique pox viral vector-based vaccine, PANVAC™, has been shown to induce a 
CD4 and CD8 antigen-specific immune response against the tumor-associated antigens 
(TAAs), carcinoembryonic antigen (CEA) and mucin-1 (MUC-1).  This vaccine also 
contains transgenes for three human T cell co-stimulatory molecules that can potentially 
augment an immune response
•
We hypothesize that the combined administration of BCG and PANVAC™ may augment the 
BCG-induced cytotoxic T lymphocyte response against bladder cancer cells expressing 
MUC-1 and/or CEA and potentially reverse BCG failure in patients that have failed one 
induction course of BCG
Objectives:
•
To determine if there is an improvement in disease-free survival (DFS*) with BCG + 
PANVAC compared with BCG alone in a phase II study in non-muscle invasive high-grade 
urothelial carcinoma of the bladder who have failed to respond to intravesical BCG.
*within 1 year post treatment
Eligibility:
•
Individuals who have failed at least one previous induction course of intravesical BCG, 
defined as histologically confirmed persistent or relapsing tumor present on post-BCG 
endoscopic evaluation.  All BCG failures will be considered for inclusion into the study, 
including BCG-refractory, -resistant, and -relapsing, as defined in the “Rationale and 
Background.”  For the purposes of the study, “BCG-refractory” and “BCG-resistant” subjects 
will be considered to have “BCG-persistent” disease.
•
Patients who are not currently candidates for radical cystectomy (e.g. patient refuses surgery, 
comorbidities preclude major surgery, etc.).
•
Normal organ function, ECOG 0-2.

Abbreviated Title: Vaccine and BCG for bladder ca
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Design:
•
This is a randomized, open label prospective, Phase II study in subjects with non-muscle 
invasive high grade urothelial carcinoma of the bladder who have failed at least one 
induction course of intravesical BCG, randomized to one of the following arms:  TICE BCG 
+PANVAC™ or TICE BCG alone. Randomization is stratified by BCG treatment subgroup.
•
All subjects will receive intravesical TICE BCG (50mg) as per usual standard of care once 
weekly (+/- 2 days) starting in week 3 for a total of 6 weeks.
•
The combination arm will receive the pox viral vaccines that contain the transgenes for CEA 
and MUC-1 (both with modified HLA-A2 agonist epitopes) as well as 3 human T-cell 
costimulatory molecules, B7-1, ICAM-1, and LFA-3 [rV-PANVAC™ (vaccinia) and rF-
PANVAC™ (fowlpox)] as follows:
o
rV-PANVAC™ 2 x 108 pfu SQ at week 0 (+/- 7 days) only.
o
rF-PANVAC™1 x 109 pfu SQ at weeks (+/- 7 days) 3, 7, 11, and 15.
•
For this Phase II study, we will test the hypothesis that subjects in the TICE BCG 
+PANVAC™ arm have better disease-free survival than subjects in the TICE BCG alone 
arm.
•
Patient accrual is targeted at one patient per month during the first 6 months and 1-2 patients 
every 1-2 months afterwards, and follow-up period after completing accrual will be 12 
months post treatment.
•
Based on a power of 84% and type 1 error (1-sided) of 0.15, a total of 49 subjects will need 
to be accrued.
•
Allowing for a proportion of the subjects not being evaluable, a maximum of 54 subjects will 
be accrued.

Abbreviated Title: Vaccine and BCG for bladder ca
Version Date: April 7, 2017
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SCHEMA
CT 
Urogram, 
CXR 
prior to 
biopsy

Abbreviated Title: Vaccine and BCG for bladder ca
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TABLE OF CONTENTS
PRÉCIS............................................................................................................................................2
SCHEMA.........................................................................................................................................4
TABLE OF CONTENTS.................................................................................................................5
1
OBJECTIVES......................................................................................................................8
1.1
Primary Objective....................................................................................................8
1.2
Secondary Objectives...............................................................................................8
1.3
Exploratory Objectives ............................................................................................8
2
BACKGROUND .................................................................................................................8
3
PATIENT SELECTION....................................................................................................11
3.1
Eligibility Criteria..................................................................................................11
3.2
Recruitment Strategies...........................................................................................14
3.3
Screening Evaluation .............................................................................................15
3.4
Baseline Evaluation ...............................................................................................15
3.5
Accrual Estimates ..................................................................................................16
4
REGISTRATION PROCEDURES ...................................................................................17
4.1
General Guidelines.................................................................................................17
4.2
Registration Procedures .........................................................................................17
4.3
Randomization Procedures ....................................................................................17
5
TREATMENT PLAN........................................................................................................18
5.1
Study Design..........................................................................................................18
5.2
Trial Outline...........................................................................................................19
5.3
Agent Administration.............................................................................................21
5.4
Dose Limiting Toxicity..........................................................................................22
5.5
General Concomitant Medication and Supportive Care Guidelines......................24
5.6
Duration of Therapy...............................................................................................25
5.7
Duration of Follow Up...........................................................................................25
5.8
Criteria for Removal from Protocol Therapy and Off Study Criteria....................25

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6
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................27
6.1
TICE BCG .............................................................................................................27
6.2
PANVAC™-V (vaccinia) and PANVAC™-F (fowlpox) .....................................27
7
NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING PLAN28
7.1
Definitions..............................................................................................................28
7.2
OHSRP Office of Compliance and Training / IRB Reporting ..............................29
7.3
NCI Clinical Director Reporting............................................................................29
7.4
NCI Guidance for Reporting Expedited Adverse Events for Multi-Center 
Trials ......................................................................................................................29
7.5
NIH Office of Science Policy (OSP)/Institutional Biosafety Committee 
(IBC) Reporting Criteria........................................................................................30
7.6
NIH Required Data and Safety Monitoring Plan...................................................31
8
ADVERSE EVENTS:  LIST AND Sponsor REPORTING REQUIREMENTS..............31
8.1
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs)...............32
8.2
Definitions..............................................................................................................38
8.3
Expedited Adverse Event Reporting to CTEP.......................................................39
8.4
Routine Adverse Event Reporting to CTEP ..........................................................42
8.5
Secondary Malignancy...........................................................................................42
8.6
Second Malignancy................................................................................................43
9
PHARMACEUTICAL INFORMATION..........................................................................43
9.1
CTEP IND Agents .................................................................................................43
9.2
Commercial agent..................................................................................................59
10
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................60
10.1
Laboratory Correlative Studies..............................................................................60
10.2
Sample Storage, Tracking and Disposition............................................................66
11
STUDY CALENDARS .....................................................................................................68
12
MEASUREMENT OF EFFECT .......................................................................................73
12.1
Response Criteria...................................................................................................73
13
DATA COLLECTION AND REPORTING/REGULATORY REQUIREMENTS.........74
13.1
Data Collection ......................................................................................................74

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13.2
Toxicity Criteria.....................................................................................................75
13.3
Data Reporting.......................................................................................................75
13.4
CTEP Multicenter Guidelines................................................................................76
13.5
Collaborative Agreements Language.....................................................................76
14
STATISTICAL CONSIDERATIONS...............................................................................78
14.1
Primary Endpoint, Stratification, and Sample Size Justification...........................78
14.2
Secondary Endpoints .............................................................................................80
14.3
Exploratory/Correlative Endpoints........................................................................80
14.4
Reporting and Exclusions ......................................................................................81
15
HUMAN SUBJECTS PROTECTIONS ............................................................................82
15.1
Rationale For Subject Selection.............................................................................82
15.2
Participation Of Children.......................................................................................82
15.3
Participation of Subjects Unable to Give Consent.................................................82
15.4
Evaluation Of Benefits And Risks/Discomforts....................................................83
15.5
Risks/Benefits Analysis .........................................................................................84
15.6
Consent Process And Documentation....................................................................84
16
REFERENCES ..................................................................................................................86
17
APPENDICES ...................................................................................................................89
17.1
Appendix A: Performance Status Criteria .............................................................89
17.2
Appendix B: CTEP Multicenter Guidelines ..........................................................90
17.3
Appendix C: PANVAC [Recombinant Vaccinia-
CEA(D609)/MUC1(L93)/TRICOM] Patient Instruction Sheet ............................92
17.4
Appendix D: NIH Problem Report Form...............................................................95
17.5
Appendix E: Specimen Collection.........................................................................97
17.6
Appendix F: Sample Shipping Manifest..............................................................104

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1
OBJECTIVES
1.1
PRIMARY OBJECTIVE
1.1.1
To determine if there is an improvement in disease-free survival (DFS*) with BCG + 
PANVAC compared with BCG alone in a phase II study in non-muscle invasive high-
grade urothelial carcinoma of the bladder who have failed to respond to intravesical 
BCG. *within 1 year post treatment
1.2
SECONDARY OBJECTIVES
1.2.1
To estimate tumor upgrading and tumor upstaging rates for each study arm.
1.2.2
To determine the safety of the combination therapy.
1.3
EXPLORATORY OBJECTIVES
1.3.1
To assess the expression of CEA and MUC-1 antigens in bladder tumor specimens pre- 
and post-treatment in both arms
1.3.2
To assess the presence of CD4 and CD8 T cells in bladder tumor specimens pre- and 
post-treatment in both arms
1.3.3
To assess the presence of Tregs by double staining with FoxP3 and CD4 in bladder tumor 
specimens pre- and post-treatment in both arms
1.3.4
To assess the presence of myeloid derived suppressor cells (MDSC) in bladder tumor 
specimens pre- and post-treatment in both arms
1.3.5
To measure the CD4 antigen-specific response to CEA in peripheral blood mononuclear 
cells (PBMCs) obtained from blood
1.3.6
To measure the CD8 antigen-specific response to CEA, MUC-1, and Brachyury in all 
subjects who have the HLA-A2 allele in PBMCs obtained from blood
1.3.7
To analyze all PBMC samples by flow cytometry for the following cell types:  CD4, 
CD8, Tregs, MDSCs, and Natural Killer (NK) cells
1.3.8
To analyze sera samples obtained from blood at all time points for antibodies to CEA, 
MUC-1, and Brachyury
1.3.9
To assess production of urinary cytokines and chemokines in collected samples
2
BACKGROUND
Bladder cancer accounts for the 4th most common cancer in men and the 12th most common 
cancer in women.  An estimated 73,510 people living in the United States will be diagnosed with 

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bladder cancer in 2012, with approximately 14,880 dying of bladder cancer in the same year.1  
Most of these patients (>75%) will be diagnosed with non-muscle invasive bladder cancer and 
approximately 50% of these patients will present with high grade disease.2  High grade non-
muscle invasive bladder cancer (Ta, T1, and/or CIS) is difficult to treat because of high rates of 
recurrence and progression. The last major advance in bladder cancer therapy was the approval 
of bacillus Calmette-Guerin (BCG) in 1990 by the FDA.3  Currently, intravesical BCG given as 
an induction course (6 weeks of intravesical therapy) is the standard of care4,5 followed by 
maintenance therapy. BCG has an initial failure rate of ~35% in terms of disease recurrence or 
progression.  In ~20-35% of cases that failed an initial induction course of BCG, a second course 
of induction BCG may be beneficial, but patients who fail two courses are often best served by 
radical cystectomy.6-8  Patients with CIS alone may respond at a higher rate to a second induction 
course, however, cystectomy may still be required in at least 1/3 of these patients.  This surgery 
involves the en bloc removal of the bladder and adjacent organs (prostate in males and uterus in 
females) and concomitant creation of a urinary diversion, which can affect a patient’s quality-of-
life significantly.  Moreover, Shabsigh et al. reported that 64% of patients who undergo 
cystectomy suffer at least one complication within the first 90 days after surgery9 and the 
operation has been reported to have at least a 2.5% perioperative mortality rate even at a high-
volume center.10  This fact is reflected in a 2003 survey, which showed that 81% of urologists 
were reluctant to refer their patients to radical cystectomy despite failing 2 courses of intravescial 
therapy.11  In summary, radical cystectomy has the potential for significant morbidity and 
therefore, an unmet clinical need for intravesical therapy exists for these high grade non-muscle 
invasive bladder cancers that fail BCG.
BCG failures can be subdivided into several groups based on the time to tumor response and/or 
recurrence.12  BCG-refractory disease is defined as the inability to be disease-free by 6 months 
after an induction course of BCG.  In contrast, BCG-resistant disease is defined as the inability to 
be disease-free by 3 months after an induction course of BCG.  Finally, BCG-relapsing disease is 
defined as recurrence of disease after being disease-free for at least 6 months after receiving 
BCG therapy.  Unfortunately, disease-free survival rates at 12 months are not as well-defined 
based on these subclassifications. Thus, clinical endpoint trials involving this population should 
be randomized and stratified according to these subgroups to help better predict responders to 
therapy.
BCG works by an unclear immunologic mechanism that promotes activation and infiltration of 
immune cells within the bladder wall. The immune system is critical as the administration of T 
cells to athymic animals has been shown to restore their ability to respond to BCG therapy.13,14   
A hypothesized mechanism for BCG is that it induces macrophage cytotoxicity and that Th1 
immune system cytokines (e.g. TNF-α, IFN-γ, IL-12, and IL-18) play a positive role in the 
macrophage cytotoxicity while Th2 immune system cytokines (e.g. IL-4, IL-10) and T regulatory 
cells (Tregs) are potentially inhibitory to this BCG-induced macrophage cytotoxicity.15  T cell 
infiltration appears important as the degree of infiltration (CD3, CD4, and CD8) has been shown 
to be significantly greater in patients with a complete response to BCG in comparison to patients 
with a partial response or treatment failure.16
Modulation of the immune system is one strategy employed in cancer therapeutics.  Tumor 
associated antigens (TAAs), which are unique molecules minimally expressed by normal tissues 
and over-expressed in cancer cells, can be used as immunologic targets.  Recently, researchers at 

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the NIH have developed a poxvirus cancer vaccine therapy called PANVAC™ that has 
demonstrated therapeutic efficacy against a variety of carcinomas. PANVAC™ consists of a 
primary vaccination with a replication competent recombinant vaccinia (rV-) viral vector 
followed by multiple booster vaccinations with a replication-incompetent recombinant fowlpox 
(rF-) viral vector. These vectors contain transgenes for both TAAs and human T cell co-
stimulatory molecules. Although TAAs are weakly immunogenic, a method of disrupting 
immune tolerance is to introduce TAAs to the immune system through poxviral vectors.17  
Antigen-specific active immunotherapy is designed to generate immune responses, particularly 
cell-mediated responses, against specific TAAs using vaccines that express one or more of these 
antigens.  
The TAAs in PANVAC™ are epithelial mucin-1 (MUC-1) and carcinoembryonic antigen (CEA) 
which are altered and overexpressed in many cancers.18    MUC-1 is a glycosylated 
transmembrane protein that is overexpressed in almost all human carcinomas.  Furthermore, it 
has been demonstrated that the c-terminus of MUC-1 functions as an oncogene.19,20  According 
to one study, MUC-1 is present in all cases of malignant urothelium, but increased expression is 
noted with higher grade and stage tumors.21  Another study demonstrated MUC-1 expression in 
93% of bladder tumors studied.22  CEA is a glycosylated cell surface protein expressed in several 
tumors as well and in particularly in colorectal, ovarian, bladder, breast, and gastric tumors.23  
CEA is expressed in 76% of high grade tumors and in 59% of pT1 bladder tumors.24  
Co-stimulatory molecules are critical in the generation of T-cell responses especially against 
weak antigens such as TAAs. The initiation of an immune response requires at least two signals 
for activation of naïve T cells by antigen-presenting cells. The first signal is antigen specific, 
delivered through the T-cell receptor via the peptide/MHC, and causes the T cell to enter the cell 
cycle. The second, “co-stimulatory,” signal is required for cytokine production and proliferation. 
At least three distinct molecules normally found on the surface of professional antigen-
presenting cells have been reported to be capable of providing the second signal critical for T-
cell activation: B7-1, ICAM-1, and LFA-3. Both antigen and co-stimulatory molecules must be 
expressed in the same cell to properly engage the TCR and co-stimulatory receptor. In order to 
achieve this, multigene constructs using poxviral vectors (avipox and vaccinia) have been 
generated.  The co-stimulatory molecules are B7.1 (CD80), ICAM01 (CD54), and LFA-3 
(CD58) and are referred to as TRICOM (triad of co-stimulatory molecules).25  Each of these co-
stimulatory molecules binds to a different ligand, and the second messenger pathways of each 
ligand are unique, raising the potential for synergy of these molecules.  The vaccines are 
therefore, summarized as rV-CEA-MUC-1-TRICOM (rV-PANVAC™) and rF-CEA-MUC-1-
TRICOM (rF-PANVAC™).  
PANVAC™ is injected subcutaneously, processed by antigen-presenting cells (APCs), and then 
induces CEA- and MUC-1-specific cytotoxic T lymphocyte responses that are then potentiated 
by the co-stimulatory molecules. The pox viral vectors have a high rate of cellular infection, can 
carry large amounts of transgenes, process genes in the cytoplasm of infected cells with a low 
risk of incorporation within the host genome, and have an established history of clinical safety in 
patients.  In fact, several hundred patients have already been treated on clinical trials with pox 
viral vectors and there have been no dose limiting toxicities attributable to these vaccines.18

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Initial studies with PANVAC showed that it was well tolerated and was associated with objective 
responses in some patients. One patient with metastatic ovarian cancer and symptomatic ascites 
had complete resolution of her ascites and normalization of her CA-125 (from 300 to <20) for 18 
months.26  A patient with metastatic breast cancer has an ongoing complete response of her 
disease for over 3 years.27  The final results of a randomized phase II study were recently 
reported. This study enrolled 48 patients with metastatic breast cancer and randomized them to 
weekly docetaxel with PANVAC monthly vs. docetaxel alone. The primary endpoint was PFS. 
The median PFS for patients randomized to the combination arm was 6.6 months vs. 3.8 months 
in the chemotherapy alone arm.28
A phase II randomized controlled study involved 74 patients with completely resected metastases 
from colorectal cancer, who had received perioperative chemotherapy.29  Patients were 
randomized to receive 4 vaccinations with either PANVAC or dendritic cells modified with 
PANVAC. There was no significant difference in 2-year recurrence-free survival among the DC 
arm (50%), the PANVAC arm (56%), and a contemporary control arm (55%). However, at a 
median follow-up of 40 months, the survival rate for vaccinated patients was 81%, which far 
exceeded that of the unvaccinated controls. 
Recently, a PSA specific vaccine, rV-PSA TRICOM and rF-PSA-TRICOM, was evaluated in a 
randomized, placebo-controlled, blinded Phase II study for minimally symptomatic metastatic 
castration-resistant prostate cancer. Although no difference in progression free survival was 
noted, patients receiving the vaccine had longer median survival by 8.5 months with hazard ratio 
of 0.56 (95% CI, 0.37 to 0.85), p=0.0061.30  Other studies have demonstrated safety of the 
vaccine in solid organ tumors when administered subcutaneously.18,26,27  These initial studies 
suggest safety and activity in a broad range of tumor types.
High grade non-muscle invasive bladder cancer tends to respond well to BCG and when it does 
not, there is evidence to suggest an incomplete or inefficient immune response.  Given that CEA 
and MUC-1 are overexpressed in bladder cancer, we hypothesize that PANVAC™ will augment 
the BCG-induced cytotoxic T lymphocyte response against bladder cancer cells expressing 
MUC-1 and/or CEA, which will clinically result in a greater disease-free survival rate than BCG 
alone in patients who have failed at least one previous course of intravesical BCG. We also 
hypothesize that the PANVAC+BCG group will demonstrate decreased tumor upgrading and 
tumor upstaging, particularly with regards to invasion of the detrusor musculature, and predict 
that the combination treatment will not demonstrate greater treatment-related toxicities to 
intravesical BCG alone.  Finally, we hypothesize that the immune response will be augmented in 
the PANVAC+BCG group compared to BCG alone as measured by secondary immunologic 
correlates described below.
3
PATIENT SELECTION
3.1
ELIGIBILITY CRITERIA 
3.1.1
Inclusion Criteria
3.1.1.1
Patients must have histologically confirmed localized high grade (G3) transitional cell 
carcinoma (urothelial carcinoma) of the bladder that is stage Ta, T1, and/or CIS 

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confirmed by the Laboratory of Pathology, NCI 90 days prior to study entry.  This can 
be obtained at an outside hospital prior to entry into the study or at the NCI.  However, 
all outside pathology specimens will require that the formalin-fixed paraffin embedded 
tissues be re-read by the Laboratory of Pathology, NCI.  For patients enrolled at 
collaborating trial sites, diagnosis must be confirmed by the Department of Pathology at 
the institution where the patient is enrolled on the trial.  Pathology can also be reviewed 
by the Laboratory of Pathology at the NCI if the participating trial site prefers another 
pathologic evaluation.  
3.1.1.2
Patients have failed at least one previous induction course of intravesical BCG, defined 
as histologically confirmed persistent or relapsing tumor present on post-BCG 
endoscopic evaluation.  All BCG failures will be considered for inclusion into the study, 
including BCG-refractory, -resistant, and -relapsing, as defined in the “Rationale and 
Background.”  For the purposes of the study, “BCG-refractory” and “BCG-resistant” 
subjects will be considered to have “BCG-persistent” disease.
3.1.1.3
Patients who are not currently candidates for radical cystectomy (e.g. patient refuses 
surgery, comorbidities preclude major surgery, etc.).
3.1.1.4
Age >18 years.  
Because no dosing or adverse event data are currently available on the use of BCG in 
combination with PANVAC™   in patients <18 years of age, children are excluded 
from this study.
3.1.1.5
ECOG performance status <2 (see Appendix A, Section 17.1).
3.1.1.6
Patients must have normal organ and marrow function as defined below: 
absolute neutrophil count
>1,500/mcL
platelets
>50,000/mcL
total bilirubin
< 1.5 X institutional upper limit of normal
AST(SGOT)/ALT(SGPT)
≤3 X institutional upper limit of normal
estimated GFR (calculated using CKD-EPI equation) ≥ 30 mL/min/1.73 
sq.m.

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3.1.1.7
Computerized Tomography (CT) urogram or Magnetic Resonance Imaging (MRI) 
urogram.  If urogram protocol not available or contrast allergy/poor renal function 
preclude such imaging, then noncontrast CT or MRI of the abdomen/pelvis within 45 
days of study entry will suffice.
3.1.1.8
Chest x-ray negative for metastatic disease.
3.1.1.9
Ability of patient to understand and the willingness to sign a written informed consent 
document.
3.1.2
Exclusion Criteria
3.1.2.1
Previous pelvic radiation for bladder or prostate cancer if performed <12 months prior 
to enrollment into the study.
3.1.2.2
Patients who are receiving any other concurrent investigational agents (patients are 
eligible to enroll 4 weeks after completion of prior agent).
3.1.2.3
Patients who have had chemotherapy within 4 weeks (6 weeks for nitrosoureas or 
mitomycin C) prior to entering the study or those who have not recovered from adverse 
events due to agents administered more than 4 weeks earlier. There will be at least a 3 
week delay from the time of a previous bladder biopsy/TURBT to allow for adequate 
bladder healing prior to enrollment. 
3.1.2.4
Patients with a history of encephalitis, multiple sclerosis, or seizures within the last year 
(from seizure disorder or brain metastasis) should be excluded from this clinical trial 
because of their poor prognosis and because they often develop progressive neurologic 
dysfunction that would confound the evaluation of neurologic and other adverse events.
3.1.2.5
History of allergy or untoward reaction to prior vaccination with vaccinia virus
3.1.2.6
Patients should have no evidence of being immunocompromised as listed below:
• Human immunodeficiency virus positivity due to the potential for decreased tolerance 
and risk for severe side effects
• Active autoimmune diseases requiring treatment or a history of autoimmune disease 
that might be stimulated by vaccine treatment.  This requirement is due to the 
potential risks of exacerbating autoimmunity.  Patients with endocrine disease that is 
controlled by replacement therapy including thyroid disease and adrenal disease and 
vitiligo may be enrolled.
• History of splenectomy
3.1.2.7
Uncontrolled intercurrent illness which would interfere with the ability of the patient to 
carry out the treatment program, including, but not limited to, active second malignancy 
other than a cancer that has been successfully treated resulting in a high likelihood of 
long-term survival (e.g. completely resected basal cell or squamous cell carcinoma of 
the skin, stage 1 renal cell carcinoma treated with partial nephrectomy, treated low risk 
prostate cancer, etc.), inflammatory bowel disease (e.g. Crohn’s disease or ulcerative 
colitis), active diverticulitis, ongoing or active infection, symptomatic congestive heart 
failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social 
situations that would limit compliance with study requirements.
3.1.2.8
Pregnant women are excluded from this study because the vaccines used in the study 

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may have the potential for teratogenic or abortifacient effects.  Because there is an 
unknown but potential risk for adverse events in nursing infants secondary to treatment 
of the mother with the vaccine, breastfeeding should be discontinued if the mother is 
treated with vaccines.  These potential risks may also apply to other agents used in this 
study. Patients must agree to use adequate contraception (hormonal or barrier method of 
birth control; abstinence) prior to study entry and for the duration of study participation.  
Should a woman become pregnant or suspect she is pregnant while her partner is 
participating in this study, she should inform her treating physician immediately
3.1.2.9
Concurrent use of systemic steroids, except for physiologic doses of systemic steroids 
for replacement or local (topical, nasal, or inhaled) steroid use.  Limited doses of 
systemic steroids to prevent IV contrast, allergic reaction, or anaphylaxis (in patients 
who have known contrast allergies) are allowed. Although topical steroids are allowed, 
steroid eye-drops are contraindicated
3.1.2.10 Altered immune function, including immunodeficiency or history of immunodeficiency; 
eczema; history of eczema, or other eczematoid skin disorders; or those with acute, 
chronic or exfoliative skin conditions (e.g. atopic dermatitis, burns, impetigo, varicella 
zoster, severe acne, or other open rashes or wounds). There is an increased risk to 
patients or contacts with eczema, atopic dermatis, and other immune deficiencies who 
are at risk for eczema vaccination.
3.1.2.11 Medical conditions which, in the opinion of the investigators, would jeopardize the 
patient or the integrity of the data obtained
3.1.2.12 Serious hypersensitivity reaction to egg products
3.1.2.13 Chronic hepatitis infection, including B and C, because of potential immune impairment
3.1.2.14 Clinically significant cardiomyopathy or cardiac complications, including recent 
myocardial infarction or cerebrovascular accident within one year, and/or unstable or 
uncontrolled angina
3.1.2.15 Previous intolerance to BCG intravesical therapy suggested by development of systemic 
BCG infection in the past and/or grade 4 or greater adverse effect by CTCAE v5.0.
3.1.2.16 Patients unable to avoid close contact or household contact with the following high-risk 
individuals for three weeks after the Day 1 vaccination: (a) children ≤ 3 years of age, (b) 
pregnant or nursing women, (c) individuals with prior or concurrent extensive eczema 
or other eczemoid skin disorders, or (d) immunocompromised individuals, such as those 
with HIV.
3.1.3
Inclusion of Women and Minorities
Both men and women of all races and ethnic groups are eligible for this trial.
3.2
RECRUITMENT STRATEGIES
This study will be listed on available websites (www.clinicaltrials.gov and others) and 
participants will be recruited from the current patient population at NIH.

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3.3
SCREENING EVALUATION
3.3.1
Clinical Evaluation (within 28 days of before starting treatment).
3.3.1.1
History and physical examination 
3.3.1.2
ECOG performance status 
3.3.2
Viral Studies and Prior Vaccination Status
3.3.2.1
HIV test within 8 weeks of initial visit and repeat if clinically indicated
3.3.2.2
Hepatitis B and C titers within 8 weeks of initial visit and repeat if clinically indicated
3.3.2.3
Document known prior vaccinia vaccination (small pox vaccine)
3.4
BASELINE EVALUATION
3.4.1
Laboratory studies (within 28 days before starting treatment)
3.4.1.1
Complete blood count plus differential and platelet count
3.4.1.2
Serum chemistries (Na+, K+, Cl-, CO2, glucose, BUN, creatinine, albumin, calcium, 
magnesium, phosphorus, alkaline phosphatase, ALT, AST, total bilirubin, LDH, pre-
albumin) with BUN and creatinine
3.4.1.3
PT, PTT
3.4.1.4
6 green top tubes of blood will be drawn for PBMCs, HLA Typing, and sera for 
correlative/exploratory research aims (e.g. ELISPOT, CD4+ Antigen-specific 
responses, etc.) on day 1 of study enrollment
3.4.1.5
Beta-HCG for women of child-bearing age (within 48 hours prior to day 1).  In 
addition, patients, both male and female, should be willing to practice effective birth 
control during the study and four months following the last study treatment, unless they 
have had a prior hysterectomy, bilateral oophorectomy, or vasectomy  
3.4.2
Urine studies 
3.4.2.1
Urinalysis with urine culture (prior to operative procedures and within 2-21 days of 
operative procedures)
3.4.2.2
Urine cytology (prior to operative procedures and within 2-21 days of operative 
procedures or at time of operative procedure)
3.4.2.3
Urine collection for correlative/exploratory research aims (e.g. inflammatory cells, 
cytokines) at the time of operative procedure
3.4.3
Imaging (within past 45 days and of adequate quality)
3.4.3.1
Chest X-ray 
3.4.3.2
Computerized Tomography (CT) urogram or Magnetic Resonance Imaging (MRI) 
urogram.  If urogram protocol not available or contrast allergy/poor renal function 
preclude such imaging, then CT or MRI of the abdomen/pelvis will suffice 
3.4.4
Pathology

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3.4.4.1
Formal review of available previous bladder tumor specimens by the Laboratory of 
Pathology, NCI, to confirm the bladder cancer diagnosis prior to enrollment into the 
study.  For patients enrolled at collaborating trial sites, diagnosis must be confirmed by 
the Department of Pathology at the institution where the patent is enrolled on the trial.  
Pathology can also be reviewed by the Laboratory of Pathology at the NCI if the 
participating trial site prefers another pathologic evaluation.  
3.4.4.2
Tissues obtained at the NCI will be used to confirm diagnosis and for study of immune-
related markers.  With preoperative patient permission, extra tissue not sent to 
Laboratory of Pathology, NCI, will be frozen for future analysis of immune-related 
markers and tumor infiltrates.  This additional harvested tissue will be used for research 
purposes only and is not required for a candidate to participate in this protocol. Tissue 
will also be collected at collaborating trial sites as specified by Appendix E (Section 
17.5).
3.5
ACCRUAL ESTIMATES
Accrual Targets
Sex
Ethnic Category
Females
Males
Total
Hispanic or Latino
4
+
4
=
8
Not Hispanic or Latino
23
+
23
=
46
Ethnic Category: Total of all   subjects
27
      +
27
=
54
Racial Category
American Indian or Alaskan Native
1
+
1
=
2
Asian
1
+
1
=
2
Black or African American
4
+
4
=
8
Native Hawaiian or other Pacific Islander
1
+
1
=
2
White
20
+
20
=
40
Racial Category: Total of all subjects
27
      +
27
     =
54
Accrual Rate: 2-3 patients/month 
Total Expected accrual: Min: 49 Max: 54
Projected Start Date of study: December 1, 2013
Anticipated Primary Completion Date: December 1, 2017

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4
REGISTRATION PROCEDURES
4.1
GENERAL GUIDELINES
Eligible patients will be entered on study centrally at the CCR by the Study Coordinator.  
Issues that would cause treatment delays should be discussed with the Principal Investigator.  
Except in very unusual circumstances, each participating institution will order DCTD-supplied 
agents directly from CTEP.  Agents may be ordered by a participating site only after the initial 
IRB approval for the site has been forwarded by the Coordinating Center to the CTEP PIO 
(PIO@ctep.nci.nih.gov) except for Group studies.
4.2
REGISTRATION PROCEDURES
4.2.1
Registration at the CCR
Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO) 
within 24 hours of signing consent.  A registration Eligibility Checklist from the web site 
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) must be completed and sent via 
encrypted email to:  NCI Central Registration Office ncicentralregistration-l@mail.nih.gov. 
After confirmation of eligibility at Central Registration Office, CRO staff will call pharmacy to 
advise them of the acceptance of the patient on the protocol prior to the release of any 
investigational agents.  Verification of Registration will be forwarded electronically via e-mail to 
the research team. A recorder is available during non-working hours. 
4.2.2
Participating Site Registration 
Registration will be a two part process as patients are screened on this protocol. A protocol 
registration form will be supplied by the CCR study coordinator and updates will be provided as 
needed. Subject eligibility and demographic information is required for registration. To initially 
register a subject, after the participant has signed consent, complete the top portion of the form 
and send to CCR study coordinator.  Once eligibility is confirmed, after completion of screening 
studies, complete the remainder of the form which is the eligibility checklist, indicating that the 
patient is being registered for treatment and send to CCR study coordinator. In addition, source 
documents supporting the eligibility criteria must be sent to the CCR study coordinator. The 
CCR study coordinator will notify you either by e-mail or fax that the protocol registration form 
has been received which will include the unique patient/subject ID number. Questions about 
eligibility should be directed to the CCR study coordinator or PI.  Questions related to 
registration should be directed to the CCR study coordinator. 
Subjects that do not meet screening criteria should be removed from the study following the 
procedure in section 5.8.3.
4.3
RANDOMIZATION PROCEDURES
There are two arms to this study and subjects will be randomized equally to either the TICE 
BCG arm or the combination arm of TICE BCG + PANVAC™.  The study arms are described in 
detail below in Section 5.1.  The arms will be stratified during randomization for TICE BCG 

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subgroup based on number of previous induction courses and time of recurrence.  This is 
described in more detail along with the statistical analysis in the statistical section (Section 14).
5
TREATMENT PLAN
5.1
STUDY DESIGN 
This is a phase II study in subjects with non-muscle invasive (stages Ta, T1, and/or CIS) high 
grade urothelial carcinoma of the bladder who have failed at least one course of intravesical 
BCG.  The study will be halted for 28 days after the first six patients with combination therapy 
are accrued and successfully treated.  If any Grade 3 or greater toxicities are observed that do not 
resolve with conservative management, then they will be discussed with CTEP.  With 
preliminary evidence of safety, the remaining subjects will be accrued to the trial. (See 
SCHEMA)
5.1.1
All subjects will receive BCG (TICE strain, 50 mg) intravesically as per usual standard of 
care once weekly (+/- 2 days) starting in week 3 for a total of 6 weeks (last dose in week 
8).
5.1.2
Subjects in the combination arm will receive the pox viral vaccines that contain the 
transgenes for CEA and MUC-1 (both with modified HLA-A2 agonist epitopes) as well 
as 3 human T-cell costimulatory molecules, B7-1, ICAM-1, and LFA-3 [rV-PANVAC™ 
(vaccinia) and rF-PANVAC™ (fowlpox)] as follows:
5.1.2.1
rV-PANVAC™ 2 x 108 pfu SQ at week 0 (+/- 7 days) only.
5.1.2.2
rF-PANVAC™ 1 x 109 pfu SQ at weeks (+/- 7 days) 3, 7, 11, and 15.
5.1.3
All subjects will provide blood, urine, and tissue (if available) at study entry and at the 
end of the study.  Tissue at study entry can be obtained either from outside FFPE or from 
previous TURBT performed at NIH (see section 3.4.4.1).  This tissue is required for 
diagnosis.  All subjects will also have blood drawn at weeks 3 and 8 to coincide with the 
start and end of BCG treatment.  Urine samples will also be obtained before and after the 
1st and 3rd instillation of BCG as defined in Section 10.1.2.
5.1.4
All subjects will undergo tuberculin skin testing using purified protein derivative (PPD) 
at study entry (prior to receiving BCG instillation #1) and around the time of the week 
17-20 cystoscopy/EUA.  The associated skin reaction will be evaluated by a health care 
provider within 48-72 hours after injection.  Skin induration greater than 10mm in 
diameter will be considered a positive result.  Initial PPD results do NOT preclude 
subsequent treatment with BCG – these results will only be used to assess the 
immunologic response to BCG (see section 10.1.1).   
5.1.5
Between weeks 17-20 (+/- 7 days), a CT urogram and chest x-ray for re-staging purposes 
prior to biopsy, a planned cystoscopy, exam under anesthesia, and biopsy of the previous 
tumor area and/or any new areas of tumor to evaluate for the presence/recurrence of 
disease.

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5.1.6
After the initial 20 week study course, subjects will be followed for up to 1 year at the 
study center every 3 months per routine standard of care for high grade urothelial cancer 
of the bladder with cystoscopy and cytology.  If recurrence is noted, it will be treated and 
if confirmed to be a recurrence on pathology, the patient will come off study.  
Surveillance and/or treatment for recurrences beyond the initial 12 months may be 
performed by outside urologists.  
5.2
TRIAL OUTLINE
5.2.1
After meeting all entry criteria based on screening evaluation, subjects will be enrolled 
into the study.   Of note, there will be at least a 3 week delay from the time a previous 
bladder biopsy/TURBT to allow for adequate bladder healing prior to enrollment.  
5.2.1.1
6 green top tubes of blood will be drawn for PBMCs, HLA Typing, and sera for 
correlative/exploratory research aims (e.g. ELISPOT, CD4+ Antigen-specific 
responses, etc.) on day 1 of study enrollment
5.2.1.2
Beta-HCG for women of child-bearing age (within 72 hours prior to day 1).  In 
addition, patients, both male and female, should be willing to practice effective birth 
control during the study and four months following the last study treatment, unless they 
have had a prior hysterectomy, bilateral oophorectomy, or vasectomy.
5.2.2
TICE BCG arm:
5.2.2.1
Weeks 3-8:  Receive weekly (+/- 2 days) intravesical doses of BCG (TICE strain, 50 
mg) as per usual standard of care for a total of 6 weeks.  Urine will be tested weekly 
prior to each BCG administration and the presence of gross hematuria or evidence of a 
urinary tract infection will result in holding that week’s BCG dose and postponing 
therapy until the following week.  Also, at the beginning of each administration, 
patients will be queried about urinary symptoms.
•
Complaints of persistent dysuria, urgency, bladder spasms, and/or frequency from 
previous week’s administration that is consistent with Grade 3 or greater toxicity 
will result in holding BCG administration for that week, supportive care (e.g. 
medications and hydration), and/or BCG dose reduction the following week at 1/3 
normal dose as this can result in less toxicity with similar results for recurrence 
and progression.31  
•
Patients will be maintained at this reduced dose if they tolerate therapy.
•
Future inability to tolerate this reduced dose will result in holding BCG for that 
week and postponing the BCG until the following week and dropping to 1/6 of the 
normal dose as this dose may still be effective in prolonging progression-free and 
cancer-specific survival times.32  

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5.2.2.2
Blood and urine will be obtained for correlative studies as described in Section 10.1.
5.2.2.3
Between weeks 17-20 (+/- 7 days), a CT urogram and chest x-ray prior to biopsy, a 
planned cystoscopy, EUA, and TURBT will be done of previous tumor area and of any 
new areas of tumor.  Tissue will be sent for pathology and be formalin-fixed paraffin 
embedded.  If possible, some tissue will also be frozen. 
•
If a suspicious lesion is identified, it will be biopsied.  If recurrent tumor is not 
found, then the subject will return every 3 months for a surveillance cystoscopy as 
per standard-of-care. If recurrent tumor is found, the patient has met the primary 
endpoint of recurrence and will be taken off study.
5.2.2.4
At every surveillance cystoscopy post-treatment up to 12 months, urine may be 
collected for cytology as well as for immune-related markers along with blood through 
6 green top tubes for correlative immunologic aims. 
5.2.3
TICE BCG + PANVAC™ ARM
5.2.3.1
Enroll into study with baseline evaluation and studies as described in Section 3.4.  Of 
note, there will be at least a 3 week delay from the time a previous bladder 
biopsy/TURBT to allow for adequate bladder healing prior to enrollment.
5.2.3.2
Week 0 (+/- 7 days) – all subjects in this arm receive single vaccinia priming vaccine - 
rV-PANVAC™ 2 x 108 pfu SQ after undergoing phlebotomy with 6 green top tubes for 
immunologic correlates.
5.2.3.3
Weeks 3-8:  Receive weekly (+/- 2 days) intravesical doses of BCG (TICE strain, 50 
mg) as per usual standard of care for a total of 6 weeks.  Urine will be tested weekly 
prior to each BCG administration and the presence of gross hematuria or evidence of a 
urinary tract infection will result in holding that week’s BCG dose and postponing 
therapy until the following week.  Also, at the beginning of each administration, 
patients will be queried about urinary symptoms.
•
Complaints of persistent dysuria, urgency, bladder spasms, and/or frequency from 
previous week’s administration that is consistent with Grade 3 or greater toxicity 
will result in holding BCG administration for that week, supportive care (e.g. 
medications and hydration), and/or BCG dose reduction (BCG can be given 1/3rd 
of the normal dose on the following week as this can result in less toxicity with 
similar results for recurrence and progression31). 
•
Subjects will be maintained at this reduced dose if they tolerate therapy.
•
Future inability to tolerate this reduced dose will result in holding BCG for that 
week and postponing the BCG until the following week and dropping to 1/6 of the 
normal dose as this dose may still be effective in prolonging progression-free and 
cancer-specific survival times.32
5.2.3.4
PANVAC administration will continue as planned regardless of any delays in BCG 
administration.  Research sample collection of urine will coincide with the first and 
third week of BCG instillation regardless of any delays with BCG administration.  
Research sample collection of blood will coincide with the first and sixth week of BCG 
instillation regardless of any delays with BCG administration.  [For example, if BCG is 
first given on week 3 of the study, but held on week 4 and resumed on week 5, then 

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urine collection would be collected on weeks 0, 3, 6 (previously week 5), 18-21 
(previously 17-20), and optionally on follow-up visits.  In this scenario, blood would be 
collected on weeks 0, 3, 9 (previously week 8), 18-21 (previously 17-20), and 
optionally on follow-up visits.  The timing of PANVAC administration will NOT 
change in this scenario.]  Week (+/- 7 days) 3, 7, 11, and 15 – all patients in this arm 
receive boost fowlpox vaccines - rF-PANVAC™ 1 x 109 pfu SQ
5.2.3.5
Blood and urine will be obtained for correlative studies as described in Section 10.1. 
5.2.3.6
Between weeks 17-20 (+/- 7 days), a CT urogram and chest x-ray prior to biopsy, a 
planned cystoscopy, EUA, and TURBT will be done of previous tumor area and of any 
new areas of tumor.  Tissue will be sent for pathology and be formalin-fixed paraffin 
embedded.  If possible, some tissue will also be frozen. 
5.2.3.7
Also at the time of the end-of-study cystoscopy, urine will be collected for cytology and 
for immune-related markers along with blood for correlative aims.
5.3
AGENT ADMINISTRATION
Treatment will be administered on an outpatient basis.  Reported adverse events and potential 
risks are described in Section 7.  Appropriate dose modifications are described in Section 6.  No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the patient's malignancy.
CTEP IND Agents:
rV-PANVAC™ (vaccinia priming vaccine)
rF-PANVAC™ (fowlpox boosting vaccine)
Other Agents:
Bacillus Calmette-Guerin (BCG) – TICE strain 
The administration of the agents is described below based on the treatment arms:
5.3.1
TICE BCG alone arm:
Weeks 3-8
Bacillus Calmette-Guerin (BCG) – TICE strain
•
Attenuated live strain of Mycobacterium bovis
•
Induction course of 6 weekly (+/- 2 days) instillations
•
Instillation volume (50 mg in 50 mL sterile saline).
•
Dose – 50 mg vial (TICE) is reconstituted in accompanying diluent and then further 
diluted in sterile, preservative-free saline according to manufacturer guidelines
•
Each week, RNs will sterilely insert a urethral catheter atraumatically into the 
subject’s bladder and administer the reconstituted BCG.  Following instillation of the 
50 mL of BCG, the urethral catheter will be removed.

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•
BCG will then be held in the bladder for 1-2 hours depending on patient ability to 
hold the medication in the bladder.  The patient will then void in a toilet and rinse the 
toilet with bleach prior to flushing.
•
All equipment in contact with BCG will be treated as chemotherapeutic waste and 
disposed of as such in a MPW container.
5.3.2
TICE BCG + PANVAC™ arm:
Week 0 
rV-PANVAC™ (vaccinia priming vaccine) 2 x 108 pfu subcutaneously (+/- 7 days).
Week 3 
BCG (+/- 2 days see details above).
rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).
Weeks 4-6
BCG (+/- 2 days see details above).
Week 7 
BCG (+/- 2 days see details above).
rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).
Week 8
BCG (+/- 2 days see details above).
Week 11 
rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).
Week 15 
rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).
5.3.3
Precautions for the vaccines
•
Prior to administration of the drugs, safe-handling precautions should 
be thoroughly reviewed (see Section 9, precautions and special handling subsections of 
“Pharmaceutical Information”).
•
The proper procedure for disposing the live vaccine is a critical part of 
drug administration (see Section 9, disposal sections of “Pharmaceutical Information”).
5.4
DOSE LIMITING TOXICITY
TICE BCG will be given in the standard dose and schedule as described above. All toxicities 
observed will be tabulated by maximum grade per subject.  A dose limiting toxicity (DLT) will 
be any grade 3 or greater adverse effect (AE) by CTCAE v5.0 related to the investigational agent 
and persisting for more than one week and not improving by routine standard of care.  In 

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addition, any grade 3 or greater AE as per a previously published vaccinia toxicity grading 
scale33 related to the investigational agent will also be considered a DLT.  
Intravesical BCG therapy can lead to common side effects that are usually self-limited, 
particularly with dose reduction.  These side effects include, but are not limited to, gross 
hematuria, dysuria, frequency, urgency, bladder spasms, and generalized cystitis.  These side 
effects will not be considered a DLT if it is related to BCG and resolves with BCG dose 
reduction and/or postponing therapy by 1-2 weeks and treating symptoms with conservative 
management.  In contrast, persistent side effects despite dose reduction/postponing of BCG 
therapy or the development of systemic BCG infection (aka “BCG-osis”) will be considered a 
DLT.  
Severe adverse events due to local instillation of BCG are uncommon. In a retrospective analysis 
of 2602 patients reported in 1989, the overall rate of serious complications was less than five 
percent.34  The most common complication was fever >103ºF in 2.9 percent followed in 
decreasing frequency by:
•
Significant hematuria (1 percent)
•
Granulomatous prostatitis (0.9 percent)
•
Pneumonitis and/or hepatitis (0.7 percent)
•
Arthralgia (0.5 percent)
•
Epididymitis (0.4 percent)
•
Sepsis (0.4 percent)
•
Rash (0.3 percent)
•
Ureteral obstruction (0.3 percent)
•
Contracted bladder (0.2 percent)
•
Renal abscess (0.1 percent)
•
Cytopenia (0.1 percent)
Systemic sepsis and even death can also develop early following local instillation of BCG. 
During the initial clinical experience with BCG as an intravesical agent, most cases of sepsis 
could be traced back to recognized errors in BCG administration such as traumatic 
catheterization, administration too early after transurethral surgery, or instillation during a 
concomitant UTI. All these conditions result in physical disruptions in the urothelial blood 
barrier.  Sepsis has been estimated to occur in approximately one in every 15,000 patients treated 
with intravesical BCG.34  Prompt recognition and administration of multidrug, antibiotic therapy 
is necessary if true BCG sepsis occurs.
5.4.1
For the purpose of protecting subject safety, we implement the following stopping rule 
for safety monitoring of subjects who receive the combination therapy.
5.4.2
If one subject experiences a grade 5 event, thought to be possibly or probably due to the 
combination therapy (PANVAC + BCG), the study will be stopped. For grade 3 or 4 

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events probably related to the investigational agent (PANVAC) and persisting for more 
than one week and not improving by routine standard of care, the study will be stopped 
according to the stopping rule described in Section 14.
5.4.2.1
The exceptions to what constitute true adverse events/DLTs are previously noted.  
5.4.3
Formal dose escalation/Phase I study is not planned as the TICE BCG doses are 
consistent with standard of care and the TICE BCG is being administered in an 
intravesical fashion while the PANVAC™ is given subcutaneously and in doses that have 
been shown to be safe in multiple Phase I and Phase II studies in a variety of different 
cancers.  
5.5
GENERAL CONCOMITANT MEDICATION AND SUPPORTIVE CARE GUIDELINES
For the vaccine administration, anti-emetics and anti-diarrheal agents may be administered as 
required, but are not anticipated to be needed and should not be used prophylactically on the first 
cycle. The selection of the specific antiemetic regimen is at the discretion of the treating 
physician. Antiemetic regimens should not include dexamethasone or other steroids.
Other supportive care with blood components, antibiotics, analgesics, general medical therapy, 
etc., will be delivered as required. Any subjects taking antibiotics for any reason must complete 
that course of therapy and be free of evidence of further infection before receiving any dose of 
vaccine.  To avoid blunting of the immune response, we will avoid administering corticosteroids 
or other immunosuppressive agents unless medically indicated. 
Symptomatic anemia should be treated with appropriate red blood cell or erythropoietin support.
Thrombocytopenia should be treated conservatively. In the absence of bleeding or a planned 
invasive procedure, platelet transfusions should be given for a platelet count below 10,000/mm3. 
If invasive procedures are planned or the subject develops bleeding, platelet transfusions should 
be administered in accordance with the standard of practice, usually maintaining a platelet count 
of >50,000/mm3.
5.5.1
Treatment of Vaccinia Vaccination Complications
5.5.1.1
Vaccinia Immune Globulin (VIG) 
Vaccinia Immune Globulin (VIG):  First-line treatment of some of the complications of 
vaccinia caused by dissemination of vaccinia virus (severe cases of inadvertent inoculation 
involving extensive lesions or if comorbid conditions exist, severe cases of generalized vaccinia 
in patients that are systemically ill and whose condition might be toxic or who have serious 
underlying immunosuppressive illnesses, eczema vaccinatum, and progressive vaccinia) is with 
VIG.  VIG is contraindicated, however, for the treatment of isolated vaccinial keratitis.  VIG is a 
sterile solution of the immunoglobulin fraction of pooled plasma from individuals inoculated 
with vaccinia vaccine.  VIG is only available through the CDC’s Strategic National 
Pharmaceutical Stockpile by contacting the CDC’s Clinician Information Line at 1-877-554-
4625 or the Director's Emergency Operations Center (DEOC) at 770-488-7100.  Upon receipt of 
a call from a patient or upon direct observation of a patient or contact who manifests signs and 
symptoms of any of the above conditions, the investigator should place a call to the CDC as soon 
as possible: 1) to initiate review of the clinical case, 2) to seek consultation on the 

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appropriateness of VIG therapy, 3) to determine the appropriate VIG dose and dosing method for 
administration, if VIG therapy is required, and 4) to determine how to access and have the 
appropriate doses of VIG delivered.  Early institution of VIG therapy is advised following 
recognition of clinical symptoms compatible with some vaccinia complications (eczema 
vaccinatum, severe generalized vaccinia, progressive vaccinia, and some cases of inadvertent 
inoculation).  The effectiveness of VIG therapy appears to be time dependent. VIG has not 
proven to be of benefit in the treatment of post-vaccinial encephalitis, and is contraindicated for 
treatment of isolated vaccinial keratitis due to the increased risk of corneal scarring.  A new IV 
formulation of VIG that has a lower level of aggregated protein allowing it to be used by either 
the IM or IV route is available through the CDC.  This formulation will most likely be preferred 
for administration and the CDC will instruct investigators regarding appropriate dosing and 
method of administration based on the formulation and availability.  There is no guarantee that 
VIG will successfully treat complications.  At present, there are no other anti-viral therapies of 
proven benefit for the treatment of vaccinia-related complications.
5.5.1.2
Cidofovir (Vistide®, Gilead Sciences)
Cidofovir (Vistide®, Gilead Sciences):  Cidofovir is an FDA-approved antiviral drug for the 
treatment of CMV retinitis among patients with AIDS. Cell-based in vitro studies and animal 
model studies have demonstrated this agent’s antiviral activity against certain orthopoxviruses.  
Currently, its efficacy in the treatment of vaccinia-related complications in humans is unknown.  
According to the CDC, VIG is recommended as first line of therapy.  Cidofovir may be 
considered as a secondary treatment, and will only be used when VIG therapy is not effective 
[Medical Management of Smallpox (Vaccinia) Vaccine Adverse Reactions: Vaccinia Immune 
Globulin 
and 
Cidofovir. 
Last 
updated 
September 
28, 
2009. 
 
Available 
at:  
http://www.bt.cdc.gov/agent/smallpox/vaccination/mgmt-adv-reactions.asp].  The CDC has 
informed the NCI/CTEP that cidofovir will not be supplied through Strategic National 
Pharmaceutical Stockpile to investigators involved in CTEP-sponsored protocols utilizing 
recombinant vaccinia-based vaccines.  Thus, investigators should obtain cidofovir for second-
line therapy through commercial sources if necessary.  Investigators should consult the CDC 
Clinician Information Line at 1-877-554-4625 or the Director's Emergency Operations Center 
(DEOC) at 770-488-7100 regarding appropriateness of therapy and guidance.
5.6
DURATION OF THERAPY
In the absence of treatment delays due to adverse event(s), therapy will continue as per the 
aforementioned schema.  Off therapy criteria is listed in Section 0.
5.7
DURATION OF FOLLOW UP
Subjects will be followed for 1 year after the initial 20 week study course is completed with 
surveillance cystoscopy or until death, whichever occurs first. 
5.8
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 30 days following the last dose of study therapy.

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5.8.1
Criteria for removal from protocol therapy 
•
Intercurrent illness or medical circumstances: if at any time the constraints of this 
protocol are detrimental to the subject’s health, the subject may be removed from 
protocol therapy. In this event, the reasons for withdrawal will be documented.
•
General or specific changes in the subject's condition render the subject unacceptable for 
further treatment in the judgment of the investigator (investigator discretion).
•
Participant requests to be withdrawn from active therapy
•
Enroll on another protocol or receives standard of care.
•
Unacceptable treatment-related toxicity (DLT) as defined in Section 5.4.
•
Grade 4 toxicity after vaccinia injection per table below35:
Vaccinia-Related Toxicity Grading
Grade 1
     
Cutaneous reaction extending to not more than 10 cm from vaccination site
Grade 2
     
Cutaneous reaction extending to more than 10 cm from the vaccination site or any 
autoinoculation that resolves without sequelae
Grade 3
     
Not applicable
Grade 4
Autoinoculation syndrome with sequelae: postvaccinia encephalitis, vaccinia 
gangrenosum, eczema gangrenosum, or Steven-Johnson syndrome
5.8.2
Off-Study Criteria
•
Completed study follow-up period (1 year post treatment)
•
Disease progression to muscle-invasive urothelial carcinoma of the bladder
•
Subject’s request to be taken off study. In this event, the reasons for withdrawal will 
be documented. 
•
If subjects are non-compliant with the protocol guidelines, they may be removed from 
the study at the discretion of the principal investigator. 
•
Death

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5.8.3
Off Protocol Therapy and Off-Study Procedure
Authorized staff must notify Central Registration Office (CRO) when a subject is taken off 
protocol therapy and when a subject is taken off study. A Participant Status Updates Form from 
the web site (https://nih.sharepoint.com/sites/NCI-CCR-OCD-Communications/SitePages/OEC-
Administrative---Clinical-Research-(ADCR).aspx?Mode=Edit) main page must be completed 
and sent via encrypted email to:  NCI Central Registration Office ncicentralregistration-
l@mail.nih.gov. 
For participating sites, the Participant Status Updates Form will be supplied by the CCR study 
coordinator. Send the completed form to the CCR study coordinator.
6
DOSING DELAYS/DOSE MODIFICATIONS
6.1
TICE BCG
The need for BCG dose modification may arise and has been described previously.  To review, 
subjects will receive weekly (+/- 2 days) intravesical doses of BCG (TICE strain, 50 mg) as per 
usual standard of care for a total of 6 weeks.  Urine will be tested weekly prior to each BCG 
administration and the presence of gross hematuria or a urinary tract infection by urinalysis will 
result in holding that week’s BCG dose and postponing therapy until the following week.  Also, 
at the beginning of each administration, subjects will be queried about urinary symptoms.  
Complaints of persistent dysuria, urgency, bladder spasms, and/or frequency from previous 
week’s administration that is consistent with Grade 3 or greater toxicity will result in holding 
BCG administration for that week, supportive care (e.g. medications and hydration), and/or BCG 
dose reduction the following week at 1/3 normal dose as this can result in less toxicity with 
similar results for recurrence and progression.31 Complaints of non-infective cystitis or hematuria 
consistent with Grade 2 or higher will result in holding BCG administration for that week.  
Therapy will resume the following week at if these symptoms are at less than or equal to Grade 
1.  Subjects will be maintained at this reduced dose if they continue to fail to tolerate full dose 
therapy.
Future inability to tolerate this reduced dose will result in holding BCG for that week and 
postponing the BCG until the following week and dropping to 1/6 of the normal dose (details in 
Section 5.2).  Of note, weekly BCG postponement or dose reductions will not alter the 
vaccination schedule.  For example, if the week 5 dose of BCG is withheld, the subject will still 
receive the next dose of PANVAC™-F on week 7, but the last dose of BCG would be given on 
week 9 instead of week 8 (assuming that no other BCG postponement is necessary).  
6.2
PANVAC™-V (VACCINIA) AND PANVAC™-F (FOWLPOX) 
6.2.1
Dosing delay
•
Subjects must have recovered to ≤ grade 1 toxicity related to vaccine for 
constitutional symptoms (that are not related to the BCG or medications related 
to BCG treatments) in order to receive a subsequent vaccination.  These 
constitutional symptoms are listed in Section 8.1.1.1.

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•
Subjects with ≤ grade 2 toxicity not related to vaccine treatment (i.e. attributed to 
BCG) will remain eligible to receive vaccine.  
•
Subjects that recover from grade 3 toxicity unrelated to vaccine treatment (i.e. 
related to BCG) will remain eligible for the vaccine.  However, subjects that 
experience a grade 4 toxicity unrelated to vaccine treatment (i.e. attributed to 
BCG) will not remain eligible for further vaccine administration.  
•
If BCG is permanently discontinued, the patient will remain eligible for further 
vaccine administration in the absence of a grade 4 toxicity.        
•
  Vaccination will be held for > grade 2 proteinuria measured initially by a urine 
dipstick but confirmed by a 24 hour urine collection.
•
If  ≥grade 2 nonautoimmune toxicity attributable to the vaccine persists for > 42 
days, the subject will not receive further vaccine inoculations and will be 
removed from the protocol treatment and followed for resolution of toxicity and 
immune endpoints.  
•
Subjects who develop grade 3 injection site reactions will have their vaccine held 
until injection site reaction resolves to grade 2 or less.
•
Subjects who develop ≥ a grade 2 allergic or autoimmune disease that threatens 
vital organ function or any ≥ grade 3 autoimmunity, not related to a therapeutic 
response, will be removed from the protocol treatment and followed for 
resolution of toxicity and immune endpoints.  Follow-up will be performed 
during each vaccination and blood draw interval for immunologic testing as 
described in Section 11
•
Subjects who develop any grade 4 toxicity attributable to the study drug(s) will be 
removed from the protocol treatment and followed for resolution of toxicity and 
immune endpoints.
•
If a scheduled vaccine dose is missed due to scheduling or logistical issues, the 
vaccine may be given within 7 days of the appointed time (which resets the 
appointed date for further vaccinations) or be considered a missed dose.  If the 
subject has a delay in vaccination not due to toxicity during the core phase, the 
vaccine may be delayed for up to 42 days without removal of the subject from 
study.  BCG administration will not be affected by missed/delayed vaccine 
administrations.
6.2.1.1
Dose modifications
No dose modifications are allowed with this vaccine  
7
NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING PLAN
7.1
DEFINITIONS
Please refer to definitions provided in Policy 801: Reporting Research Events found 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements.

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7.2
OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING
7.2.1
Expedited Reporting 
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802 Non-Compliance Human Subjects Research found 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements. Note: Only IND Safety 
Reports that meet the definition of an unanticipated problem will need to be reported per these 
policies.
If the study is under review by an IC specific IRB, the following should be noted:
•
Reports referenced in policy 801 are made to the IC Specific IRB rather than to the 
OHSRP Office of Compliance and Training.  
•
Section 5.2 of the policy 801 does not apply
•
Policy 802 does not apply  
7.2.2
IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements. 
7.3
NCI CLINICAL DIRECTOR REPORTING 
Problems expeditiously reviewed by the OHSRP in the NIH eIRB system will also be reported to 
the NCI Clinical Director/designee; therefore, a separate submission for these reports is not 
necessary.
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email to the Clinical Director unless they are due to 
progressive disease.  
To report these deaths, please send an email describing the circumstances of the death to 
NCICCRQA@mail.nih.gov within one business day of learning of the death.
7.4
NCI GUIDANCE FOR REPORTING EXPEDITED ADVERSE EVENTS FOR MULTI-CENTER 
TRIALS
The site PI must immediately report to the coordinating center PI any serious adverse event, 
whether or not considered drug related, including those listed in the protocol or investigator 
brochure and must include an assessment of whether there is a reasonable possibility that the 
drug caused the event within 24 hours of PI awareness of the event.  The Site PI must also report 
any protocol deviations to the coordinating center PI within 7 days of PI awareness as per the 
form provided in Appendix D (Section 17.4). Participating centers must also submit the report to 
their IRB in accordance with their institutional policies. The appendices will be made available 
to other participating sites.

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7.5
NIH OFFICE OF SCIENCE POLICY (OSP)/INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) 
REPORTING CRITERIA
7.5.1
Serious Adverse Event Reports to OSP/IBC
The Principal Investigator (or delegate) will notify OBA via email 
(HGTprotocols@mail.nih.gov) and IBC of any unexpected fatal or life-threatening experience 
associated with the use of the vaccine as soon as possible but in no event later than 7 calendar 
days of initial receipt of the information.  Serious adverse events that are unexpected and 
associated with the use of the vaccine, but are not fatal or life-threatening, much be reported to 
NIH OSP/IBC as soon as possible, but not later than 15 calendar days after the sponsor’s initial 
receipt of the information.  Adverse events may be reported by using the Adverse Event 
Reporting template available on the NIH OSP website at:  http://osp.od.nih.gov/office-
biotechnology-activities/biomedical-technology-assessment/hgt/gemcris or by using the FDA 
Form 3500a.
7.5.2
Annual Reports to OSP/IBC
The study Principal Investigator will submit to OSP via email (HGTprotocols@mail.nih.gov) 
and IBC  a brief report annually of the progress of the trial within 60 days of the anniversary date 
that the IND went into effect unless the IND sponsor has been authorized to submit this report. 
Within 60 days after the one-year anniversary of the date on which the investigational new drug 
(IND) application went into effect, and after each subsequent anniversary until the trial is 
completed, the Principal Investigator (or delegate) shall submit the information described below.  
Alternatively, the FDA annual report can be sent to OSP/IBC in lieu of a separate report.  Please 
include the OSP/IBC protocol number on the annual report, and the updated clinical protocol.
7.5.2.1
Clinical Trial Information 
A brief summary of the status of each trial in progress and each trial completed during the 
previous year. The summary is required to include the following information for each 
trial: 
•
the title and purpose of the trial 
•
clinical site
•
the Principal Investigator
•
clinical protocol identifiers including the NIH OSP protocol number, NIH grant 
number(s) (if applicable), and the FDA IND application number; 
•
participant population (such as disease indication and general age group, e.g., adult or 
pediatric); 
•
the total number of participants planned for inclusion in the trial; the number entered into 
the trial to date whose participation in the trial was completed; and the number who 
dropped out of the trial with a brief description of the reasons 
•
the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, 
or fully completed, 

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•
if the trial has been completed, a brief description of any study results. 
7.5.2.2
Progress Report and Data Analysis
Information obtained during the previous year's clinical and non-clinical investigations, 
including: 
•
a narrative or tabular summary showing the most frequent and most serious adverse 
experiences by body system
•
a summary of all serious adverse events submitted during the past year
•
a summary of serious adverse events that were expected or considered to have causes not 
associated with the use of the gene transfer product such as disease progression or 
concurrent medications
•
if any deaths have occurred, the number of participants who died during participation in 
the investigation and causes of death
•
a brief description of any information obtained that is pertinent to an understanding of the 
gene transfer product’s actions, including, for example, information about dose-response, 
information from controlled trials, and information about bioavailability. 
7.6
NIH REQUIRED DATA AND SAFETY MONITORING PLAN
7.6.1
Principal Investigator/Research Team 
All data will be abstracted in a timely manner and entered into C3D. Adverse events will be 
reported as required above. Any safety concerns, or new information that might affect either the 
ethical and or scientific conduct of the trial will be reported to the IRB using iRIS to the Sponsor. 
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff. 
7.6.2
Safety Monitoring Committee
This protocol will require oversight from the Safety Monitoring Committee (SMC).  Initial 
review will occur as soon as possible after the annual NCI-IRB continuing review date.   
Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting 
schedule permits or more frequently as may be required by the SMC.   For initial and subsequent 
reviews, protocols will not be reviewed if there is no accrual within the review period. Written 
outcome letters will be generated in response to the monitoring activities and submitted to the 
Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI.
8
ADVERSE EVENTS:  LIST AND SPONSOR REPORTING REQUIREMENTS 
Study closed with CTEP as of 5/1/2019. No further reporting is required.

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Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 8.1) and the characteristics of an observed AE (Section 8.2) will 
determine whether the event requires expedited reporting (via CTEP-AERS) in addition to 
routine reporting.
8.1
COMPREHENSIVE ADVERSE EVENTS AND POTENTIAL RISKS LIST(S) (CAEPRS)
The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system.  In addition to the comprehensive list, a subset of AEs, 
the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column 
and is identified with bold and italicized text.  The SPEER is a list of events that are protocol-
specific exceptions to expedited reporting to NCI via CTEP-AERS (except as noted below).  
Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm for 
further clarification. 
NOTE:  The highest grade currently reported is noted in parentheses next to the AE in the 
SPEER.  Report ONLY AEs higher than this grade expeditiously via CTEP-AERS.  If this 
CAEPR is part of a combination protocol using multiple investigational agents and has an AE 
listed on different SPEERs, use the lower of the grades to determine if expedited reporting is 
required.
8.1.1
CAEPRs for CTEP IND Agents
For protocols with CAEPRs not including a “SPEER” category, protocol-specific exceptions to 
the CTEP-AERS reporting table can be found in the CAEPR’s “ASAEL” category instead.  This 
protocol-specific exception is limited to Grade 1 and Grade 2 ASAEL events, i.e. Grade 3 
through Grade 5 ASAEL-listed events are NOT exceptions to CTEP-AERS reporting.
8.1.1.1
PANVAC-V and PANVAC-F
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and 
is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are 
protocol specific exceptions to expedited reporting to NCI (except as noted below). Refer to the 
'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification. Below is the CAEPR for PANVAC-VF/TRICOM.
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses 
next to the AE in the SPEER. If this CAEPR is part of a combination protocol using 
multiple investigational agents and has an AE listed on different SPEERs, use the lower 
of the grades to determine if expedited reporting is required.

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Version 1.3, May 30, 20141
Adverse Events with Possible Relationship 
to PANVAC-VF/TRICOM
(CTCAE 4.0 Term)
 Specific Protocol Exceptions to 
Expedited Reporting (SPEER) 
BLOOD AND LYMPHATIC SYSTEM DISORDERS
Anemia
GASTROINTESTINAL DISORDERS
Diarrhea
Nausea
Pancreatitis2
Vomiting
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
Chills
Chills (Gr 2)
Fatigue
Fatigue (Gr 2)
Fever
Fever (Gr 2)
Flu like symptoms
Flu like symptoms (Gr 2)
Injection site reaction
Injection site reaction (Gr 2)
Pain
INVESTIGATIONS
Alanine aminotransferase increased
METABOLISM AND NUTRITION DISORDERS
Anorexia
Hypoalbuminemia
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
Arthralgia

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Back pain
Bone pain
Generalized muscle weakness
Myalgia
Myalgia (Gr 2)
Pain in extremity
NERVOUS SYSTEM DISORDERS
Headache
Headache (Gr 2)
Syncope
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS
Cough
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
Hyperhidrosis
Pruritus
Skin induration
1This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed 
to all Principal Investigators at the time of revision. The current version can be obtained by 
contacting PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and 
the agent should be included in the e-mail.
2Transient pancreatitis was observed in at least one patient who received endoscopic ultrasound 
(EUS)-guided intra-pancreatic tumor injection. 
Non-serious adverse events also reported on PANVAC-VF/TRICOM trials but with the 
relationship to PANVAC-VF/TRICOM still undetermined due to low frequency (i.e., <3%):
EYE DISORDERS - Eye pain
GASTROINTESTINAL DISORDERS - Abdominal pain; Colitis; Gastrointestinal disorders - 
Other (fluid around pancreas); Mucositis oral; Stomach pain
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; 
Edema limbs; Non-cardiac chest pain
IMMUNE SYSTEM DISORDERS - Allergic reaction

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INVESTIGATIONS - Alkaline phosphatase increased; Aspartate aminotransferase increased; 
Blood bilirubin increased; Lipase increased; Lymphocyte count decreased; Serum amylase increased
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hypomagnesemia
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Neck pain
NERVOUS SYSTEM DISORDERS - Dysgeusia
PSYCHIATRIC DISORDERS - Agitation; Insomnia
RENAL AND URINARY DISORDERS - Proteinuria
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Erythema multiforme; Rash maculo-
papular
VASCULAR DISORDERS - Hot flashes; Hypotension
Notes:  
1. PANVAC-V [Recombinant Vaccinia-CEA(D609)/MUC1(L93)/TRICOM] and 
PANVAC-F [Recombinant Fowlpox-CEA(D609)/MUC1(L93)/TRICOM] when used in 
combination with other agents, either commercial or investigational, could be associated 
with changes in the frequency or severity of known events or the emergence of new 
patterns of events. 
2. Other potential risks or complications associated with the use of the vaccinia vaccine 
strain from which the attenuated recombinant vector is derived, include those observed 
during the smallpox vaccination programs:
• Inadvertent inoculation (autoinoculation and direct contact transmission)
• Non-specific erythematous or urticarial rashes (generally self-limiting) and rarely, 
more serious bullous erythema multiforme (Stevens-Johnson syndrome)
• Generalized vaccinia (disseminated maculopapular or vesicular rash of varying 
extent on any part of the body)
• Eczema vaccinatum (vaccinial lesion development on areas of the skin that are, or 
had at one time been, eczematous)
• Progressive vaccinia (local vaccination lesion fails to heal and develops 
progressive necrosis, with destruction of large areas of skin, subcutaneous tissue, 
and underlying structures. Progressive lesions may spread to other skin surfaces 
and to bone and viscera)
• Post-vaccinial encephalitis/encephalomyelitis
• Fetal vaccinia
• Myocarditis/pericarditis
3. The inclusion of co-stimulatory molecules in these agents may theoretically stimulate 
autoimmunity or exacerbate existing disease in susceptible individuals.
4. Thrombotic thrombocytopenic purpura (TTP) occurred with closely related agents, 
PROSTVAC-V/TRICOM [Recombinant Vaccinia-PSA(L155)/TRICOM] and 
PROSTVAC-F/TRICOM [Recombinant Fowlpox-PSA(L155)/TRICOM].

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8.1.2
Adverse Event List(s) for Commercial Agents
8.1.2.1
TICE Bacillus Calmette-Guerin (BCG)
(See package insert for complete list of side effects)
Symptoms of bladder irritability, related to the inflammatory response induced, are reported in 
approximately 60% of patients receiving TICE® BCG. The symptoms typically begin 4–6 hours 
after instillation and last 24–72 hours. The irritative side effects are usually seen following the 
third instillation, and tend to increase in severity after each administration. 
The irritative bladder adverse effects can usually be managed symptomatically with products 
such as pyridium, propantheline bromide, oxybutynin chloride and acetaminophen. The 
mechanism of action of the irritative side effects has not been firmly established, but is most 
consistent with an immunological mechanism. There is no evidence that dose reduction or 
antituberculous drug therapy can prevent or lessen the irritative toxicity of TICE® BCG. “Flu-
like” symptoms (malaise, fever, and chills) which may accompany the localized, irritative 
toxicities often reflect hypersensitivity reactions which can be treated symptomatically. 
Antihistamines have also been used. Adverse reactions to TICE® BCG tend to be progressive in 
frequency and severity with subsequent instillation. Delay or postponement of subsequent 
treatment may or may not reduce the severity of a reaction during subsequent instillation. 
Although uncommon, serious infectious complications of intravesical BCG have been reported. 
The most serious infectious complication of BCG is disseminated sepsis with associated 
mortality. In addition, M. bovis infections have been reported in lung, liver, bone, bone marrow, 
kidney, regional lymph nodes, and prostate in patients who have received intravesical BCG. 
Some male genitourinary tract infections (orchitis/epididymitis) have been resistant to multiple 
drug antituberculous therapy and required orchiectomy. If a patient develops persistent fever 
or experiences an acute febrile illness consistent with BCG infection, BCG treatment 
should be discontinued and the patient immediately evaluated and treated for systemic 
infection. The local and systemic adverse reactions reported in a review of 674 patients with 
superficial bladder cancer, including 153 patients with carcinoma in situ, are summarized.
SUMMARY OF ADVERSE EFFECTS SEEN IN 674 PATIENTS WITH SUPERFICIAL 
BLADDER CANCER, INCLUDING 153 WITH CARCINOMA IN SITU
Adverse Event
N
Overall (Grade 
≥3)
Adverse Event
N
Overall 
(Grade ≥3)
Dysuria Urinary 
Frequency Flu-
Like Syndrome 
Hematuria Fever 
Malaise/Fatigue 
Cystitis Urgency 
Nocturia 
Cramps/Pain 
Rigors 
Nausea/Vomiting 
401 
272 
224 
175 
134 
50 40 
39 30 
27 22 
20 
60% (11%) 
40% (7%) 33% 
(9%) 26% (7%) 
20% (8%) 7% 
(0) 6% (2%) 6% 
(1%) 5% (1%) 
4% (1%) 3% 
(1%) 3% (<1%) 
Arthritis/Myalgia 
Headache/Dizziness Urinary 
Incontinence Anorexia/Weight 
Loss Urinary Debris Allergy 
Cardiac (Unclassified) Genital 
Inflammation/ Abscess 
Respiratory (Unclassified) 
Urinary Tract Infection 
Abdominal Pain 
18 
16 
16 
15 
15 
14 
13 
12 
11 
10 
10 
3% (<1%) 
2% (0) 2% 
(0) 2% 
(<1%) 2% 
(<1%) 2% 
(<1%) 2% 
(1%) 2% 
(<1%) 2% 
(<1%) 2% 
(1%) 2% 
(1%) 

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The following adverse events were reported in ≤1% of patients: anemia, BCG sepsis, 
coagulopathy, contracted bladder, diarrhea, epididymitis/prostatitis, hepatic granuloma, hepatitis, 
leukopenia, neurologic (unclassified), orchitis, pneumonitis, pyuria, rash, thrombocytopenia, 
urethritis, and urinary obstruction. 
In SWOG study 8795, toxicity evaluations were available on a total of 222 TICE® BCG-treated 
patients and 220 MMC-treated patients. Direct bladder toxicity (cramps, dysuria, frequency, 
urgency, hematuria, hemorrhagic cystitis, or incontinence) was seen more often with TICE® 
BCG, with 356 events compared to 234 events for MMC. Grade ≤2 toxicity was seen 
significantly more frequently following TICE® BCG treatment (p=0.003). No life-threatening 
toxicity was seen in either arm. Systemic toxicity with TICE® BCG was markedly increased 
compared to that of MMC, with 181 events for TICE® BCG compared to 80 for MMC. The 
frequency of toxicity was increased in all grades, particularly for grades 2 and 3. The most 
common complaints were malaise, fatigue and lethargy, fever, and abdominal pain. Thirty-two 
TICE® BCG patients were reported to have been treated with isoniazid. Five TICE® BCG 
patients had liver enzyme elevation, including two with grade 3 elevations. Eighteen of the 222 
(8.1%) TICE® BCG patients failed to complete the prescribed protocol compared to 6.2% in the 
MMC group. 
8.2
DEFINITIONS
8.2.1
Adverse Event
Any untoward medical occurrence in a human subject, including any abnormal sign (for 
example, abnormal physical exam or laboratory finding), symptom, or disease, temporally 
associated with the subject’s participation in research, whether or not considered related to the 
subject’s participation in the research. 
8.2.1.1
Adverse Event Characteristics 
•
CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 will be utilized death on study requires both  for AE reporting.  CTCAE version 5.0 
will be utilized for AE reporting beginning April 1, 2018. All appropriate treatment areas 
should have access to a copy of the CTCAE version 5.0.  A copy of the CTCAE version 
5.0 can be downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
•
For expedited reporting purposes only:  
-
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 8.1.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER.
-
Other AEs for the protocol that do not require expedited reporting are outlined in 
Section 8.4.

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•
Attribution of the AE:
-
Definite – The AE is clearly related to the study treatment.
-
Probable – The AE is likely related to the study treatment.
-
Possible – The AE may be related to the study treatment.
-
Unlikely – The AE is doubtfully related to the study treatment.
-
Unrelated – The AE is clearly NOT related to the study treatment.
8.3
EXPEDITED ADVERSE EVENT REPORTING TO CTEP 
Study Closed with CTEP on 5/1/2019.  No further reporting is required
8.3.1
Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event 
Reporting System), accessed via the CTEP Web site (http://ctep.cancer.gov).  The 
reporting procedures to be followed are presented in the “NCI Guidelines for 
Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) and 
DCP INDs and IDEs” which can be downloaded from the CTEP Web site 
(http://ctep.cancer.gov).  These requirements are briefly outlined in the tables below 
(Section 8.3.3).
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497.  Once Internet connectivity is restored, the 
24-hour notification phoned in must be entered electronically into CTEP-AERS by the 
original submitter at the site.
CTEP-AERS is programmed for automatic electronic distribution of reports to the 
following individuals:  Study Coordinator of the Lead Organization, Principal 
Investigator, and the local treating physician.  CTEP-AERS provides a copy feature for 
other e-mail recipients. 
8.3.2
Expedited Reporting Guidelines
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports.
Note:  A death on study requires both routine and expedited reporting regardless of 
causality.  Attribution to treatment or other cause must be provided.
Death due to progressive disease should be reported as Grade 5 “Disease progression” 
in the system organ class (SOC) “General disorders and administration site conditions.”.  
Evidence that the death was a manifestation of underlying disease (e.g., radiological 
changes suggesting tumor growth or progression: clinical deterioration associated with a 
disease process) should be submitted. 
Pregnancy loss
•
Pregnancy loss is defined in CTCAE as “Death in utero.”

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•
Any Pregnancy loss should be reported expeditiously, as Grade 4 “Pregnancy 
loss” under the Pregnancy, puerperium and perinatal conditions SOC.
•
A Pregnancy loss should NOT be reported as a Grade 5 event under the 
Pregnancy, puerperium and perinatal conditions SOC, as currently CTEPAERS 
recognizes this event as a patient death.
A neonatal death should be reported expeditiously as Grade 4, “Death neonatal” under 
the General disorders and administration SOC.
Late Phase 2 and Phase 3 Studies: Expedited Reporting Requirements for Adverse Events 
that Occur on Studies under an IND/IDE within 30 Days of the Last Administration of the 
Investigational Agent/Intervention1, 2
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312)
NOTE:  Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not they are 
considered related to the investigational agent(s)/intervention (21 CFR 312.64)
An adverse event is considered serious if it results in ANY of the following outcomes:  
1)
Death
2)
A life-threatening adverse event 
3)
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 hours 
4)
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions 
5)
A congenital anomaly/birth defect. 
6)
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. (FDA, 21 CFR 312.32; ICH 
E2A and ICH E6).
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via CTEP-AERS 
within the timeframes detailed in the table below.
Hospitalization
Grade 1 
Timeframes
Grade 2 
Timeframes
Grade 3 Timeframes
Grade 4 & 5 
Timeframes
Resulting in 
Hospitalization 
≥ 24 hrs
10 Calendar Days
Not resulting in
Hospitalization 
≥ 24 hrs
Not required
10 Calendar Days
24-Hour 5 
Calendar Days
NOTE:  Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific Protocol 
Exceptions to Expedited Reporting (SPEER) portion of the CAEPR
Expedited AE reporting timelines are defined as:
o
“24-Hour; 5 Calendar Days” - The AE must initially be reported via CTEP-AERS within 24 hours of learning of the 
AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report.

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o
“10 Calendar Days” - A complete expedited report on the AE must be submitted within 10 calendar days of learning 
of the AE.
1Serious adverse events that occur more than 30 days after the last administration of investigational agent/intervention and have 
an attribution of possible, probable, or definite require reporting as follows: 
Expedited 24-hour notification followed by complete report within 5 calendar days for:
•
All Grade 4, and Grade 5 AEs
Expedited 10 calendar day reports for:
•
Grade 2 adverse events resulting in hospitalization or prolongation of hospitalization 
•
Grade 3 adverse events
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, rounded UP to the 
nearest whole day, after the agent/intervention was last administered.  Footnote “1” above applies after this reporting period.
Effective Date:  May 5, 2011

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8.3.3
Additional Protocol-Specific Expedited Adverse Event Reporting Exclusions
For this protocol only, the AEs/grades listed below do not require expedited reporting via 
CTEP-AERS.  However, they still must be reported through the routine reporting 
mechanism (Section 8.4):
CTCAE 
SOC
Adverse 
Event
Grades
Hospitalization/ 
Prolongation of 
Hospitalization
Attribution
Comments
Renal and 
urinary 
disorders
Gross 
hematuria
1 & 2
This AE should not 
lead to hospitalization 
except in the event of 
continuous bladder 
irrigation (CBI)
Intravesical 
BCG
Can be managed with 
oral hydration and 
possible BCG dose 
reduction (per PI 
discretion)
Renal and 
urinary 
disorders
Cystitis (non-
infective)
1 & 2
This AE should not 
lead to hospitalization 
except in the event of 
continuous bladder 
irrigation (CBI)
Intravesical 
BCG
Can be managed with 
oral anti-cholinergics or 
analgesics and possible 
BCG dose reduction 
(per PI discretion)
Renal and 
urinary
Frequency/ 
urgency 
1 & 2
This AE should not 
lead to hospitalization
Intravesical 
BCG
Can be managed with 
oral anti-cholinergics or 
analgesics and possible 
BCG dose reduction 
(per PI discretion)
Renal and 
urinary
Bladder 
pain/spasms 
1 & 2
This AE should not 
lead to hospitalization
Intravesical 
BCG
Can be managed with 
oral anti-cholinergics or 
analgesics and possible 
BCG dose reduction 
(per PI discretion)
8.4
ROUTINE ADVERSE EVENT REPORTING TO CTEP
All Adverse Events must be reported in routine study data submissions.  AEs reported through 
CTEP-AERS must also be reported in routine study data submissions.
8.5
SECONDARY MALIGNANCY
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A secondary 
malignancy is not considered a metastasis of the initial neoplasm. 

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CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported via CTEP-AERS. Three options are available to describe the event: 
•
Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML]) 
•
Myelodysplastic syndrome (MDS) 
•
Treatment-related secondary malignancy 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol. 
8.6
SECOND MALIGNANCY
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy).  Second malignancies require ONLY routine reporting 
via CDUS unless otherwise specified. 
9
PHARMACEUTICAL INFORMATION
A list of the adverse events and potential risks associated with the investigational agents or 
commercial agents administered in this study can be found in Section 8.1.
9.1
CTEP IND AGENTS
9.1.1
PANVAC-V (NSC 727026)
Other Names: Recombinant-Vaccinia-CEA(D609)/MUC-1(L93)/TRICOM
Classification:  Recombinant vaccinia virus vector vaccine of the genus Orthopoxvirus.
Description: PANVAC-V is a recombinant vaccinia virus vector vaccine containing genes for 
human CEA, MUC-1 and three co-stimulatory molecules (designated TRICOM): B7.1, ICAM-1 
(intercellular adhesion molecule-1), and LFA-3 (leukocyte function-associated antigen-3). The CEA 
gene coding sequence is modified to code for a single amino acid substitution (aspartic acid, instead 
of asparagine at amino acid position 609) in one 9-mer, HLA-A2-restricted, immunodominant 
epitope designed to enhance immunogenicity. The MUC-1 gene coding sequence is also modified 
to code for a single amino substitution (leucine, instead of threonine at amino acid position 93) in 
one 10-mer, HLA-A2-restricted, immunodominant epitope designed to enhance immunogenicity. 
TBC-vTRICOM, is used as the parental virus for this recombinant vaccine, and is generated by 
insertion of the genes for the three co-stimulatory molecules into an attenuated, live, derivative of 
the Wyeth (New York City Board of Health) strain of vaccinia virus. A plasmid vector containing 
the modified CEA and MUC-1 genes is used to transfect primary chicken embryo dermal (CED) 
cells infected with the parental vaccinia virus to generate the recombinant vaccinia virus. The final 
PANVAC-V recombinant vaccine is generated by infection of primary CED cells with the 
recombinant vaccinia virus.  Vaccinia virus can infect mammalian cells and express the inserted 
transgenes, and is a potent immune stimulator, eliciting both a strong humoral and cellular immune 

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response. Vaccinia virus is replication competent in mammalian cells, making systemic infections 
possible. 
How Supplied: 
Lot: 2-050103: PANVAC-V is supplied by the Pharmaceutical Management Branch, CTEP, NCI 
in vials containing 0.3 mL of the vaccine at a final viral concentration titer of 2.1 x 109 pfu/mL 
formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 6.3 x 108 
pfu’s).
All other lots: PANVAC-V is supplied by the Pharmaceutical Management Branch, CTEP, NCI in 
vials containing 0.75 mL of the vaccine at a final viral concentration titer of 4 x 108 pfu/mL 
formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 3 x 108 
pfu’s). 
Note: The PANVAC-V concentration varies between lots, requiring changes to dose preparation 
instructions. Use extreme caution when preparing each dose.
Preparation: Thaw vials completely at room temperature. Ensure the thawed contents are at the 
bottom of the upright vial and vortex vigorously at high power for at least ten seconds prior to 
dose preparation. Perform all dilutions of the vaccine with 0.9% sodium chloride for injection, 
USP and vortex all dilutions vigorously again for at least ten seconds prior to withdrawing the 
final dose.  Note the concentration of the current supply of PANVAC-V on your institutional 
preparation guidelines to avoid potentially serious dosing errors. 
PANVAC™-V (vaccinia) Lot: 2-050103 (2.1 x 109 pfu/mL, 0.3 mL vial): 
Allow the contents of one vial to thaw completely at room temperature. Ensure the thawed 
contents are at the bottom of the upright vial and vortex vigorously at high power for at least ten 
seconds. Add 0.7 mL of 0.9% sodium chloride, USP to the thawed vial to yield 1 mL of 
PANVAC™-V (vaccinia) at a concentration of 6.3 x 108 pfu/mL. Vortex vigorously at high 
power for at least ten seconds. Withdraw 0.32 mL (2 x 108 pfu) for subcutaneous administration.
PANVAC™-V (vaccinia) all other lots:
Allow the contents of one vial to thaw completely at room temperature. Ensure the thawed 
contents are at the bottom of the upright vial and vortex vigorously at high power for at least ten 
seconds. Withdraw 0.5 mL (2 x 108 pfu) for subcutaneous administration.
Storage: Store intact vials of PANVAC-V at –70oC or colder.
Stability: Shelf-life studies of the intact vials are ongoing. Once the intact vials are thawed, the 
vaccines maintain their potency for up to 4 days when stored at 2-8oC. Do not re-freeze thawed 
vials. Vials of PANVAC-V are for single-use only and do not contain a preservative. Administer 
prepared doses as soon as possible following preparation (i.e., within one hour). If necessary, store 
prepared doses at 2-8oC for up to 4 hours following preparation.

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Route of Administration: PANVAC-V is administered by subcutaneous injection. 
Special Handling and Precautions
Vaccinia virus is classified as a Biosafety Level 2 agent. These agents are associated with human 
disease and are of moderate potential hazard to personnel and the environment. The recombinant 
vaccine is a preparation of a live virus affecting humans and contains DNA sequences derived 
from the human genome. Handle the recombinant vaccine as an infectious hazardous biological 
substance and dispose of waste materials as infectious hazardous biological waste, with 
incineration according to local institutional policies and according to local, state, and federal 
regulations. 
Preparation, Handling and Disposal Recommendations 
1. Prepare a biosafety manual which advises personnel of special hazards and specific 
instructions on practices and procedures.
2. Post warning hazard signs on access doors, identifying the agents, the biosafety level, the 
name and phone number of the Principal Investigator or other responsible person, and any 
special requirements for entry.
3. Establish policies and procedures allowing only personnel who are knowledgeable of the 
potential hazards and meet specific entry requirements (e.g., immunization) into agent 
preparation or storage areas.
4. Strictly adhere to standard microbiological practices and techniques.
5. Limit/restrict access to preparation areas while dose preparation is in progress.
6. Use appropriate infection control measures (e.g., thorough hand washing) after handling any 
materials.
7. Institute and follow policies for safe handling of sharps. Use only needle-lock syringes and 
needles for dose preparation. Use extreme caution to prevent autoinoculation. Do not bend, 
shear, or replace the needle guard from the syringe following use. Promptly place used 
needles and syringes in puncture-resistant containers for disposal.
8. Perform all dose preparations in a certified Class II biological safety cabinet, generally using 
procedures, guidelines and personal protective apparel used during preparation of 
antineoplastic agents [e.g., minimizing creation of aerosols; no eating, drinking, handling 
contact lenses or applying cosmetics in the work area; using appropriate personal protective 
apparel - gowns, sterile latex gloves (double-gloving is recommended), respirator masks, 
protective eye wear, hair cover]. 
9. Perform all procedures carefully to minimize aerosol creation.
10. Decontaminate the biological safety cabinet prior to dose preparation with sterile gauze 
soaked in 10% bleach solution (0.52% sodium hypochlorite solution), or other appropriate 
disinfectant suitable for decontamination, rinsing, then wiping down with sterile gauze 
soaked in 70% alcohol. Consult specific manufacturer’s recommendations with respect to 
disinfectant concentration, contact time and method of application. 
11. Have all necessary supplies on-hand before beginning the preparation procedure. Develop a 
detailed worksheet outlining all supplies, dose calculations, and preparation procedures, and 
keep it available.

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12. Place an empty biohazard sharps container in the biosafety cabinet to dispose of all waste 
generated.
13. Transport the agent from the –70oC freezer to the work area in leak proof bag. 
14. Wipe or spray items used for dose preparation with 70% alcohol before placing in the 
biological safety cabinet. Disinfectants should remain in contact with the surfaces for at least 
five minutes prior to dose preparation. Avoid exposing the virus to disinfectants.
15. Wipe the syringe containing the prepared dose with 70% alcohol before removing it from the 
biological safety cabinet; transport it in a leak proof bag or container labeled with a 
biohazard symbol.
16. Place all waste into a sharps container lined with the leak proof biohazard bag and 
decontaminate the biological safety cabinet again by wiping down all surfaces with sterile 
gauze soaked in 10% bleach solution, or other appropriate disinfectant, rinsing, then wiping 
down with sterile gauze soaked in 70% alcohol. Following decontamination, dispose of 
personal protective apparel in the biohazard safety bag.
17. Place all waste and protective apparel in a leak proof biohazard bag, and place the bag inside 
a biohazard sharps container for incineration according to institutional policy and according 
to local, state, and federal regulations.
18. Handle accidental spills similarly to antineoplastic spills and/or according to institutional 
policy:
•
Prevent others from entering the area and allow aerosols time to settle (approximately 10 
minutes). 
•
Use protective apparel, eyewear, mask, and gloves. 
•
Cover spills with disposable absorbent towels. 
•
Decontaminate the area with 10% bleach solution, or other appropriate disinfectant 
suitable for decontamination, allowing approximately a 20-minute contact time. 
•
Dispose of all waste and protective apparel as infectious biohazardous waste and 
incinerate according to institutional policy and according to local, state, and federal 
regulations. 
19. Immediately report spills and accidents resulting in overt exposure to recombinant DNA 
molecules to the Institutional Biosafety Committee and NIH/OSP (Office of Science Policy). 
Send reports to the Office of Science Policy, National Institutes of Health, 6705 Rockledge 
Drive, Suite 750, MSC 7985, Bethesda, MD 20892-7985. Phone (301) 496-9838. Provide 
medical evaluation, surveillance, and treatment as appropriate and maintain written records 
of the event.
For more information about biohazard risk group classification and biohazard safety levels: 
•
NIH Guidelines for Research Involving Recombinant DNA Molecules (NIH 
Guidelines). See current version at: 
http://osp.od.nih.gov/sites/default/files/resources/NIH_Guidelines.pdf
•
Biosafety in Microbiological and Biomedical Laboratories; U. S. Department of Health and 
Human Services Centers for Disease Control and Prevention and National Institutes of 
Health. See current edition at: http://www.cdc.gov/biosafety/publications/index.htm
Precautions for Healthcare Workers 

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Recombinant vaccinia virus transmission risk to exposed healthcare workers is unknown. To 
date, no reports of transmission to healthcare personnel from vaccine recipients have been 
published. If appropriate infection control precautions are observed (such as covering the 
vaccination site and washing hands after contact with the vaccination site or bandages), 
healthcare workers are probably at less risk of infection than laboratory workers because of the 
smaller volume and lower titers of virus in clinical specimens as compared with laboratory 
material. However, because of the potential risk for transmission, healthcare personnel who 
prepare or administer doses of recombinant vaccinia vaccine or have direct contact with 
contaminated dressings or other infectious material from participants in clinical studies must 
adhere to appropriate infection control measures and should be offered vaccination with the 
licensed vaccinia vaccine. Do not administer routine, non-emergency vaccination with the 
licensed vaccinia vaccine to healthcare workers, if they, or for at least three weeks after 
vaccination, their close household contacts (close household contacts are those who share 
housing or have close physical contact): 
•
have active eczema or a history of eczema or atopic dermatitis, or Darier’s disease.
•
have other acute, chronic, or exfoliative skin conditions (e.g., burns, impetigo, varicella 
zoster, severe acne, or other open rashes or wounds), until the condition resolves.
•
are pregnant or intend to become pregnant within 4 weeks of vaccination or are breast-feeding.
•
are immunodeficient or immunocompromised (by disease or therapy), including HIV 
infection.
Additionally, do not administer routine, non-emergency vaccination with the licensed vaccinia 
vaccine to healthcare workers if the vaccinee:  
•
has a moderate or severe acute illness, until the illness resolves.
•
is less than 18 years of age, unless specifically indicated.
•
is undergoing topical steroid therapy for inflammatory eye diseases or undergoing therapy 
with systemic steroids; potential immune suppression increases risk for vaccinia-related 
complications. 
•
has a history of allergy or serious reaction to prior vaccinia vaccination or any of the 
vaccine’s components.
•
As a precaution, the CDC recommends that individuals with known cardiac disease (e.g., 
previous MI, angina, CHF, cardiomyopathy, stroke or TIA) or who have > 3 known risk 
factors for cardiac disease (e.g., hypertension, hypercholesterolemia, diabetes, first degree 
relative with onset of cardiac complications prior to age 50, smoker), not receive routine, 
non-emergency, prophylactic vaccination with the licensed vaccinia vaccine while a possible 
causal relationship between vaccination and cardiac events is being evaluated.
Avoid exposure to the recombinant vaccinia vaccine, any contaminated dressings, or other 
infectious materials from patients, or the patient’s inoculation site if you are pregnant or breast-
feeding; have a history or presence of active eczema or atopic dermatitis; have acute, chronic or 
exfoliative skin conditions; or, are immunocompromised. More information on vaccinia 
precautions for healthcare workers can be obtained from 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5010a1.htm#tab2 and 
http://www.cdc.gov/mmwr/PDF/rr/rr5207.pdf.

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The CDC is the only source of the licensed vaccinia vaccine. The CDC will provide vaccinia 
vaccine to protect laboratory and other healthcare personnel, whose occupations place them at 
risk of exposure to vaccinia and other closely related orthopoxviruses, including vaccinia 
recombinants. The vaccine should be administered under the supervision of a physician selected 
by the study institution. Revaccination is recommended every 10 years. For instructions on 
obtaining the licensed vaccinia vaccine, contact Drug Services, National Center for Infectious 
Diseases, CDC at (404) 639-3670.
Recombinant Vaccinia Vaccine Patient Care Implications, Contraindications and Potential 
Complications  
Patient Care Implications and Contraindications
Cover vaccination sites with a sterile dry dressing (e.g., Telfa pad). Instruct patients on proper hand-
hygiene, sterile dressing care, bathing, laundering of clothing, etc. Treat patient bandages or 
dressings removed from the vaccination site as infectious waste and dispose in appropriate 
biohazard containers. Do not administer the recombinant vaccinia vaccine if the recipient, or for at 
least three weeks after vaccination, their close household contacts (close household contacts are 
those who share housing or have close physical contact): 
•
have active eczema or a history of eczema or atopic dermatitis, or Darier’s disease.
•
have other acute, chronic, or exfoliative skin conditions (e.g., burns, impetigo, varicella zoster, 
severe acne, contact dermatitis, psoriasis, herpes or other open rashes or wounds), until the 
condition resolves.
•
are pregnant or intend to become pregnant (due to the potential risk of fetal vaccinia); or are 
breast-feeding (due to the potential risk of contact transmission and inadvertent inoculation). 
It is currently unknown if vaccinia virus or antibodies are excreted in breast milk.  Because 
there is no safety data available, patients (i.e., vaccinees) should avoid becoming pregnant, 
fathering a child, or breast-feeding for at least 4 months following completion of therapy 
with the recombinant vaccine.
•
are in close contact with children less than 3 years of age (due to the potential risk of contact 
transmission and inadvertent inoculation). 
•
are immunodeficient or immunocompromised (by disease or therapy), including individuals 
with HIV infection.
Additionally, do not administer the recombinant vaccinia vaccine if the vaccinee: 
•
has a moderate or severe acute illness, until the illness resolves.
•
is undergoing topical steroid therapy for inflammatory eye diseases, or undergoing therapy 
with systemic steroids; potential immune suppression increases risk for vaccinia-related 
complications.
•
At this time, until a more definitive causal relationship is determined, it is recommended that 
patients with known CHF or clinically significant cardiomyopathy, not be vaccinated with 
recombinant vaccinia-based vaccines, due to the potential for development of myocarditis 
and/or pericarditis. 

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Although the CDC believes that there is no evidence to conclude that the licensed vaccinia 
vaccine used in the Smallpox Vaccination Program caused angina or heart attacks, it 
acknowledges a possible causal relationship between the vaccination and heart inflammation.  
The CDC continues to study the relationship, but in the meantime, recommends excluding 
individuals with underlying heart disease from participation in the current Smallpox 
Vaccination Program. Patients are being immunized with recombinant vaccinia vaccines with 
therapeutic intent and will be evaluated for cardiovascular risk factors and recent or 
symptomatic cardiac events per protocol eligibility criteria. Patients will be encouraged to 
minimize cardiovascular disease risks and encouraged to follow risk reduction according to 
standard medical practice.  
Due to the method of manufacturing (virus grown in primary chicken embryo dermal cells), do 
not administer the recombinant vaccinia vaccine to patients with a history of allergy to eggs or 
egg products. Do not administer the recombinant vaccinia vaccine to patients with a history of 
allergy or serious reaction to prior vaccinia vaccination (e.g., smallpox vaccination).
Potential Complications Associated With Recombinant Vaccinia Vaccination 
When vaccinia vaccine is administered by scarification for vaccination against smallpox, 
expected local reactions in individuals that have not previously been vaccinated with vaccinia 
include the appearance of a red papule in 3-4 days, followed by vesiculation in 5-6 days, and 
then the formation of a pustule on days 8-9. A large area of erythema may surround the vesicle 
and pustule. A crusted scab usually forms by the second week and sloughs by the third week, 
leaving a well-formed scar. Maximal viral shedding occurs from days 4-14, but can continue 
until the scab is shed from the skin. Other normal local reactions can include development of 
local satellite lesions, regional lymphadenopathy that can persist for weeks following healing of 
the skin lesion, considerable local edema, and intense inflammation from the vaccination (i.e., 
viral cellulites), which may be confused with bacterial cellulites. Systemic symptoms typically 
occur between 8-10 days post-vaccination and include fever, malaise, headache, chills, nausea, 
myalgia, local lymphadenopathy, soreness and intense erythema surrounding the vaccination 
site.
When administered by scarification in individuals that have previously been vaccinated with 
vaccinia, expected local reactions include the appearance of a clear cut pustule 6-8 days 
following vaccination or the development of an area of definite induration around a central lesion 
that may be an ulcer or scab 6-8 days following vaccination. The response to re-vaccination 
depends on the degree of residual immunity following previous vaccination. Similar systemic 
symptoms may occur, but typically at a lower frequency. 
When recombinant vaccinia vaccines are administered by intradermal, intralesional, 
subcutaneous or intramuscular routes of injection, milder local reactions are expected, but similar 
systemic symptoms may occur.
There have been a number of complications reported in the literature associated with vaccinia 
vaccination for smallpox. Reported complications from vaccinia vaccine when given by 
scarification include: a) auto-inoculation of other sites with vaccinia, b) generalized vaccinia, c) 
eczema vaccinatum, d) progressive vaccinia (vaccinia necrosum), or e) post-vaccinial 

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encephalitis.  In a 1968 ten-state survey, cases of these complications per million vaccinations in 
adult recipients (> 20 years of age) of vaccinia primary vaccination and revaccination were:
Primary Vaccination
Revaccination
auto-inoculation
606.1
25
generalized vaccinia
212.1
9.1
eczema vaccinatum
30.3
4.5
progressive vaccinia
none reported
6.8
postvaccinial encephalitis
none reported
4.5
Based on a 1968 national survey, the number of deaths in primary vaccinees was approximately 
1 per million and the number of deaths in recipients of revaccination was approximately 0.25 per 
million. Deaths were most often the result of postvaccinial encephalitis or progressive vaccinia.
Information has been reported by the US Department of Defense (DoD) during the post-
vaccination surveillance assessment of adverse events in military personnel following 
implementation of a smallpox vaccination program from the period of December 13, 2002 
through May 28, 2003. Although not directly comparable to historical numbers, due to 
differences in multiple population variables, estimated cases (number of cases per million 
vaccinations based on vaccination of 450,293 personnel, with a median age of 26 years and 
70.5% as primary vaccinees) of these same complications per million vaccinations were:
auto-inoculation
107
generalized vaccinia
80
eczema vaccinatum
none reported
progressive vaccinia
none reported
postvaccinial encephalitis
2.2
Generally, self-limited adverse reactions that can be serious, but not life-threatening include 
autoinoculation, erythematous and urticarial rashes, and generalized vaccinia. More serious life-
threatening complications include progressive vaccinia, eczema vaccinatum, and post-vaccinial 
encephalitis/encephalomyelitis. The complications of vaccinia vaccination may involve a number 
of different reactions:
1. Non-specific erythematous or urticarial rashes: These rashes can appear 
approximately 10 days after vaccination and may sometimes be confused with 
generalized vaccinia, but are generally self-limiting. Patients are usually afebrile and 

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these benign rashes usually resolve spontaneously within 2-4 days. Erythema multiforme 
can present as different types of lesions, including macules, papules, urticaria, and bull’s 
eye lesions (dark papule or vesicle surrounded by a pale zone and an area of erythema). 
These lesions may be extremely pruritic, lasting up to four weeks. Rarely, more serious 
bullous erythema multiforme (Stevens-Johnson syndrome) may occur, requiring 
hospitalization. Vaccinia Immune Globulin (VIG) therapy is not indicated to treat these 
rashes. Supportive care measures are warranted since these rashes are likely 
manifestations of an immune response or hypersensitivity reaction to the vaccine and are 
not likely to contain vaccinia virus.
2. Bacterial Infection: Vaccination site infection, most likely due to staphylococcus and 
streptococcus normal skin flora, is rare. Onset is approximately 5 days post-vaccination 
and is more common in children. Appropriate antibiotic therapy is required.
3. Inadvertent Inoculation: This can occur in the vaccinee (autoinoculation) as well as in 
close contacts (contact transmission). Accidental infection is the most common 
complication of vaccinia vaccination, accounting for approximately 50% of all 
complications associated with vaccination and revaccination. This usually results from 
autoinoculation of vaccinia virus transferred from the site of the vaccination. Sites 
typically involved include the face, eyelids, nose, mouth, genitalia, or rectum, but can 
also involve the arms, legs, and trunk. Contact transmission of vaccinia, with 
accompanying toxicities, may occur when a recently vaccinated individual has contact 
with a susceptible individual.  In a 1968 ten-state survey, contact transmissions were 
reported to occur at a rate of 27 infections per million vaccinations.  The age group in 
which contact transmission occurred most commonly was in children  5 years. Eczema 
vaccinatum as a result of contact transmission may result in a more severe syndrome than 
that seen in vaccinees, perhaps because of multiple simultaneous inoculations. About 
30% of eczema vaccinatum cases reported in the 1968 ten-state survey were a result of 
contact transmission. It is possible that the number of cases of contact transmission would 
be greater in today’s population, due to a largely unvaccinated patient population against 
smallpox. Contact transmission rarely results in postvaccinial encephalitis or progressive 
vaccinia. Most cases of inadvertent inoculation usually resolve without specific therapy 
and resolution of lesions follow the same course as the vaccination site in 
immunocompetent individuals. VIG can be used for severe cases involving extensive 
lesions or if comorbid conditions exist. VIG is contraindicated in the presence of isolated 
keratitis due to the risk of increased corneal scarring. VIG use can be considered in cases 
of ocular implantation, with keratitis, if vision-threatening or if other life-threatening 
vaccinia-related complications exist that require VIG therapy.  
4. Generalized vaccinia: Generalized vaccinia is characterized by a disseminated 
maculopapular or vesicular rash of varying extent on any part of the body and typically 
develops 6-9 days after vaccination. The lesions follow the same course as the 
vaccination site lesion. The lesions are hematogenously spread and may contain vaccinia 
virus. In immunocompetent individuals, the rash is generally self-limiting and requires 
supportive care therapy. VIG treatment can be used in severe cases for patients who are 
systemically ill and whose condition might be toxic or who have serious underlying 
immunosuppressive illnesses. The differential diagnosis of GV includes eczema 
vaccinatum, erthyema multiforme, inadvertent inoculation at multiple sites, and 

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uncommonly, early stages of progressive vaccinia or other vesicular diseases (e.g., severe 
chickenpox or disseminated herpes). Several publications have investigated the reporting 
of GV among those individuals who received smallpox vaccinations during 2003.  Out of 
38,440 vaccine recipients, 29 reports of possible GV during January 2003–December 
2003 were identified but only 2 reports met the case definition. More than 75% of the 
reports received a final diagnosis of hypersensitivity reaction or nonspecific rash after 
review by dermatologists or because laboratory results were negative for vaccinia and 
other orthopox viruses.  Of 74 cases investigated in 753,226 smallpox vaccinations 
administered in December 2002 to December 2004, 50 (67.6%) met the case definition of 
possible GV.  Cases occurred more frequently in primary vaccinees (rate, 81 per 1 
million vaccinees) than in those revaccinated (rate, 32 per 1 million vaccinees).  
However, none met the case definition of probable or confirmed GV, including 15 with 
virologically negative laboratory evaluations (e.g., culture, polymerase chain reaction, or 
skin biopsy).  Twenty-one reports of postscab lesions were made between January and 
August 2003 among 37,542 smallpox vaccinees.  The lesions (scab and/or fluid) of seven 
patients were tested for vaccinia virus by use of polymerase chain reaction and/or 
immunohistochemistry; all were found to be negative.  In addition, the postscab lesions 
of four of the patients were biopsied.  The results from two of the biopsies suggested an 
allergic contact dermatitis, and results of one each demonstrated chronic dermatitis and 
squamous cell carcinoma.  None of the four biopsied lesions had histologic evidence of 
viropathic changes and no evidence supported smallpox vaccination as a cause for any of 
the lesions.  
5. Eczema vaccinatum: Eczema vaccinatum is a serious complication in persons with 
eczema and other types of chronic or exfoliative skin conditions. It can also occur among 
eczematous contacts of recently vaccinated persons. Vaccinial lesions (generalized 
papular, vesicular or pustular lesions) develop on areas of the skin that are, or had at one 
time been, eczematous. These areas become highly inflamed and lesions may spread to 
healthy skin. The rash is often accompanied by fever and individuals are systemically ill. 
The fatality rate for untreated cases (prior to availability of VIG) has been reported from 
30-40%. Following availability of VIG, mortality was reduced to approximately 7%. 
Early diagnosis and prompt treatment with VIG is necessary to reduce mortality. 
6. Progressive vaccinia: Progressive vaccinia is the most serious cutaneous complication, 
occurring when the local vaccination lesion fails to heal and develops progressive 
necrosis, with destruction of large areas of skin, subcutaneous tissue, and underlying 
structures. Progressive lesions may spread to other skin surfaces and to bone and viscera.   
Progressive vaccinia is associated with a high mortality rate. This complication has been 
seen in patients with a compromised immune system due to a congenital deficiency, 
lymphoproliferative 
disease, 
immunosuppressive 
treatment, 
or 
HIV 
infection. 
Management should include aggressive VIG therapy.
7. Post-Vaccinial Encephalitis/Encephalomyelitis: Vaccinial complications affecting the 
CNS are unpredictable. Post-vaccinial encephalitis typically affects children < 2 years of 
age and is characterized by an onset of symptoms 6-10 days following vaccination, which 
include seizures, hemiplegia, aphasia, and transient amnesia. Histopathological changes 
include generalized cerebral edema, mild lymphocytic meningeal infiltration, ganglion 
degenerative changes and perivascular hemorrhages. Older children and adults can 

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develop encephalitis or encephalomyelitis characterized by an onset of symptoms 11-15 
days following vaccination, which include fever, vomiting, headache, malaise, and 
anorexia, progressing to loss of consciousness, amnesia, confusion, disorientation, 
restlessness, delirium, drowsiness, seizures and coma. Histopathological changes include 
demyelination with lymphocytic infiltration, but limited cerebral edema. Mortality rates 
have ranged from 15-25%, with 25% of patients who recover being left with varying 
degrees and types of neurological deficits. VIG has not been shown to be effective in 
treating 
CNS 
disease 
and 
is 
not 
recommended. 
Post-vaccinial 
encephalitis/encephalomyelitis are diagnoses of exclusion and are not believed to be a 
result of replicating vaccinia virus.  Although no specific therapy exists, supportive care, 
anticonvulsants, and intensive care might be required. A review of vaccinia-related 
deaths (68) during a 9-year period (1959–1966 and 1968) revealed that among first-time 
vaccines, 36 (52%) patients died as a result of post-vaccinial encephalitis.    
8. Fetal Vaccinia: Fetal vaccinia is a rare, but serious complication following vaccinia 
vaccination during pregnancy or shortly before conception (e.g., within four weeks).  To 
date, fewer than 50 cases have been reported and often result in fetal or neonatal death. 
Efficacy of VIG therapy in a viable infant or used prophylactically in women during 
pregnancy is unknown. The CDC has established a National Smallpox Vaccine in 
Pregnancy Registry. This registry will follow women during their pregnancies and their 
babies, after they are born, to determine the outcome of such pregnancies. The CDC can 
be contacted at (404) 639-8253.
9. Myocarditis/Pericarditis:  The CDC has recommended a temporary medical deferral to 
the voluntary Smallpox Vaccination Program for persons with heart disease or 
cardiovascular risk factors (March 25, 2003) and issued “interim supplementary 
information” regarding evidence that smallpox vaccination may cause myocarditis and/or 
pericarditis (March 31, 2003) in people recently vaccinated with the smallpox vaccine. 
The cardiac events reported include myocardial infarction, angina, myocarditis, 
pericarditis, and myopericarditis. Although the CDC believes that there is no evidence to 
conclude that the licensed vaccinia vaccine causes angina or heart attacks, it 
acknowledges a possible causal relationship between the vaccination and heart 
inflammation.  The CDC continues to study the relationship, but in the meantime, 
recommends that individuals with underlying heart disease be excluded from 
participation in the current Smallpox Vaccination Program. While it is currently not 
possible to fully evaluate the risk of cardiac events or the risk of myocarditis, pericarditis, 
or myopericarditis associated with vaccinia vaccination, it is reasonable to inform 
patients participating in studies using recombinant vaccinia virus of these reports and 
provide relevant guidance for evaluating these events. Further investigation from the 
ongoing vaccine program may provide additional data regarding an association or lack of 
association with cardiovascular disease. Patients are being immunized with recombinant 
vaccinia vaccines with therapeutic intent and will be evaluated for cardiovascular risk 
factors and recent or symptomatic cardiac events per protocol eligibility criteria. Patients 
will be encouraged to minimize cardiovascular disease risks and encouraged to follow 
risk reduction according to standard medical practice. At this time the evidence for an 
association with myocarditis, pericarditis, or myopericarditis seems plausible, but a rare 

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event.  If not otherwise excluded, patients with known CHF or clinically significant 
cardiomyopathy requiring treatment should be excluded from protocol eligibility.      
Out of a total of 540,824 military personnel vaccinated with a New York City Board of 
Health strain of vaccinia from December 2002 through December 2003, 67 developed 
symptomatic myopericarditis.  In the 61 ECGs that were reviewed, an identifiable 
abnormality was evident in 46 (75.4%).  The most common abnormalities included ST-
segment changes observed evident in 40 patients (65.6%); 5 patients (8.2%) had normal 
variant early repolarization, and T-wave abnormalities were noted in 11 patients (18.0%).  
In addition, cardiac enzymes were elevated in 60 of 61 (98.4%) patients evaluated with 
this assay.  On follow-up of 64 patients, all patients had objective normalization of 
electrocardiography, echocardiography, graded exercise testing, laboratory testing, and 
functional status; 8 (13%) reported atypical, non-limiting persistent chest discomfort.  
Among 37,901 health care workers vaccinated with the identical strain, 21 
myo/pericarditis cases were identified; 18 (86%) were revacinees. Twelve met criteria for 
either myocarditis or myopericarditis, and 9 met criteria for pericarditis only (6 suspected 
and 3 probable).  The severity of myo/pericarditis was mild, with no fatalities, although 9 
patients (43%) were hospitalized.     
Treatment of Vaccinia Vaccination Complications
Vaccinia Immune Globulin (VIG):  First-line treatment of some of the complications of 
vaccinia caused by dissemination of vaccinia virus (severe cases of inadvertent inoculation 
involving extensive lesions or if comorbid conditions exist, severe cases of generalized vaccinia 
in patients that are systemically ill and whose condition might be toxic or who have serious 
underlying immunosuppressive illnesses, eczema vaccinatum, and progressive vaccinia) is with 
VIG.  VIG is contraindicated, however, for the treatment of isolated vaccinial keratitis.  VIG is a 
sterile solution of the immunoglobulin fraction of pooled plasma from individuals inoculated 
with vaccinia vaccine.  VIG is only available through the CDC’s Strategic National 
Pharmaceutical Stockpile by contacting the CDC’s Clinician Information Line at 1-877-554-
4625 or the Director's Emergency Operations Center (DEOC) at 770-488-7100.  Upon receipt of 
a call from a patient or upon direct observation of a patient or contact who manifests signs and 
symptoms of any of the above conditions, the investigator should place a call to the CDC as soon 
as possible: 1) to initiate review of the clinical case, 2) to seek consultation on the 
appropriateness of VIG therapy, 3) to determine the appropriate VIG dose and dosing method for 
administration, if VIG therapy is required, and 4) to determine how to access and have the 
appropriate doses of VIG delivered.  Early institution of VIG therapy is advised following 
recognition of clinical symptoms compatible with some vaccinia complications (eczema 
vaccinatum, severe generalized vaccinia, progressive vaccinia, and some cases of inadvertent 
inoculation).  The effectiveness of VIG therapy appears to be time dependent. VIG has not 
proven to be of benefit in the treatment of post-vaccinial encephalitis, and is contraindicated for 
treatment of isolated vaccinial keratitis due to the increased risk of corneal scarring.  A new IV 
formulation of VIG that has a lower level of aggregated protein allowing it to be used by either 
the IM or IV route is available through the CDC.  This formulation will most likely be preferred 
for administration and the CDC will instruct investigators regarding appropriate dosing and 

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method of administration based on the formulation and availability.  There is no guarantee that 
VIG will successfully treat complications.  At present, there are no other anti-viral therapies of 
proven benefit for the treatment of vaccinia-related complications.
Cidofovir (Vistide®, Gilead Sciences):  Cidofovir is an FDA-approved antiviral drug for the 
treatment of CMV retinitis among patients with AIDS. Cell-based in vitro studies and animal 
model studies have demonstrated this agent’s antiviral activity against certain orthopoxviruses.  
Currently, its efficacy in the treatment of vaccinia-related complications in humans is unknown.  
According to the CDC, VIG is recommended as first line of therapy.  Cidofovir may be 
considered as a secondary treatment, and will only be used when VIG therapy is not effective 
[Medical Management of Smallpox (Vaccinia) Vaccine Adverse Reactions: Vaccinia Immune 
Globulin 
and 
Cidofovir. 
Last 
updated 
February 
21, 
2003. 
 
Available 
at:  
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5204a1.htm ].  The CDC has informed the 
NCI/CTEP that cidofovir will not be supplied through Strategic National Pharmaceutical 
Stockpile to investigators involved in CTEP-sponsored protocols utilizing recombinant vaccinia-
based vaccines.  Thus, investigators should obtain cidofovir for second-line therapy through 
commercial sources if necessary.  Investigators should consult the CDC Clinician Information 
Line at 1-877-554-4625 or the Director's Emergency Operations Center (DEOC) at 770-488-
7100 regarding appropriateness of therapy and guidance.
9.1.2
PANVAC-F (NSC 727027)
Other Names: Recombinant-Fowlpox-CEA(D609)/MUC-1(L93)/TRICOM
Classification:  Recombinant fowlpox virus vector vaccine of the genus Avipoxvirus.
Product Description:  PANVAC-F is a recombinant fowlpox virus vector vaccine containing 
genes for human CEA, MUC-1 and three co-stimulatory molecules (designated TRICOM): 
B7.1, ICAM-1 (intercellular adhesion molecule-1), and LFA-3 (leukocyte function-associated 
antigen-3).  The CEA gene coding sequence is modified to code for a single amino acid 
substitution (aspartic acid, instead of asparagine at amino acid position 609) in one 9-mer, HLA-
A2-restricted, immunodominant epitope designed to enhance immunogenicity. The MUC-1 gene 
coding sequence is also modified to code for a single amino substitution (leucine, instead of 
threonine at amino acid position 93) in one 10-mer, HLA-A2-restricted, immunodominant 
epitope designed to enhance immunogenicity. An attenuated, live, plaque-purified isolate from 
the POXVAC-TC strain of fowlpox virus was used as the parental virus for this recombinant 
vaccine. A plasmid vector containing the modified CEA and MUC-1 genes and a plasmid vector 
containing the genes for the three co-stimulatory molecules were used to transfect primary 
chicken embryo dermal (CED) cells infected with the parental virus to generate the recombinant 
fowlpox virus. The final PANVAC-F recombinant vaccine is manufactured by infection of 
primary CED cells with the recombinant fowlpox virus. Fowlpox virus can infect mammalian 
cells and express the inserted transgenes to stimulate both humoral and cellular immunity, but 
cannot replicate in non-avian species, making systemic infections unlikely. 

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How Supplied:
Lot: 3-052203: PANVAC-F is supplied by the Pharmaceutical Management Branch, CTEP, NCI in 
vials containing 0.3 mL of the vaccine at a final viral concentration titer of 5.8 x 109 pfu/mL 
formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 1.74 x 109 
pfu’s).
All other lots: PANVAC-F is supplied by the Pharmaceutical Management Branch, CTEP, NCI in 
vials containing 0.75 mL of the vaccine at a final viral concentration titer of 2 x 109 pfu/mL 
formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 1.5 x 109 
pfu’s). 
Note: The PANVAC-F concentration may vary between lots, requiring changes to dose 
preparation instructions. Use extreme caution when preparing each dose.
Preparation: Thaw vials completely at room temperature. Ensure the thawed contents are at the 
bottom of the upright vial and vortex vigorously at high power for at least ten seconds prior to 
dose preparation. Perform all dilutions of the vaccine with 0.9% sodium chloride for injection, 
USP and vortex all dilutions vigorously again for at least ten seconds prior to withdrawing the 
final dose. Note the concentration of the current supply of PANVAC-F on your institutional 
preparation guidelines to avoid potentially serious dosing errors. 
PANVAC–F (fowlpox), Lot 3-052203 (5.8 x 109 pfu/mL, 0.3mL vial):
Thaw one vial completely at room temperature. Ensure the thawed contents are at the bottom of 
the upright vial and vortex vigorously at high power for at least 10 seconds. Withdraw 0.18mL (1 
x 109 pfu) from the thawed vial for subcutaneous injection. 
PANVAC–F (fowlpox) All other lots:
Thaw one vial completely at room temperature. Ensure the thawed contents are at the bottom of 
the upright vial and vortex vigorously at high power for at least 10 seconds. Withdraw 0.5mL (1 
x 109 pfu) from the thawed vial for subcutaneous injection. 
Storage: Store intact vials of PANVAC-F at –70oC or colder. 
Stability: Shelf-life stability studies of the intact vials are ongoing. Once the intact vials are thawed, 
the vaccines maintain their potency for up to 4 days when stored at 2-8oC. Do not re-freeze thawed 
vials. Vials of PANVAC-F are for single-use only and do not contain a preservative. Administer 
prepared doses as soon as possible following preparation (i.e., within one hour). If necessary, store 
prepared doses at 2-8oC for up to 4 hours following preparation.

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Route of Administration: PANVAC-F is administered by subcutaneous injection. Other routes 
of administration have been studied. Refer to protocol for specific information.
Special Handling
Fowlpox virus is classified as a Biosafety Level 1 agent.  These agents are not known to cause 
disease in healthy human adults and are of minimal potential hazard to personnel and the 
environment under ordinary conditions of use. Clinicians can use techniques generally 
acceptable for nonpathogenic material. The recombinant vaccine is a preparation of a live virus 
(infectious for birds) containing DNA sequences derived from the human genome. Handle the 
recombinant vaccine as a hazardous biological substance and dispose of waste materials as 
hazardous biological waste, with incineration according to local institutional policy and 
according to local, state, and federal regulations. Healthcare workers handling the recombinant 
fowlpox vaccine should avoid direct contact with pet birds for at least 72 hours after working 
with the agent. 
Preparation, Handling and Disposal Recommendations 
1. Strictly adhere to standard microbiological practices and techniques.
2. Limit/restrict access to preparation areas while dose preparation is in progress. 
3. Use appropriate infection control measures (e.g., thorough hand washing) after handling any 
materials.
4. Institute and follow policies for safe handling of sharps.
5. Perform all dose preparations in a certified Class II biological safety cabinet, generally using 
procedures, guidelines and personal protective apparel used during preparation of 
antineoplastic agents [e.g., minimizing creation of aerosols; no eating, drinking, handling 
contact lenses or applying cosmetics in the work area; using appropriate personal protective 
apparel - gowns, sterile latex gloves (double-gloving is recommended), respirator masks, 
protective eye wear, hair cover]. 
6. Decontaminate the biological safety cabinet prior to dose preparation with sterile gauze 
soaked in 10% bleach solution (0.52% sodium hypochlorite solution), or other appropriate 
disinfectant suitable for decontamination, rinsing, then wiping down with sterile gauze 
soaked in 70% alcohol. Consult specific manufacturer’s recommendations with respect to 
disinfectant concentration, contact time and method of application. 
7. Have all necessary supplies on-hand before beginning the preparation procedure. Develop a 
detailed worksheet outlining all supplies, dose calculations, and preparation procedures, and 
keep it available.
8. Place an empty biohazard sharps container lined with a leak-proof biohazard bag in or near 
the biosafety cabinet to dispose of all waste generated.
9. Transport the agent from the –70oC freezer to the work area in leak proof bag. 
10. Wipe or spray items used for dose preparation with 70% alcohol before placing in the 
biological safety cabinet. Disinfectants should remain in contact with the surfaces for at least 
five minutes prior to dose preparation. Avoid exposing the virus to disinfectants.

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11. Wipe the syringe containing the prepared dose with 70% alcohol before removing it from the 
biological safety cabinet; transport it in a leak proof bag or container labeled with a 
biohazard symbol.
12. Place all waste into the sharps container lined with the leak proof biohazard bag and 
decontaminate the biological safety cabinet again by wiping down all surfaces with sterile 
gauze soaked in 10% bleach solution, or other appropriate disinfectant, rinsing, then wiping 
down with sterile gauze soaked in 70% alcohol. Following decontamination, dispose of 
personal protective apparel in the biohazard safety bag.
13. Incinerate waste according to institutional policy and according to local, state, and federal 
regulations.
14. Handle accidental spills similarly to antineoplastic spills and/or according to institutional 
policy:
•
Prevent others from entering the area and allow aerosols time to settle (approximately 10 
minutes). 
•
Use protective apparel, eyewear, mask, and gloves. 
•
Cover spills with disposable absorbent towels. 
•
Decontaminate the area with 10% bleach solution, or other appropriate disinfectant 
suitable for decontamination, allowing approximately a 20-minute contact time. 
•
Dispose of all waste as biohazardous waste and incinerate according to institutional 
policy and according to local, state, and federal regulations. 
15. Immediately report spills and accidents resulting in overt exposure to recombinant DNA 
molecules to the Institutional Biosafety Committee and NIH/OSP (Office of Science Policy). 
Send reports to the Office of Science Policy, National Institutes of Health, 6705 Rockledge 
Drive, Suite 750, MSC 7985, Bethesda, MD 20892-7985. Phone (301) 496-9838. Provide 
medical evaluation, surveillance, and treatment as appropriate and maintain written records 
of the event.
For more information about biohazard risk group classification and biohazard safety levels: 
•
NIH Guidelines for Research Involving Recombinant DNA Molecules (NIH 
Guidelines). See current version at: 
http://osp.od.nih.gov/sites/default/files/resources/NIH_Guidelines.pdf
•
Biosafety in Microbiological and Biomedical Laboratories; U. S. Department of 
Health and Human Services Centers for Disease Control and Prevention and National 
Institutes of Health. See current edition at: 
http://www.cdc.gov/biosafety/publications/index.htm
Patient Care Implications 
Cover vaccination sites with a sterile dry dressing (e.g., Telfa pad). Once the injection site is 
healed, no further barrier is necessary. As a precaution, protect injection sites that are exhibiting 
evidence of weeping, oozing or ulceration with a sterile dry dressing. In these circumstances, 
instruct patients to avoid direct contact of the injection site with susceptible individuals (e.g.; 
those who may be immunocompromised by disease or therapy). Instruct patients to avoid 
becoming pregnant, breast feeding or fathering a child for at least 4 months following therapy 

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completion with the recombinant vaccine. Instruct patients receiving fowlpox vaccines to avoid 
direct contact with pet birds for at least 72 hours after vaccination or while there are any visible 
lesions at the injection site.
Due to the method of manufacturing (virus grown in primary chicken embryo dermal cells), 
patients with a history of allergy to eggs or egg products should not receive the vaccine.
9.1.3
Agent Procurement 
9.1.3.1
Agent Ordering and Agent Accountability
NCI-supplied PANVAC-V (NSC 727026) and PANVAC-F (NSC 727027) may be 
requested by the Principal Investigator (or their authorized designee) at each participating 
institution.  Pharmaceutical Management Branch (PMB) policy requires that agent be shipped 
directly to the institution where the patient is to be treated.  PMB does not permit the transfer of 
agents between institutions (unless prior approval from PMB is obtained.) The CTEP assigned 
protocol number must be used for ordering all CTEP supplied investigational agents.  The 
responsible investigator at each participating institution must be registered with CTEP, DCTD 
through an annual submission of FDA form 1572 (Statement of Investigator), Curriculum Vitae, 
Supplemental Investigator Data Form, and Financial Disclosure Form. If there are several 
participating investigators at one institution, CTEP supplied investigational agents for the study 
should be ordered under the name of one lead investigator at that institution. 
Active CTEP-registered investigators and investigator-designated shipping designees and 
ordering designees can submit agent requests through the PMB Online Agent Order Processing 
(OAOP) application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx).  Access to OAOP 
requires the establishment of a CTEP Identity and Access Management (IAM) account 
(https://eapps-ctep.nci.nih.gov/iam/) and the maintenance of an “active” account status and a 
“current” password.  For questions about drug orders, transfers, returns, or accountability, call 
240-276-6575 Monday through Friday between 8:30 am and 4:30 pm (ET) or email 
PMBAfterHours@mail.nih.gov anytime.
9.1.3.2
Agent Inventory Records 
The investigator, or a responsible party designated by the investigator, must maintain a careful 
record of the inventory and disposition of all agents received from DCTD using the NCI Drug 
Accountability Record Form (DARF).  (See the NCI Investigator’s Handbook for Procedures for 
Drug Accountability and Storage.)
9.2
COMMERCIAL AGENT 
9.2.1
TICE Bacillus Calmette-Guerin (BCG)
(Please see package insert for complete drug information)
9.2.1.1
Indications and Usage 
TICE® BCG is indicated for the treatment and prophylaxis of carcinoma in situ (CIS) of the 
urinary bladder, and for the prophylaxis of primary or recurrent stage Ta and/or T1 papillary 

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tumors following transurethral resection (TUR). TICE® BCG is not recommended for stage 
TaG1 papillary tumors, unless they are judged to be at high risk of tumor recurrence. 
TICE® BCG is not indicated for papillary tumors of stages higher than T1. 
9.2.1.2
Dosage and Administration 
The dose for the intravesical treatment of carcinoma in situ and for the prophylaxis of recurrent 
papillary tumors consists of one vial of TICE® BCG suspended in 50 ml preservative-free 
saline. 
Do not inject subcutaneously or intravenously.
9.2.1.3
Contraindications 
TICE® BCG should not be used in immunosuppressed patients or persons with congenital or 
acquired immune deficiencies, whether due to concurrent disease (e.g., AIDS, leukemia, 
lymphoma) cancer therapy (e.g., cytotoxic drugs, radiation) or immunosuppressive therapy (e.g., 
corticosteroids). 
Treatment should be postponed until resolution of a concurrent febrile illness, urinary tract 
infection, or gross hematuria. Seven to 14 days should elapse before BCG is administered 
following biopsy, TUR, or traumatic catheterization. 
TICE® BCG should not be administered to persons with active tuberculosis. Active tuberculosis 
should be ruled out in individuals who are PPD positive before starting treatment with TICE® 
BCG.
10 BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES
10.1 LABORATORY CORRELATIVE STUDIES
Please refer to Appendix E (Section 17.5) for more information.
10.1.1 Tuberculin Skin Testing 
PPD results will be used to assess the immunologic response to BCG therapy.  This premise is 
based on a previous report that correlates PPD positivity with improved tumor recurrence-free 
intervals after BCG treatment (Luftenegger et al, J Urol, Feb 1996, Vol 155, 1483-7).  
10.1.2 Urine 
For the BCG alone arm, urine may be collected at weeks 3, 5, and at the end of the study.  
For the BCG + PANVAC vaccine arm, urine may be collected at weeks 0, 3, 5, and at the end 
of the study.  
Collection volume will range from 30 to 100 mL with each collection.  An attempt will be made 
to collect urine prior to BCG instillation and 2 hours after BCG drainage, based on previous 

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study demonstrating urinary cytokine changes during these time points (Bisiaux et al, J Urol, Vol 
181, April 2009, 1571-80).
The aliquot will be stored in the Linehan’s laboratory at -80ºC for future proteomic and/or 
biomarker discovery studies depending on availability.  Studies have shown minimal degradation 
of urinary peptides upon thawing and analysis of specimens 36. Urinary levels of certain 
cytokines can be prognostic for response to bladder immunotherapy.  For example, large 
amounts of TRAIL are noted in the urine of patients who have responded to BCG therapy 37. 
Therefore, we will potentially check urinary levels of the following cytokines and chemokines by 
ELISA:  TRAIL, IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-18, IFN-γ, and TNF-α at week 0, 
week 3, week 5 (2-8 hours after last BCG dose has best yield) 38 and at the end of the study.  
10.1.3 Blood 
For the BCG alone arm, blood samples for research analysis will be obtained 
•
at week 0 or at randomization by 1 10cc purple top tube
•
prior to treatment at weeks 3 and 8 by 2 10cc red top tubes and 6 10cc green top tubes 
•
at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes 
and 6 10cc green top tubes. 
For the BCG + PANVAC vaccine arm, blood samples for research analysis will be obtained 
•
at week 0 by 1 10cc purple top tube
•
prior to treatment at weeks 0, 3, 8, 11, and 15 by 2 10cc red top tubes and 6 10cc green 
top tubes 
•
at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes 
and 6 10cc green top tubes.  
Blood may also be collected on follow-up visits for up to 12 months following end of study 
cystoscopy.  No more than 10.5 mL/kg or 550 mL, whichever is smaller, will be obtained from 
adult subjects over an 8-week period.  The studies and method of storage for these specimens are 
described in Sections 10.1.5 and 10.2.
10.1.4 Tissue (if clinically available)
For subjects at the NIH: If tissue is clinically available, the Urologic Oncology Branch 
procedures for tissue collection will be followed.  A procurement form will be completed.  The 
tissue procurement nurse or a UOB-designated procurement staff member will work with an NCI 
pathologist following resection of the specimen to obtain tumor tissue from the resected 
specimen.  This will then be delivered by the procurement nurse or UOB Procurement staff 
member to the Urologic Oncology Branch Research Laboratory for individual processing.  
Specimens will be placed in cryovials and also be snap frozen in OCT for frozen tissue sections.  
Additional tissue will be placed into antibiotic-enriched culture media in order to establish an 
urothelial cancer cell line.  Patients will have the opportunity to opt out of cell line creation from 

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their tissues.  Tissue that is used solely for research purposes will be obtained only if it can be 
obtained with minimal risk of complications from the procedure and only after the procedure has 
been explained to the patient and informed consent obtained.  In that event, the patient will be 
invited to participate in a tissue procurement protocol such as 97-C-0147.
cDNA arrays may be performed on tumor tissues to compare gene expression profiles in tumor 
cells before and after treatment with BCG or BCG and PANVAC.  Immunohistochemical and or 
cytogenetic analyses may be performed, depending on the tumor of origin.  Cell lines may be 
characterized by karyotyping, interphase fluorescence in situ hybridization (FISH) mapping, 
immunohistochemistry, and/or flow cytometry.  Differences between cell lines will be 
manipulated to study the various molecular pathways active in nutrient sensing, cell cycle, cell 
signaling, proliferation, apoptosis, angiogenesis, and metastatic potential in urothelial cancer. 
Tumor-produced factors may be evaluated in serum or urine or a search for new tumor markers 
may be performed.  We may evaluate proteomic profiles of tissues or serum or urine and 
correlate these with disease and stage. This may potentially allow for the detection of non-
invasive predictive and/or prognostic biomarkers from urine specimens.  
Pathologic material, such as fixed tissue blocks from surgery performed at the NIH Clinical 
Center, outside surgeries or autopsy materials, may be obtained at the request of, and with 
written permission from the subject, or appropriate relatives.  These samples may undergo 
pathologic analysis by individuals in the NCI Laboratory of Pathology to confirm diagnosis and 
may undergo histo-immunologic or other analysis.  In particular to the current study, we would 
like to study the T-cell infiltration pattern within bladder tumors pre- and post-treatment.  
Specifically, we will look at:
•
The expression of CEA and MUC-1 antigens in bladder tumor specimens pre- and post-
treatment in both arms
•
The presence of CD4 and CD8 T cells in bladder tumor specimens pre- and post-treatment in 
both arms
•
The presence of regulatory T cells (Tregs) by double staining with FoxP3 and CD4 in 
bladder tumor specimens pre- and post-treatment in both arms
•
The presence of myeloid derived suppressor cells (MDSC) in bladder tumor specimens pre- 
and post-treatment in both arms
10.1.5 Collection of immunologic blood samples
For the BCG alone arm: 
•
at week 0 or at randomization by 1 10cc purple top tube
•
prior to treatment at weeks 3 and 8 by 2 10cc red top tubes and 6 10cc green top tubes 
•
at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes 
and 6 10cc green top tubes. 
For the BCG + PANVAC vaccine arm: 
•
at week 0 by 1 10cc purple top tube

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•
prior to treatment at weeks 0, 3, 8, 11, and 15 by 2 10cc red top tubes and 6 10cc green 
top tubes 
•
at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes 
and 6 10cc green top tubes.  
Additionally, blood may be collected on follow-up visits for up to 12 months following end of 
study cystoscopy/ bladder biopsy.  From this blood, PBMCs and sera will be isolated, when 
appropriate samples are available, for the following immune correlates: 
Immunologic testing will include:
1. Circulating Tumor Cytokines (CTC) analysis
2. IFN-gamma ELISPOT assays for CD8 T-cell responses specific for CEA, MUC-1, and 
Brachyury  (Limited to patients with HLA-A2 allele)
3. Measure CD4 antigen-specific response to CEA
4. Sera samples will be analyzed for the development of antibodies to CEA, MUC-1 and 
Brachyury.  (Samples from baseline and at end of study)
5. Flow cytometry analysis using 10 markers of all PBMC samples for each of the following 
cell types:  CD4, CD8, Tregs, MDSCs, and NK.
6. Serum for NCA (CEA-CAM) titers will be drawn anytime that a patient exhibits new 
onset neutropenia (ANC <1000) 
7. Immunologic studies will be repeated more frequently if clinically indicated, and any 
abnormalities potentially related to treatment will be followed until they have resolved, or 
have been determined to not be treatment-related or until the participant’s primary 
medical care is transferred from the principal investigator.
10.1.6 The immunologic testing samples for CTC analysis will be processed at:
Dr. William Linehan’s Lab
10 Center Drive, 1W-5888 
Bethesda, MD 20892
For patients at CINJ, research samples consisting of 2 purple top tubes (week 0 and week 17-20) 
will be drawn.  These tubes will be further processed as per Appendix E, Section 17.5 and then 
shipped via Fed-Ex to Dr. Linehan’s lab:
William Linehan, MD
c/o Julian Custer or Quentin Li
Urologic Oncology Branch
10 Center Drive, 1W-5888
Bethesda, MD 20892 
10.1.7 The other immunologic testing samples will be processed at:
Clinical Services Program
NCI Frederick Cancer Research and Development Center
PO Box B

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Frederick MD 21702
301-846-1000
On days samples are drawn, Jen Bangh at CSP should be notified (phone: [301] 846-5893; fax 
[301] 846-6222).  She will arrange same day courier delivery of the specimens drawn at NIH. 
For patients at CINJ, research samples consisting of 6 green top tubes and 2 red top tubes will be 
drawn at multiple time points (see Study Calendar, Section 11). The green top tubes will be sent 
via overnight Fed-Ex to the NCI Frederick Repository at the address below (see Appendix E, 
Section 17.5):
Leidos Biomedical Research
Attn: Bill Kopp/Theresa Burks
1050 Boyles Street
Bldg. 469/Room 121
Frederick, MD 21702
Phone 301-846-5125 or 301-846-1707
The red top tubes will be spun down and stored in a -80˚C freezer at CINJ. These serum samples 
will be batched and then shipped to the NCI Frederick Repository (address above) at intervals.
Once a patient’s treatment schedule has been determined, Caroline Jochems at the Laboratory of 
Tumor Immunology and Biology/NIH should be notified at jochemscm@mail.nih.gov for 
planning purposes.
 
10.1.7.1 Biopsies
Biopsies will be obtained at the end of therapy solely for diagnostic purposes as per standard of 
care to ensure that cancer is no longer present. After pathologic diagnosis, each biopsy specimen 
will be further analyzed by immunohistochemistry for the following: (a) expression of CEA and 
MUC-1 antigens on tumor cells, (b) the presence of CD4 and CD8 T cells, (c) the presence of 
regulatory T cells (Tregs) by double staining with FoxP3 and CD4, and (d) the presence of 
myeloid derived suppressor cells (MDSC). 
Satisfactory analytical performance characteristics (specificity, sensitivity and reproducibility at 
the minimum) of individual antibodies or affinity ligands for use in immunohistochemistry will 
be demonstrated prior to analyses of glycosylated CEA and MUC-1 on tumor cells, CD4 and 
CD8 T cells, Tregs by double staining with FoxP3 and CD4, and MDSC.
10.1.7.2 PBMCs, sera, and urine
The following time points will be analyzed: baseline (prior to vaccination in vaccination arm), 
week 3 (prior to BCG for both arms), week 8 (prior to last BCG for both arms), and at end of 
study (between weeks 17-20).  
PBMCs

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All patients who have the HLA-A2 allele will be analyzed by ELISPOT for CD8 T-cell 
responses specific for CEA, MUC-1, and a cascade antigen Brachyury. All samples will be 
evaluated for CD4 responses specific for CEA protein. All immune assays will have appropriate 
antigen controls. All PBMC samples will be analyzed by flow cytometry using 10 markers for 
each of the following cell types: CD4, CD8, Tregs, MDSCs, and NK. 
• Satisfactory analytical performance characteristics of individual antibodies or affinity ligands 
for use in ELISPOT, flow cytometry, or ELISA will be demonstrated prior to analyses of the 
proposed protein markers, cytokines and chemokines.
• Analyses of sera samples for quantitation of antibodies to CEA, MUC-1 and a cascade antigen 
Brachyury will be described in detail to show clinically recapitulated tumor-associated 
antigens, including glycosylated proteins, are used in measuring autoantibodies in sera.
Background:  Our studies in the LTIB have demonstrated the ELISPOT assay for IFN-γ 
production to be quantitative and reproducible as a measure of human T-cell responses to 
vaccination (26).  The continued use of one reproducible assay has been instrumental in our 
ability to evaluate and compare patients’ immune responses using different vaccines and vaccine 
strategies in the same institution, and among different cancer centers. ELISPOT assays 
employing the CEA agonist peptide and the MUC-1 agonist peptide have already been 
developed.
Sera
Sera samples at all time points will be analyzed for the development of antibodies to CEA, 
MUC-1, and a cascade antigen Brachyury. 
Urine
Urine samples may be collected at baseline and at the end of therapy (week 17-20) for the 
presence of cytokines and chemokines. In addition, an effort will be made to collect urine at the 
time of BCG instillation #1 and #3 to assess for cytokine production in response to BCG therapy 
(as described earlier in section 10.1.2 and in Section 17.5 (Appendix E).  
For patients at CINJ, research samples consisting of urine (week 0, week 3, week 5, and week 
17-20) will be drawn.  These tubes will be further processed as per Appendix E, Section 17.5 and 
then shipped via Fed-Ex to Dr. Linehan’s lab:
William Linehan, MD
c/o Julian Custer or Quentin Li
Urologic Oncology Branch
10 Center Drive, 1W-5888
Bethesda, MD 20892 
Bladder cancer is believed to be an immune-modulated malignancy and therefore the immune 
correlatives will be used to establish whether or not there is an immune basis for bladder cancer.  
If tumors are found to have a certain proportion of immune subsets, then the correlatives may be 
used as potential markers of disease in the future.

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10.2 SAMPLE STORAGE, TRACKING AND DISPOSITION
All specimens obtained for research purposes will be coded upon arrival in the UOB research 
laboratory to maintain patient confidentiality.  All samples will be accessioned and entered into a 
database (such as LabMatrix) with access limited to the PI and UOB research data managers.  
The location of all samples will be carefully tracked in the database.  All stored samples will be 
coded and identifying patient information will not be placed on sample containers.  Stored 
samples will be kept in freezers/refrigerators or secure containers located in the Urologic 
Oncology Branch research laboratories or in approved storage facilities.  The research samples 
collected will be used for the correlative/biomarker studies mentioned above in Section 10.1.  
Tissue slides/blocks may be obtained in order to determine protocol eligibility.  Tissues are 
submitted to the NCI Laboratory of Pathology at the NIH Clinical Center for clinical 
determination of histologic features.  Specialized stains/assays may be used to clarify tissue 
phenotype.  After completion of analysis, tissue slides/blocks are either returned to the 
originating pathology department or archived in the Laboratory of Pathology or Urologic 
Oncology Branch and tracked in the UOB database (LabMatrix).  Archived material will be 
retained for the duration of the study unless the originating pathology department requests return.
Coded/anonymous samples with minimal clinical information may be shared with qualified NIH 
and non-NIH researchers who have IRB-approved protocols with similar research objectives.   
No personal identifying information such as name, address, or date of birth will be provided to 
the non-UOB investigator.  In the event a subject is eligible to participate in a clinical trial based 
on tumor characteristics, coded tissue samples may be sent to an outside laboratory.  Samples 
will be ordered and tracked through CRIS Screens.  Should a CRIS screen not be available, the 
NIH form 2803-1 will be completed and will accompany the specimen and be filed in the 
medical records.  Samples will not be sent outside the NIH without IRB notification and an 
executed MTA.
Subjects will be given the option of consenting to current and future use of their research 
samples per the informed consent process with their option declared in the consent document.  
Samples will be destroyed at the completion of the study on those subjects who decline future 
use of their samples.  Otherwise, any specimens that are remaining at the completion of the 
protocol will be stored for an indefinite amount of time.  These specimens may be banked and 
used in the future to investigate new scientific questions related to this study.  However, this 
research may only be done if the risks of any new questions were covered in the consent 
document and protocol.  Any new uses of the samples other than those defined in this protocol 
will be submitted prospectively for IRB review and approval.  The IRB will be notified in the 
event research samples are inadvertently lost or destroyed and meet the criteria in section 7.2.1.
10.2.1 Storage and Tracking of Collected Blood Samples 
All data associated with the patient samples is protected by using a secure database.  All samples 
drawn at the NIH Clinical Center will be stored in the laboratories of the Urologic Oncology 
Branch as previously described.  

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Serum samples will be stored in -80˚C freezers and PBMC samples will be stored in vapor phase 
liquid nitrogen at the NCI Frederick Central Repository in Frederick, MD. Samples drawn at the 
NIH Clinical Center will be transported by the Leidos couriers; samples from CINJ will be sent 
via Fed-Ex, as previously described.
Samples will be tracked and managed by the Central Repository database. Leidos Biomedical 
Research, Inc. manages the NCI Frederick Central Repositories. NCI Frederick Central 
Repositories store, among other things, biological specimens in support of NIH clinical studies. 
All specimens are stored in secure, limited access facilities with sufficient security, back-up and 
emergency support capability and monitoring to ensure long-term integrity of the specimens for 
research. 
Sample data is stored in the BioSpecimen Inventory (BSI) System II. This inventory tracking 
system is used to manage the storage and retrieval of specimens as well as maintain specimen 
data. BSI is designed for controlled, concurrent access. It provides a real-time, multi-user 
environment for tracking millions of specimens. The system controls how and in what order 
database updates and searches are performed. This control prevents deadlocks and race 
conditions. For security, BSI has user password access, 3 types of user access levels, and 36 user 
permissions (levels of access) that can be set to control access to the system functions. BSI 
provides audit tracking for processes that are done to specimens including shipping, returning to 
inventory, aliquoting, thawing, additives, and other processes. BSI tracks the ancestry of 
specimens as they are aliquoted, as well as discrepancies and discrepancy resolution for 
specimens received by the repository. If a specimen goes out of the inventory, the system 
maintains data associated with the withdrawal request. Vials are labeled with a unique BSI ID 
which is printed in both eye-readable and bar-coded format. No patient-specific information is 
encoded in this ID. 
Investigators are granted view, input and withdrawal authority only for their specimens.  They 
may not view specimen data or access specimens for which they have not been authorized. 
Access to specimen storage is confined to repository staff. Visitors to the repositories are 
escorted by repository staff at all times.
10.2.2 Protocol Completion/Sample Destruction
Once primary research objectives for the protocol are achieved, intramural researchers can 
request access to remaining samples providing they have an IRB approved protocol and patient 
consent.
Samples, and associated data, will be stored permanently unless the patient withdraws consent.  
Loss or unanticipated destruction of samples will be reported per section 7.2.1.

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11 STUDY CALENDARS
Evaluations below may be performed within ± 5 days of indicated time in order to accommodate patient schedules, holidays and 
weather emergencies.
A) STUDY CALENDAR FOR BCG + PANVAC ARM
Baseline 
(On study)
Week 
0
Week 
3
Week 
4
Week 
5
Week 
6
Week 
7
Week 
8
Week 
11
Week 
15
Week17-
20
Follow-
up10
BCG
X
X
X
X
X
X
PANVAC-V1
X
PANVAC-F1
X
X
X
X
NIH Advanced 
Directives 
Form11
X
History and 
Physical2
X
X
X
X
X
X
X
X
X
X
X
CBC with 
differential3
X
X
Xo
Chemistry3,4
X
X
Xo

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Baseline 
(On study)
Week 
0
Week 
3
Week 
4
Week 
5
Week 
6
Week 
7
Week 
8
Week 
11
Week 
15
Week17-
20
Follow-
up10
PT, PTT3
X
X
Xo
PPD (Research)
X
X
Urinalysis5 
X
X
X
X
X
X
X
X
X
Urine Cytology6
X
X
X
Urine 
(Research)7
X
X*
X*
X
Xo
Immunology 
(Research 
blood)8
X
X
X
X
X
X
Xo
Serum Beta-
HCG9
X
Biopsy
X
X
Chest X-ray
X
X
CT urogram
X
X

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B) STUDY CALENDAR FOR BCG ONLY ARM
Baseline 
(On study)
Week 
0
Week 
3
Week 
4
Week 
5
Week 
6
Week 
7
Week 
8
Week 
11
Week 
15
Week17-
20
Follow-
up10
BCG
X
X
X
X
X
X
NIH Advanced 
Directives 
Form11
X
History and 
Physical2
X
X
X
X
X
X
X
X
X
X
CBC with 
differential3
X
X
Xo
Chemistry3,4
X
X
Xo
PT, PTT3
X
X
Xo
PPD (Research)
X
X
Urinalysis5 
X
X
X
X
X
X
X
X
X

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Baseline 
(On study)
Week 
0
Week 
3
Week 
4
Week 
5
Week 
6
Week 
7
Week 
8
Week 
11
Week 
15
Week17-
20
Follow-
up10
Urine Cytology6
X
X
X
Urine 
(Research)7
X*
X*
X
Xo
Immunology 
(Research 
blood)8
X
X
X
X
Xo
Serum Beta-
HCG9
X
Biopsy
X
X
Chest X-ray
X
X
CT urogram
X
X
1 Applies only to treatment arm 2 (BCG + PANVACTM).  Panvac administration continues as planned regardless of any delays in BCG 
administration.
*These time periods should correspond to BCG instillations #1 and #3, respectively.  If a postponement of an instillation occurs, urine 
collection will occur after instillations #1 and #3 irrespective of the trial week.  On these weeks, urine will be collected twice: first 
collection will be prior to BCG instillation and second collection of urine will be 2 hours after drainage of BCG.
2 Baseline: H & P and laboratory studies should be completed within 28 days of initiating treatment.  This will include determination 
of ECOG performance status.  
3 Baseline laboratory studies should be completed within 28 days of initiating treatment.

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4 Chemistry panel:  Na+, K+, Cl-, CO2, glucose, BUN, creatinine, albumin, calcium, magnesium, phosphorus, alkaline phosphatase, 
ALT, AST, total bilirubin, pre-albumin, and LDH.
5 Urinalysis:  If prior to an operative procedure, then will be obtained within 2-21 days of surgery and with an accompanying urine 
culture.  If prior to BCG administration, a simple urinalysis will be performed in the hospital on the day of administration.  ***Urine 
will be tested weekly prior to each BCG administration and the presence of gross hematuria or a urinary tract infection by urinalysis 
will result in holding that week’s BCG dose as specified in the protocol.
6 Urine cytology:  will be obtained from voided urine within 2-21 days of operative procedures OR through instrumentation at the time 
of an operative procedure
7 Urine (research):  Urine will be obtained for correlative immune studies checking for chemokine and cytokine levels
8 Blood will be obtained for immunologic/research assays.  CTC analysis, plasma and sera will be isolated to look for CD4 antigen-
specific responses, CD8 antigen-specific responses, and flow cytometry profiles of various immune cell types.  
9 In females of child-bearing age, Beta-HCG to be done at baseline within 48 hours prior to receiving vaccinia
10 These patients will be followed every 3 months for 1 year after the completion of the initial 20 week study course with standard of 
care for non-muscle invasive high grade bladder cancer. This includes urinalysis, urine cytology, cystoscopy, possible bladder biopsy, 
and medical assessments.  For patients unable to complete every 3 month follow-up at the NIH or CINJ after week 20, we will keep 
them on study and obtain their outside pathologic records and labs from their outside urologists who will perform these evaluations.
11  As indicated in section 15.3, all subjects will be offered the opportunity to complete an NIH advanced directives form.  This should 
be done preferably at baseline but can be done at any time during the study as long as the capacity to do so is retained.  The 
completion of the form is strongly recommended, but is not required.  Participating sites should adhere to appropriate procedures 
specific to their site. 
Xo = optional

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12 MEASUREMENT OF EFFECT
12.1 RESPONSE CRITERIA
12.1.1.1 Evaluable for toxicity
All patients who receive at least one dose of protocol therapy will be evaluable for toxicity from 
the time of their first treatment with TICE BCG or rV-PANVAC™.   All observed toxicities will 
be tabulated using CTCAE v4.1 and a previously published, vaccinia toxicity grading scale used 
with this vaccine 33 by the highest grade experienced for each patient and presented for each 
study arm.
12.1.1.2 Evaluable for objective response
Only those patients who have biopsy-proven disease present at baseline, have received at least 
one cycle of therapy (6 or fewer weekly intravesical doses of BCG), and have had their disease 
re-evaluated will be considered evaluable for response.  These patients will have their response 
classified according to the definitions stated below.  
In order to compare the secondary outcomes between study arms, all durations will be measured 
from the start of TICE BCG therapy (week 3).  This is the start of therapy for the TICE BCG arm 
alone.  BCG is not started at week 0 for two reasons:  1) to allow adequate healing from previous 
TURBT and 2) allow vaccinia priming vaccine to be given to combination group at week 0 with 
enough recovery time to possibly make the administration of BCG in week 3 safer in these 
patients.  Furthermore, by following this schema, patients in each group will start BCG at the 
same time after study entry.
12.1.1.3 Recurrence-free survival
The recurrence-free survival duration will be measured from the start of TICE BCG therapy 
(week 3) until disease recurrence or death due to any cause in each arm.  Recurrence is suspected 
and/or determined by urine cytology and/or cystoscopic exam and then confirmed pathologically 
after a TURBT.  Positive cytology in the absence of pathologic confirmation is not considered to 
be a recurrence.
12.1.1.4 Progression-Free Survival
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first. The duration of progression-free survival is measured from the start of 
TICE BCG therapy (week 3) until progression or death due to any cause in each study arm. 
Progression is defined as upstaging from a lower stage to a higher stage (e.g., Ta to T1 or T1 to 
T2-4; or any N+ or M+ in these high grade tumors.  
12.1.1.5 Time to Tumor Recurrence
The duration of time measured from the start of TICE BCG therapy (week 3) until recurrence is 
noted.

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13 DATA COLLECTION AND REPORTING/REGULATORY REQUIREMENTS
13.1 DATA COLLECTION
An enrollment log will be maintained in the regulatory binder/file which is the only location of 
personal identifiers with unique subject identification number.
All data will be stored by a patient code identification number only, without personal identifiers, 
and linked to samples by that identification number in Labmatrix.  Clinical Data will be entered 
into the NCI C3D database.  Data will be collected using protocol-specific case report forms, and 
verified for accuracy and completeness.  Data should be entered into the data base in a timely 
manner. Hard copies of data will be stored in locked secured areas and data will be entered onto 
a secured electronic data base. The following protocol-specific study forms will be complete and 
stored: eligibility checklist (developed by Central Registration Office, CRO). A copy of all 
serious AE forms will be kept in the research record.   
Data will be verified to ensure that: 
•
Eligible patients are confirmed and eligibility checklist was completed. Consent form 
must be signed prior to registration with Central Registration.
•
Treatment is given according to protocol (dated notes about doses given, complications, 
and clinical outcomes).
•
Toxicity is assessed according to protocol (laboratory report slips, etc.)
•
Response is assessed according to protocol (X-ray, scan, lab reports, and date noted on 
clinical assessment, as appropriate).
•
Drug Accountability Records are kept for each patient.
All data obtained during the conduct of the protocol will be kept in secure network drives or in 
approved alternative sites that comply with NIH security standards. Primary and final analyzed 
data will have identifiers so that research data can be attributed to an individual human subject 
participant.
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event. Patients 
will be followed for adverse events for 30 days after removal from study treatment or until off-
study, whichever comes first.
An abnormal laboratory value will be considered an AE if the laboratory abnormality is 
characterized by any of the following:
•
Results in discontinuation from the study
•
Is associated with clinical signs or symptoms 
•
Requires treatment or any other therapeutic intervention
•
Is associated with death or another serious adverse event, including hospitalization. 

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•
Is judged by the Investigator to be of significant clinical impact
•
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome.
End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable. 
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred,  this will be reported expeditiously per 
requirements in section 7.2.1 . 
13.2 TOXICITY CRITERIA
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study.  The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE 
reporting until March 31, 2018.  CTCAE version 5.0 will be utilized for AE reporting beginning 
April 1, 2018. All appropriate treatment areas should have access to a copy of the CTCAE 
version 5.0.  A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_40). 
13.2.1 Toxicity Grading for Vaccinia Toxicity 33 
Grade 1:  Cutaneous reaction extending no more than 10 cm from the vaccination site (i.e., 
limited to the upper arm)
Grade 2:  Any autoinoculation syndrome that resolves without sequelae; Generalized vaccinia 
extending more than 10 cm from the vaccination site
Grade 3:  Any toxicity that is between grade 2 and 4
Grade 4:  Autoinoculation syndrome (e.g. blindness); post vaccinia encephalitis; vaccinia 
gangrenosum; eczema gangrenosum; Stevens-Johnson syndrome
13.3 DATA REPORTING 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.
13.3.1 Method
This study will be monitored by the Clinical Data Update System (CDUS) Version 3.0.  
Cumulative protocol- and patient-specific CDUS data will be submitted electronically to CTEP 
on a quarterly basis, either by FTP burst of data or via the CDS web application.  Reports are due 
January 31, April 30, July 31, and October 31.  Instructions for submitting data using the CDUS 
can be found on the CTEP Web site
(http://ctep.cancer.gov/reporting/cdus.html). 

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Note:  If your study has been assigned to CDUS-Complete reporting, all adverse events (both 
routine and expedited) that have occurred on the study and meet the mandatory CDUS reporting 
guidelines must be reported via the monitoring method identified above.  If your study has been 
assigned to CDUS-Abbreviated reporting, no adverse event reporting (routine or expedited) is 
required to be reported via CDUS
13.3.2 Responsibility for Data Submission
Participating study sites are responsible for submitting CDUS data and/or data forms to either the 
Coordinating Center or to the Lead Organization on the study quarterly.  The date for submission 
to the Coordinating Center or to the Lead Organization will be set by them.  CDUS does not 
accept data submissions from the participants on the study.  When setting the dates, allow time 
for Coordinating Center compilation, Principal Investigator review, and timely submission to 
CTEP by the quarterly deadlines (see Section 13.3).  
Either the Coordinating Center or the Lead Organization is responsible for compiling and 
submitting CDUS data to CTEP for all participants and for providing the data to the Principal 
Investigator for review.  
13.4 CTEP MULTICENTER GUIDELINES
This protocol will adhere to the policies and requirements of the CTEP Multicenter Guidelines.  
The specific responsibilities of the Principal Investigator and the Coordinating Center (Study 
Coordinator) and the procedures for auditing are presented in Appendix B (Section 0).
•
The Principal Investigator/Coordinating Center is responsible for distributing all 
IND Action Letters or Safety Reports received from CTEP to all participating institutions 
for submission to their individual IRBs for action as required.
•
Except in very unusual circumstances, each participating institution will order 
DCTD-supplied agents directly from CTEP.  Agents may be ordered by a participating 
site only after the initial IRB approval for the site has been forwarded by the 
Coordinating Center to the CTEP PIO (PIO@ctep.nci.nih.gov) except for Group studies.
13.5 COLLABORATIVE AGREEMENTS LANGUAGE
The PANVAC™-V (vaccinia) and PANVAC™-F (fowlpox) (hereinafter referred to as Agents) 
supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI under a 
Collaborative Agreement (CRADA, CTA, CSA) between BNIT (Bavarian Nordic 
ImmunoTherapeutics) (hereinafter referred to as “Collaborator(s)”) and the NCI.  Therefore, the 
following obligations/guidelines, in addition to the provisions in the “Intellectual Property 
Option to Collaborator” 
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within the 
terms of award, apply to the use of the Agent(s) in this study:

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1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can 
Agent(s) be transferred or licensed to any party not participating in the clinical study.  
Collaborator(s) data for Agent(s) are confidential and proprietary to Collaborator(s) and shall 
be maintained as such by the investigators.  The protocol documents for studies utilizing 
Agents contain confidential information and should not be shared or distributed without the 
permission of the NCI.  If a copy of this protocol is requested by a patient or patient’s family 
member participating on the study, the individual should sign a confidentiality agreement.  A 
suitable model agreement can be downloaded from: http://ctep.cancer.gov.
2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other Agent(s), each the subject of different Collaborative Agreements, the access to and 
use of data by each Collaborator shall be as follows (data pertaining to such combination use 
shall hereinafter be referred to as "Multi-Party Data”):
a) NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the proposed 
combination protocol, and the existence of any obligations that would tend to restrict NCI's 
participation in the proposed combination protocol.
b) Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial by 
any other Collaborator solely to the extent necessary to allow said other Collaborator to 
develop, obtain regulatory approval or commercialize its own Agent.
c) Any Collaborator having the right to use the Multi-Party Data from these trials must agree in 
writing prior to the commencement of the trials that it will use the Multi-Party Data solely for 
development, regulatory approval, and commercialization of its own Agent.
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and 
disclosed consistent with all applicable federal statutes and regulations for the protection of 
human subjects, including, if applicable, the Standards for Privacy of Individually 
Identifiable Health Information set forth in 45 C.F.R. Part 164.
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them.

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5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial.
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and 
comment prior to submission for publication.  Collaborator(s) will have 30 days from the 
date of receipt for review.  Collaborator shall have the right to request that publication be 
delayed for up to an additional 30 days in order to ensure that Collaborator’s confidential and 
proprietary data, in addition to Collaborator(s)’s intellectual property rights, are protected.  
Copies of abstracts must be provided to CTEP for forwarding to Collaborator(s) for courtesy 
review as soon as possible and preferably at least three (3) days prior to submission, but in 
any case, prior to presentation at the meeting or publication in the proceedings.  Press 
releases and other media presentations must also be forwarded to CTEP prior to release.  
Copies of any manuscript, abstract and/or press release/ media presentation should be sent to:
Email:  ncicteppubs@mail.nih.gov
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ 
proprietary information.
13.5.1 Material Transfer Agreement (MTA)
A Material Transfer Agreement (MTA) is in process in order to receive specimens from 
participating sites for storage and future analysis.
14 STATISTICAL CONSIDERATIONS
14.1 PRIMARY ENDPOINT, STRATIFICATION, AND SAMPLE SIZE JUSTIFICATION
The study is to test the hypothesis that patients in the TICE BCG+PANVAC arm have better 
recurrence-free survival than patients in the TICE BCG alone arm. Patients to be accrued to the 
study are adults with high grade non-muscle invasive bladder cancer who failed at least 1 
induction course of BCG. These patients comprise 3 subgroups, namely, BCG persistent with 
one failure of BCG induction course, BCG persistent with 2 or more failures of BCG induction 
courses, and BCG relapsing that can behave like BCG naïve. The ratio of the composition of the 
three subgroups is expected to be 1:5:1 with the majority of the patients being BCG persistent 
and having failed 2 or more BCG induction courses. In order to achieve the balance of treatment 
in each subgroup, stratified randomization will be implemented in this study. However, although 
the three subpopulations have different recurrence-free survival experience and may respond to 
treatment benefit differently, the study is powered to test the overall treatment benefit of 
BCG+PANVAC on the entire patient population.   

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In the first subgroup of BCG persistent patients with one failure of BCG induction course, it is 
assumed that the 1-year recurrence-free survival rate is 37.5% 7,8 in the TICE BCG alone arm 
and 65% in the TICE BCG+PANVAC arm.38,39 Under the assumption of exponential distribution 
for the recurrence-free survival in both arms, the difference in recurrence-free at 1-year 
corresponds to hazard ratio (HR) of 2.277. In the second subgroup of BCG persistent patients 
with 2 or more failures of BCG induction courses, the 1-year recurrence-free survival rate in the 
TICE BCG alone arm is expected to be 20%.40 Assume that the treatment benefit of TICE 
BCG+PANVAC in the second subgroup is lower than in the first subgroup and HR is set at 2, 
which corresponds to a one-year recurrence-free survival of 44.7% in the TICE BCG+PANVAC 
arm. In the third subgroup of BCG relapsing patients, it is expected that the 1-year recurrence-
free survival rate is 48% and 65% in the TICE BCG alone and TICE BCG+PANVAC arm, 
respectively. This corresponds to HR=1.70.
Patient accrual is targeted at one patient per month during the first 6 months and 2 patients per 
month afterwards, and follow-up period after completing accrual will be 12 months. The power 
calculation was based on one-sided log-rank test at 15% significance level. Sample size, power 
and duration of the study are presented in the table below. With a total number of 49 patients, the 
power is 84% (see table below). Under this scenario, the expected number of events (recurrence 
or death) is 40. In order to allow for the possibility of a small number of unevaluable patients, the 
accrual ceiling will be set at 54 patients.
Subgroup 1
1-year 
recurrence-free 
survival for BCG 
persistent 
patients who 
failed 1 BCG 
induction course
Subgroup 2
1-year 
recurrence-free 
survival for BCG 
persistent 
patients who 
failed 2 or more 
BCG induction 
courses
Subgroup 3
1-year 
recurrence-free 
survival for BCG 
naïve patients
Total 
sample 
size
Power 
(%)
Duration 
of 
accrual
(months)
Expected 
number of 
events 
(recurrence 
or death)
Treatment 
benefit
HR=2.277
1-year RFS:
BCG alone: 
37.5%
BCG+PANVAC: 
65%
HR=2
1-year RFS:
BCG alone: 20%
BCG+PANVAC: 
44.7%
HR=1.7
1-year RFS:
BCG alone: 48%
BCG+PANVAC: 
65%
49
84
28
40
One interim analysis for futility will be performed according to the stopping procedure. 39 
Specifically, the interim analysis will be performed when half of the expected events (20) have 
been observed. At that time, if the observed event rate of the TICE BCG+PANVAC arm is 
higher than that of the TICE BCG alone arm (i.e. the hazard ratio ≥ 1), we would consider 
terminating the trial and concluding that an advantage for the BCG+PANVAC regimen has not 
been established.
For the purpose of protecting patient safety, we implement the following stopping rule for safety 
monitoring of patients who receive the combination therapy.

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If one patient experiences a grade 5 event, thought to be possibly or probably due to the 
combination therapy, the study will be stopped. For grade 3 or 4 event, the study will be stopped 
according to the following stopping rule.  These adverse events are described in more detail in 
Section 7.
Number of patients
No. of grade 3 or 4 serious adverse events
3-9
3
10-18
4
19-26
5
The operating characteristic of the stopping rule was assessed by simulations. Based on 10,000 
simulations, the probability of stopping early for an excess of serious adverse event over the 
course of trial is 0.04 when the serious adverse event rate is at the anticipated level of 6% and 
0.94 when the serious adverse event rate is 30%. This is deemed reasonable for protecting patient 
safety.
14.2 SECONDARY ENDPOINTS
Using Kaplan-Meier methods, we will estimate the probability distribution of progression-free 
survival and the time to recurrence.  Results will be summarized by point estimates (12 months) 
with 95% CI.  Exploratory analyses of these secondary objectives will compare the two 
treatment arms using the log rank test.  Fisher’s exact test will be used to compare frequency 
distributions of toxicity grades between the two arms.  
14.3 EXPLORATORY/CORRELATIVE ENDPOINTS
14.3.1 To characterize the expression of MUC1 and CEA in bladder tumor specimens pre- 
(week 0) and the change in expression post-vaccination (on tissue obtained between 
weeks 17-20) for patients treated with TICE BCG+PANVAC™.
14.3.1.1 MUC1 expression will be evaluated using IHC. A positive result is defined if >5% of 
tumor cells reacted with any intensity.  Intensity will be arbitrarily scored on a 4 point 
scale:  0 (no staining), 1+ (weak staining), 2+ (moderate staining), and 3+ (strong 
staining).  Potential antibody will be clone Ma695 dilution 1:100 (Novocastra, 
Newcastle upon Tyne, England) but has to be analytically validated using appropriate 
positive and negative controls prior to use.22
14.3.1.2 CEA expression in FFPE pre- and post-treatment tissues will be evaluated by IHC. A 
positive result is defined when the cytoplasmic staining is equal in intensity to 
glycocalyceal staining.  Tumors will be scored as 0 (no signal), 1+ (signal in <25% 
sampled tumor area), 2+ (26-75% of tumor cells), and 3+ (>75% of tumor cells).  The 
potential antibody will be CD66e (clone 12-140-10; Novocastra, Newcastle upon-Tyne, 
England; dilution 1:500; Ventana NexES immunostainer; protease digestion). 

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14.3.1.3 Statistical Analysis:  For both MUC1 and CEA expression the distributions of IHC 
staining intensity at baseline and post-vaccination as well as the change in score will be 
summarized with descriptive statistics. The results will be summarized by calculating 
the proportion and 95% confidence interval of positive staining tissue samples at 
baseline and the distribution of pre and post-vaccination combinations (--, -+, +-, ++) 
characterizing the change with treatment.  Results will be presented separately for each 
treatment arm.  The distributions for the two treatment arms will be compared using a 
chi square test.
14.3.2 To explore the CD4 Antigen-Specific response to MUC1 and CEA
14.3.2.1 The CD4 antigen-specific response will be assessed by culturing CD4+ T cells obtained 
from PBMCs pre- and post-treatment with irradiated APCs in the presence of MUC1 
and CEA peptides/proteins. The IFN-γ levels will be measured by ELISA.  Flu protein 
(positive control) and myoglobulin (negative control) will serve as controls.  
14.3.2.2 Statistical Analysis:  Descriptive statistics will be calculated to summarize the CD4 
antigen-specific response to MUC1 and CEA determined pre-treatment as well as the 
change post-vaccination. The same methods for analysis for each treatment arm and the 
comparison of arms as described for evaluation of the immune response to the vaccines 
will be applied.  
14.3.3 To explore the CD8-mediated immune response to MUC1 and CEA
14.3.3.1 Assess CD8 T cell response by ELISPOT assay in pre- and post-treatment PBMCs 
using CEA and MUC1-specific T lymphocytes.  We will be using an overlapping 
peptide library that will allow for the ability to test ~65% of HLA groups for MUC1 and 
~80% of HLA groups for CEA
14.3.3.2 Statistical Analysis:  A positive CD8 T cell response is defined as  ≥ 2-fold increase 
post treatment compared with the pretreatment value in IFN-γ-secretion.  Descriptive 
statistics will be calculated to summarize the CD8 T cell response as continuous 
variables to MUC1 and CEA at both time points for each study arm.  In addition, the 
change from pre- to post-treatment will be summarized by the proportion of patients 
achieving a positive response.  The proportion with 95% confidence intervals will be 
presented for each treatment arm along with additional descriptive statistics (e.g. mean 
change, the mean percent change).  Fisher’s exact test will be performed to compare the 
positive CD8 T cell response between the two treatment arms.  
14.4 REPORTING AND EXCLUSIONS
14.4.1 Evaluation of Toxicity
All patients will be evaluable for toxicity from the time of their first treatment with rV-
PANVAC™ and rF-PANVAC™.
14.4.2 Evaluation of Response
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations or if they are ineligible.  

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All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) should be included in the main analysis of the response rate.  
All conclusions should be based on all eligible patients.  Subanalyses may then be performed on 
the basis of a subset of patients, excluding those for whom major protocol deviations have been 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major 
protocol deviations, etc.).  However, these subanalyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the 
analysis should be clearly reported.  The 95% confidence intervals should also be provided. 
15 HUMAN SUBJECTS PROTECTIONS 
15.1 RATIONALE FOR SUBJECT SELECTION
15.1.1 Selection Based on sex, Ethnicity, and Race
Subjects from all racial/ethnic groups and both sex are eligible for this study if they meet the 
eligibility criteria. To date, there is no information that suggests that differences in drug 
metabolism, immune response or disease response would be expected in one group compared 
with another. Efforts will be made to extend accrual to a representative population, but in this 
preliminary study, a balance must be struck between patient safety considerations and limitations 
on the number of individuals exposed to potentially toxic and/or ineffective treatments on one 
hand and the need to explore sex and ethnic aspects of clinical research on the other hand. If 
differences in outcome that correlate with ethnic identity are noted, accrual may be expanded or 
a follow-up study may be written to investigate those differences more fully. 
15.1.2 Justification for Exclusions
Due to impaired cellular immunity, HIV patients are at an increased risk of serious side effects 
from vaccinations with infectious agents and are excluded. This is based on recommendations 
from the CDC and FDA. In addition, pregnant women are also excluded due to potentially 
increased risks of serious side effects from vaccinations with infectious agents. 
15.2 PARTICIPATION OF CHILDREN
Individuals under the age of 18 will not be eligible for participation in this study based on the 
fact that patients under 18 are unlikely to have this disease and there are unknown toxicities in 
pediatric patients.
15.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT
Adults unable to give consent are excluded from enrolling in the protocol.  However re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (section 15.5), will be offered the opportunity to fill in their wishes for 
research and care, and assign a substitute decision maker on the “NIH Advance Directive for 
Health Care and Medical Research Participation” form so that another person can make 
decisions about their medical care in the event that they become incapacitated or cognitively 

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impaired during the course of the study. Note: The PI or AI will contact the NIH Ability to 
Consent Assessment Team for evaluation.  For those subjects that become incapacitated and do 
not have pre-determined substitute decision maker, the procedures described in MEC Policy 87-4 
for appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, 
and (b) who do not have a legal guardian or durable power of attorney, will be followed.
Participating sites should adhere to appropriate procedures specific to their site.
15.4 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS
BCG is a standard of care treatment and will be used in this study.   The biggest risk of using this 
agent after failing an initial induction course of BCG is progression of disease to muscle-invasive 
disease.  However, this occurs after multiple, failed BCG induction treatments and occurs more 
often after 2 years of such therapy40.  In addition, patients will be accurately staged for disease 
with imaging, TURBT, and in some cases, repeat TURBT.  They will be followed quite 
rigorously throughout the study and thereafter with a planned biopsy between weeks 17-20 to 
ensure that no progression of disease has occurred during the treatment period.  Patients who 
progress will promptly undergo radical cystectomy.  Radical cystectomy and pelvic 
lymphadenectomy is also considered a standard of care treatment for high grade BCG refractory 
NMIBC.  However, since enrollment into this study requires patients to refuse radical surgery or 
not be medically fit for surgery, we believe the risk of proceeding with another induction course 
of BCG is outweighed by its benefit.  
Other risks of the use of BCG include local bladder symptoms such as blood in the urine, urinary 
frequency, urgency of urination, dysuria (pain), and bladder spasms which are often self-limiting 
and usually resolve within a week by withholding BCG and administering standard of care 
medications (e.g. anti-inflammatories, anti-spasmodics, hydration, etc.).  Finally, a rare potential 
risk of BCG administration is development of “BCG-osis” which is a form of 
bacteremia/urosepsis or systemic BCG infection that occurs with BCG administration on very 
rare occasions.  In this event, patients will be taken off the study and treated with anti-microbials 
as per recommendations by infectious disease consultants.  The addition of PANVAC™ is 
unknown but given the relative safety of both agents and different routes of administration, we 
presume that the risk is minimal. 
15.4.1 Alternative Approaches or Treatments
Patients will be consented verbally and in writing regarding the risks and benefits of this trial, the 
treatment requirements, and alternative approaches to entering on this trial.
15.4.2 Procedure for Protecting Against or Minimizing any Potential Risks
All care will be taken to minimize side effects, but they can be unpredictable in nature and 
severity. This study may involve risks to patients, which are currently unforeseeable.  All 
patients will have blood tests, examinations and CT scans of the chest/abdomen/pelvis as 
described in the monitoring schedule as described in Appendix C (Section 17.3). Patients will 
also be required to have a local physician to provide long-term care and to monitor for 
complications.  If patients suffer any physical injury as a result of the participation in this study, 
immediate medical treatment is available at the Warren Grant Magnuson Clinical Center, 
Bethesda, Maryland.  Although no compensation is available, any injury will be evaluated and 

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treated in keeping with the benefits or care to which patients are entitled under applicable 
regulations.
15.4.3 Provisions for Monitoring Data Collection to Ensure Safety of Subjects
As information is gathered from this trial, clinical results will be shared with patients. Laboratory 
and clinical data will be frequently gathered and any new significant finding(s) found during the 
course of the research, which may affect a patient’s willingness to participate further, will be 
explained.  Confidentiality of information concerning participants will be maintained, including 
in all publications and presentations resulting from this study.  Names of participants or material 
identifying participants will not be released without permission, except as such release is 
required by law. Records at the Clinical Center are maintained according to current legal 
requirements, and are made available for review by Cancer Therapy Evaluation Program, the 
Food and Drug Administration, or other authorized users, as stated under the guidelines 
established by the Federal Privacy Act.  
15.5 RISKS/BENEFITS ANALYSIS
The patients we will be enrolling have high grade NMIBC that has already failed the standard of 
care therapy, BCG induction.  These patients are on the verge of developing muscle-invasive 
disease which requires potentially morbid surgery and change in quality of life.  Therefore, they 
are very interested in strategies to preserve the bladder.  Repeat induction BCG therapy is a 
standard of care and is being given to all patients in this study.  The addition of PANVAC™ may 
potentially improve upon the poor RFS seen with BCG alone and hopefully this study will bear 
that out.  Alternative treatments besides surgery include other intravesical agents that have not 
shown to be that effective.  Whether the vaccine will have any clinical effect upon improving the 
outcome with BCG is unknown, therefore, benefit cannot be promised nor can the chance of 
benefit be accurately predicted.  Patients’ participation in this study is voluntary and refusal will 
not result in penalty or loss of benefit to which patient is otherwise entitled.  
Participation may be discontinued at any time without penalty and the patient can ask questions.
15.6 CONSENT PROCESS AND DOCUMENTATION
The investigational nature and objectives of this trial, the procedures involved, and their 
attendant risks and discomforts, potential benefits, and potential alternative therapies will be 
explained to the patient and a signed informed consent document obtained. All listed associate 
investigators are permitted to obtain informed consent.
The informed consent process will be documented on a progress note by the consenting 
investigator and a copy of the informed consent document and note will be kept in the subject’s 
research record.
15.6.1 Telephone Consent
The informed consent document will be sent to the subject.  An explanation of the study will be 
provided over the telephone after the subject has had the opportunity to read the consent form.  
The subject will sign and date the informed consent. A witness to the subject’s signature will 
sign and date the consent.

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The original informed consent document will be sent back to the consenting investigator who 
will sign and date the consent form with the date the consent was obtained 
via telephone.  
A fully executed copy will be returned via mail for the subject’s records.
The informed consent process will be documented on a progress note by the consenting 
investigator and a copy of the informed consent document and note will be kept in the subject’s 
research record.
15.6.2 Informed consent of non-English speaking subjects
If there is an unexpected enrollment of a research participant for whom there is no translated 
extant IRB approved consent document, the principal investigator and/or those authorized to 
obtain informed consent will use the Short Form Oral Consent Process as described in MAS 
Policy M77-2, OHSRP SOP 12, 45 CFR 46.117 (b) (2), (If a study with an IND or IDE, also cite 
21 CFR 50.27 (b) (2)).  The summary that will be used is the English version of the extant IRB 
approved consent document.  Signed copies of both the English version of the consent and the 
translated short form will be given to the subject or their legally authorized representative and 
the signed original will be filed in the medical record.
Unless the PI is fluent in the prospective subject’s language, an interpreter will be present to 
facilitate the conversation (using either the long translated form or the short form). Preferably 
someone who is independent of the subject (i.e., not a family member) will assist in presenting 
information and obtaining consent. Whenever possible, interpreters will be provided copies of 
the relevant consent documents well before the consent conversation with the subject (24 to 48 
hours if possible). 
We request prospective IRB approval of the use of the short form process for non-English 
speaking subjects and will notify the IRB at the time of continuing review of the frequency of the 
use of the Short Form.

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Clin 62:10-29, 2012
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Donat SM: Evaluation and follow-up strategies for superficial bladder 
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Herr HW, Morales A: History of bacillus Calmette-Guerin and bladder 
cancer: an immunotherapy success story. J Urol 179:53-6, 2008
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Crawford ED: Intravesical therapy for superficial cancer: need for more 
options. J Clin Oncol 20:3185-6, 2002
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Morales A: Long-term results and complications of intracavitary bacillus 
Calmette-Guerin therapy for bladder cancer. J Urol 132:457-9, 1984
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Di Lorenzo G, Perdona S, Damiano R, et al: Gemcitabine versus bacille 
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cancer: a multicenter prospective randomized trial. Cancer 116:1893-900, 2010
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Kavoussi LR, Torrence RJ, Gillen DP, et al: Results of 6 weekly 
intravesical bacillus Calmette-Guerin instillations on the treatment of superficial bladder tumors. 
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O'Donnell MA, Boehle A: Treatment options for BCG failures. World J 
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Shabsigh A, Korets R, Vora KC, et al: Defining early morbidity of radical 
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Stein JP, Lieskovsky G, Cote R, et al: Radical cystectomy in the treatment 
of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 19:666-75, 2001
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superficial bladder cancer in the United States: a pattern of care analysis. Urology 62:1083-8, 
2003
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Lightfoot AJ, Rosevear HM, O'Donnell MA: Recognition and treatment of 
BCG failure in bladder cancer. ScientificWorldJournal 11:602-13, 2011
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immune response for BCG-mediated antitumor activity. J Urol 137:155-8, 1987
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Ratliff TL, Ritchey JK, Yuan JJ, et al: T-cell subsets required for 
intravesical BCG immunotherapy for bladder cancer. J Urol 150:1018-23, 1993
15.
Luo Y, Knudson MJ: Mycobacterium bovis bacillus Calmette-Guerin-
induced macrophage cytotoxicity against bladder cancer cells. Clin Dev Immunol 2010:357591, 
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therapy: quantitative immunohistochemical analysis of the immune response within the bladder 
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Hodge JW, Grosenbach DW, Aarts WM, et al: Vaccine therapy of 
established tumors in the absence of autoimmunity. Clin Cancer Res 9:1837-49, 2003
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Madan RA, Arlen PM, Gulley JL: PANVAC-VF: poxviral-based vaccine 
therapy targeting CEA and MUC1 in carcinoma. Expert Opin Biol Ther 7:543-54, 2007
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Kufe DW: Mucins in cancer: function, prognosis and therapy. Nat Rev 
Cancer 9:874-85, 2009
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oncoprotein in non-small cell lung cancer cells. Mol Cancer Ther 10:806-16, 2011
21.
Walsh MD, Hohn BG, Thong W, et al: Mucin expression by transitional 
cell carcinomas of the bladder. Br J Urol 73:256-62, 1994
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Lau SK, Weiss LM, Chu PG: Differential expression of MUC1, MUC2, 
and MUC5AC in carcinomas of various sites: an immunohistochemical study. Am J Clin Pathol 
122:61-9, 2004
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of carcinoembryonic antigen in conventional histopathology specimens. Cancer 42:1546-53, 
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Cardillo MR, Castagna G, Memeo L, et al: Epidermal growth factor 
receptor, MUC-1 and MUC-2 in bladder cancer. J Exp Clin Cancer Res 19:225-33, 2000
25.
Hodge JW, Grosenbach DW, Rad AN, et al: Enhancing the potency of 
peptide-pulsed antigen presenting cells by vector-driven hyperexpression of a triad of 
costimulatory molecules. Vaccine 19:3552-67, 2001
26.
Gulley JL, Arlen PM, Tsang KY, et al: Pilot study of vaccination with 
recombinant CEA-MUC-1-TRICOM poxviral-based vaccines in patients with metastatic 
carcinoma. Clin Cancer Res 14:3060-9, 2008
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Mohebtash M, Tsang KY, Madan RA, et al: A pilot study of MUC-
1/CEA/TRICOM poxviral-based vaccine in patients with metastatic breast and ovarian cancer. 
Clin Cancer Res 17:7164-73, 2011
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C. Heery NI, R.A. Madan, M. Mohebtash, P. Arlen, M. Bilusic, J. Kim, 
N.K. Singh, S McMahon, S. Hodge, S.M. Steinberg, J. Schlom, J. Hodge, J.L. Gulley: A phase 2 
randomized trial of docetaxel alone or in combination with therapeutic cancer vaccine, CEA-, 
MUC-1-TRICOM. Presented at the ESMO 2012, Vienna, Austria, 2012
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M. Morse DN, J. Marshall, C. R. Garrett, D. Z. Chang, M. Aklilu, T. S. 
Crocenzi, D. J. Cole, S. Dessureault, A. Hobeika, T. Osada, B. M. Clary, S. D. Hsu, G. Devi, A. 
Bulusu, R. Annechiarico, V. Chadaram, T. M. Clay, H. K. Lyerly: Survival rates among patients 
vaccinated following resection of colorectal cancer metastases in a phase II randomized study 
compared with contemporary controls. Presented at the 2011 ASCO Annual Meeting, 2011

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30.
Kantoff PW, Schuetz TJ, Blumenstein BA, et al: Overall survival analysis 
of a phase II randomized controlled trial of a Poxviral-based PSA-targeted immunotherapy in 
metastatic castration-resistant prostate cancer. J Clin Oncol 28:1099-105, 2010
31.
Martinez-Pineiro JA, Flores N, Isorna S, et al: Long-term follow-up of a 
randomized prospective trial comparing a standard 81 mg dose of intravesical bacille Calmette-
Guerin with a reduced dose of 27 mg in superficial bladder cancer. BJU Int 89:671-80, 2002
32.
Ojea A, Nogueira JL, Solsona E, et al: A multicentre, randomised 
prospective trial comparing three intravesical adjuvant therapies for intermediate-risk superficial 
bladder cancer: low-dose bacillus Calmette-Guerin (27 mg) versus very low-dose bacillus 
Calmette-Guerin (13.5 mg) versus mitomycin C. Eur Urol 52:1398-406, 2007
33.
Gulley J, Chen AP, Dahut W, et al: Phase I study of a vaccine using 
recombinant vaccinia virus expressing PSA (rV-PSA) in patients with metastatic androgen-
independent prostate cancer. Prostate 53:109-17, 2002
34.
Lamm DL: Efficacy and safety of bacille Calmette-Guerin immunotherapy 
in superficial bladder cancer. Clin Infect Dis 31 Suppl 3:S86-90, 2000
35.
Vaccinia (smallpox) vaccine. Recommendations of the Immunization 
Practices Advisory Committee (ACIP). MMWR Recomm Rep 40:1-10, 1991
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Theodorescu D, Wittke S, Ross MM, et al: Discovery and validation of 
new protein biomarkers for urothelial cancer: a prospective analysis. Lancet Oncol 7:230-40, 
2006
37.
Ludwig AT, Moore JM, Luo Y, et al: Tumor necrosis factor-related 
apoptosis-inducing ligand: a novel mechanism for Bacillus Calmette-Guerin-induced antitumor 
activity. Cancer Res 64:3386-90, 2004
38.
Mitropoulos DN: Novel insights into the mechanism of action of 
intravesical immunomodulators. In Vivo 19:611-21, 2005
39.
Wieand S, Schroeder G, O'Fallon JR: Stopping when the experimental 
regimen does not appear to help. Stat Med 13:1453-8, 1994
40.
Herr HW, Sogani PC: Does early cystectomy improve the survival of 
patients with high risk superficial bladder tumors? J Urol 166:1296-9, 2001
17

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

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17.2 APPENDIX B: CTEP MULTICENTER GUIDELINES
If an institution wishes to collaborate with other participating institutions in performing a 
CTEP sponsored research protocol, then the following guidelines must be followed.
Responsibility of the Protocol Chair 
•
The Protocol Chair will be the single liaison with the CTEP Protocol and Information 
Office (PIO).  The Protocol Chair is responsible for the coordination, development, 
submission, and approval of the protocol as well as its subsequent amendments.  The 
protocol must not be rewritten or modified by anyone other than the Protocol Chair.  
There will be only one version of the protocol, and each participating institution will use 
that document.  The Protocol Chair is responsible for assuring that all participating 
institutions are using the correct version of the protocol.
•
The Protocol Chair is responsible for the overall conduct of the study at all participating 
institutions and for monitoring its progress.  All reporting requirements to CTEP are the 
responsibility of the Protocol Chair. 
•
The Protocol Chair is responsible for the timely review of Adverse Events (AE) to assure 
safety of the patients.
•
The Protocol Chair will be responsible for the review of and timely submission of data 
for study analysis.
Responsibilities of the Coordinating Center
•
Each participating institution will have an appropriate assurance on file with the Office 
for Human Research Protection (OHRP), NIH.  The Coordinating Center is responsible 
for assuring that each participating institution has an OHRP assurance and must maintain 
copies of IRB approvals from each participating site. 
•
Prior to the activation of the protocol at each participating institution, an OHRP form 310 
(documentation of IRB approval) must be submitted to the CTEP PIO.
•
The Coordinating Center is responsible for central patient registration.  The Coordinating 
Center is responsible for assuring that IRB approval has been obtained at each 
participating site prior to the first patient registration from that site.
•
The Coordinating Center is responsible for the preparation of all submitted data for 
review by the Protocol Chair.
•
The Coordinating Center will maintain documentation of AE reports.  There are two 
options for AE reporting: (1) participating institutions may report directly to CTEP with a 
copy to the Coordinating Center, or (2) participating institutions report to the 
Coordinating Center who in turn report to CTEP.  The Coordinating Center will submit 
AE reports to the Protocol Chair for timely review.
•
Audits may be accomplished in one of two ways:  (1) source documents and research 
records for selected patients are brought from participating sites to the Coordinating 
Center for audit, or (2) selected patient records may be audited on-site at participating 

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sites.  If the NCI chooses to have an audit at the Coordinating Center, then the 
Coordinating Center is responsible for having all source documents, research records, all 
IRB approval documents, NCI Drug Accountability Record forms, patient registration 
lists, response assessments scans, x-rays, etc. available for the audit.
Inclusion of Multicenter Guidelines in the Protocol
•
The protocol must include the following minimum information: 
➢The title page must include the name and address of each participating institution and 
the name, telephone number and e-mail address of the responsible investigator at each 
participating institution.
➢The Coordinating Center must be designated on the title page.
➢Central registration of patients is required.  The procedures for registration must be 
stated in the protocol.
➢Data collection forms should be of a common format.  Sample forms should be 
submitted with the protocol.  The frequency and timing of data submission forms to 
the Coordinating Center should be stated.
➢Describe how AEs will be reported from the participating institutions, either directly 
to CTEP or through the Coordinating Center.
➢Describe how Safety Reports and Action Letters from CTEP will be distributed to 
participating institutions.
Agent Ordering
•
Except in very unusual circumstances, each participating institution will order DCTD-
supplied investigational agents directly from CTEP.  Investigational agents may be 
ordered by a participating site only after the initial IRB approval for the site has been 
forwarded by the Coordinating Center to the CTEP PIO. 

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17.3 APPENDIX C: PANVAC [RECOMBINANT VACCINIA-
CEA(D609)/MUC1(L93)/TRICOM] PATIENT INSTRUCTION SHEET
1.
What vaccination site reactions can you expect?
2.
How should you care for the vaccination site? 
3.
Are there any activities I should avoid?
4.
What about contact with other people?
5.
Who do I contact when I have a question?
 1.
What vaccination site reactions can you expect?
A typical reaction in a patient who has been previously vaccinated with vaccinia includes the 
appearance of a small swelling in 2-3 days that may enlarge to 1-2 inches across, a small blister or 
pustule after 5-7 days, and healing with little scarring within 2-3 weeks. Some patients may have 
very little skin reaction.   Often the leg that received the vaccine may become swollen.  Swollen or 
tender lymph nodes (“glands”) in the groin may be felt. A fever to 100-101F may occur on the 
second or third day.  You may notice that you feel tired for 3 or 4 days. The vaccination site may 
itch for about 2 weeks while the scab is forming.  You can take acetaminophen ("Tylenol") if you 
have any aches or fever but should avoid aspirin.  If fever continues for more than a day or two, 
you should call to speak to the clinic nurse or the research nurse. 
In patients who have never received vaccinia or in some who received it a very long time ago, a 
red swelling is followed by a blisters on day 5 to 6 and then formation of a pustule (or "boil") 1-2 
inches in diameter on day 9 to 11.  A large area of redness may surround this area.  A crusted scab 
usually forms by the second week and falls off by the third week leaving a scar roughly 1/2 inch in 
diameter.  Fever and malaise (the "blahs") may occur during the blister and pustular phases. 
Swollen and tender lymph nodes may persist for months. Many of the local toxicities described 
(e.g., pustule and scab formation) are typical of reactions seen when vaccinia is administered via 
scarification or intradermal administration. These reactions may be seen, but are usually not seen 
when administered via subcutaneous injection.
 2.
How should you care for the vaccination site?
Live vaccinia virus is in skin cells at the vaccination site during the 1-2 weeks until healing has 
occurred.  Maximal viral "shedding" from the vaccination site occurs from days 4-14, but can 
continue until the scab falls off from the skin. After that there is no vaccinia virus in your body.  
You can spread the virus to other parts of your body or to other people by touching the vaccination 
site and then touching your eyes, mouth, a cut or some other break in the skin.You do not pass 
vaccinia virus by coughing or sneezing or by sharing food or cups and dishes.

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In general, frequent careful hand washing by you and by any persons in physical contact with you 
is the best way to prevent transmission of virus.  You should also use two types of barriers over 
your vaccination site at all times until the scab is gone.  These barriers are (1) the bandage and (2) 
clothing (pants or elbow length sleeves depending on the site of vaccination).  These barriers 
should remain in place until the scab has fallen off.
For dressing care you will have a bag with some no-stick "First-Aid" or "Telfa" pads, disposable 
gloves, and zip-lock plastic bags.  If you run out of supplies between visits, you can use a dry 
sterile bandage (gauze or "First-Aid" or "Telfa") from the drug store.
The no-stick pad ("First-Aid" or "Telfa" pad) dressing should be worn until the site has healed.  If 
it remains clean and dry and is not coming off, you do not need to change it.  If the dressing gets 
wet either from drainage from the vaccination or from water when you are showering or if it starts 
coming off, you should remove it and put on a clean bandage.  Wear the gloves when handling the 
old dressings.  Put the old dressing and the gloves in the zip-lock bag, then wash your hands, put 
on the new bandage, and wash your hands again.  You do not need to wear gloves for the new 
bandage.  You do not need to wash the vaccination site, but while the dressing is off, you may 
wash it lightly with a cloth, soap, and water.  If you do wash, blot the site dry with a towel (don't 
rub), then put the wash cloth and the towel in the laundry.  Do not let the shower run on the 
unbandaged site because live virus could be washed onto other areas on your body. Do not put any 
steroid cream, medicated creams, or other ointments on the vaccination site.
Before you throw away the zip-lock bag with the old dressing and gloves in it, pour a little bleach 
(about a quarter cup) in the bag to help kill any virus.
Wash your hands after each step.
 3. Are there any activities I should avoid or take special care?
You should not go swimming until the vaccination site has healed and you no longer need to wear 
a bandage on it. 
If you wear contact lenses, have removable dentures, have a colostomy or any other "open" area on 
your body that needs daily care, always wash your hands very well before handling your contact 
lenses, dentures, dressings, etc.  Take care of all of these procedures before changing your 
vaccination dressing.

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 4.
What about contact with other people?
Remember, frequent careful hand washing by you and by any persons with whom you have 
physical contact is the best way to prevent transmission of virus.  During the time you need to wear 
a bandage (for 7-14 days after vaccination) there are several kinds of people with whom you 
should avoid close contact.  "Close contact" means that you sleep in the same bed with the person, 
give the person baths, and/or touch their bare skin to change their clothes (or diapers), apply 
ointments, or change their bandages. 
The individuals you should avoid include children < 3years of age; pregnant women or nursing 
women; individuals with eczema, history of eczema or other skin conditions such as active cases 
of extensive psoriasis, severe rashes, generalized itching, infections, burns, chicken pox, or skin 
trauma; and/or immune suppressed individuals such as individuals with leukemia or lymphoma, 
with AIDS, or those receiving immunosuppressive treatment (for example, after organ transplant).  
 5.
Who do I contact when I have a question?
If you have any questions at any time, please call.  A nurse or a physician is available 24 hours a 
day by telephone.  To speak with your main doctor or with a clinic nurse, call the Urology Clinic 
between 8 AM and 4:30 PM Monday to Friday.  To speak with the research nurses, call the 
research nurse office during the day; during nights, weekends, and sometimes during the day, 
when the research office is empty, you may leave a message for the research nurse on the 
answering machine.  You can call the principal investigator any time during weekday hours.  In an 
emergency on weekends, evenings, or holidays, you can always get in touch with the on-call 
urologic oncology doctor (fellow) (listed below). This doctor can be contacted by calling the NIH 
Clinical Care Center operator, who will page the on call doctor.  The on call doctor will then call 
you back.   If you have to go to an emergency room near your home, go to the hospital first, and 
then have the doctors there call the NIH for more information.
PHONE NUMBERS
Urology Outpatient Clinic (3rd floor)
(301) 496-5484
Sonia Bellfield, RN
(240) 760-6118 
Rebecca Dolan, CRNP
(301) 827-1007
Raju Chelluri
(240) 858-3700*
*after clinic hours the NCI Urology Oncology physician on call through NIH page operator
(301) 496-1211

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17.4
 APPENDIX D: NIH PROBLEM REPORT FORM 
NCI Protocol #: 
Protocol Title: 
Report version: (select one)
____Initial Report 
____Revised Report
____Follow-up 
Site Principal Investigator:
 
Date of problem:    
Location of problem: (e.g.,  patient’s home, doctor’s 
office )
Who identified the problem? (provide role (not name of person): nurse, investigator, monitor, etc…)
Brief Description of Subject (if 
applicable) 
(Do NOT include personal identifiers) 
Sex:  ___ Male  ___ Female
Age:  
 ___ Not applicable (more than subject is involved)
Diagnosis under study:  
Name the problem: (select all that apply)  
[  ] Adverse drug reaction  
[  ] Abnormal lab value  
[  ] Death  
[  ] Cardiac Arrest/ code 
[  ] Anaphylaxis 
[  ] Sepsis/Infection  
[  ] Blood product reaction
[  ] Unanticipated surgery/procedure  
[  ] Change in status (e.g. increased level of care required)   

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[  ] Allergy (non-medication) 
[  ] Fall 
[  ] Injury/Accident (not fall) 
[  ] Specimen collection issue  
[  ] Informed consent issue  
[  ] Ineligible for enrollment  
[  ] Breach of PII 
[  ] Tests/procedures not performed on schedule 
[  ]  Other, brief  1-2 word description: _________________________
Detailed Description of the problem: (Include any relevant treatment, outcomes or pertinent history):
*Is this problem unexpected? (see the definition of unexpected in the protocol))  __YES __NO  Please 
explain:
 *Is this problem related or possibly related to participation in the research?  __YES __NO  Please explain:
*Does the problem suggest the research places subjects or others at a greater risk of harm than was 
previously known or recognized?    __YES __NO      Please explain:
Is this problem? (select all that apply)
[  ] An Unanticipated Problem* that is:       [  ] Serious        [  ] Not Serious 
[  ] A Protocol Deviation that is:                  [  ] Serious        [  ] Not Serious
[  ] Non-compliance
*Note if the 3 criteria starred above are answered, “YES”, then this event is also a UP.
Is the problem also (select one)  [  ] AE  [  ] Non-AE
Have similar problems occurred on this protocol at your site? __YES __NO      
If “Yes”, how many? ____      Please describe:

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Describe what steps you have already taken as a result of this problem:
In addition to the NCI IRB, this problem is also being reported to: (select all that apply)
[  ] Local IRB
[  ] Study Sponsor
[  ] Manufacturer : ____________________ 
[  ] Institutional Biosafety Committee 
[  ] Data Safety Monitoring Board
[  ] Other: ____________________________________ 
[  ] None of the above, not applicable
INVESTIGATOR’S SIGNATURE: 
DATE:  
17.5 APPENDIX E: SPECIMEN COLLECTION 
The following protocols are used in the Linehan Laboratory and efforts will be made at 
collaborating centers to collect bio-specimens in a similar fashion.  When feasible and when an 
appropriate materials transfer agreement is in place specimens used for correlative endpoints can 
be transferred from collaborating centers to the NIH for storage and future analysis.  Until then, 
specimens will be stored at the collaborating sites under the following conditions.
Urine Protocol
A. Urine will be collected at room temperature from patients through voiding or instrumentation 
and transported to laboratory staff on ice.  Collection will be 30-100 mL of urine in a sterile 
urine container.
B. Time points for collection
BCG/PANVAC arm
BCG arm
•
Week 0 – collect before vaccine 
administration
•
Week 3 – Two samples:
o
Pre-BCG urine prior to BCG 
instillation
o
Post-BCG urine after BCG is 
drained from bladder.  This sample 
is the first voided urine obtained 
after the BCG instillation is 
completed and all of the BCG is first 
•
Week 3 – Two samples:
o
Pre-BCG urine prior to BCG 
instillation
o
Post-BCG urine after BCG is drained 
from bladder.  This sample is the first 
voided urine obtained after the BCG 
instillation is completed and all of the 
BCG is first drained.  
•
Week 5 – Two samples:
o
Pre-BCG urine prior to BCG 

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drained.  
•
Week 5 – Two samples:
o
Pre-BCG urine prior to BCG 
instillation
o
Post-BCG urine after BCG is 
drained from bladder.  This sample 
is the first voided urine obtained 
after the BCG instillation is 
completed and all of the BCG is first 
drained.  
•
Week 17-20 – collect urine prior to 
bladder biopsy.
instillation
o
Post-BCG urine after BCG is drained 
from bladder.  This sample is the first 
voided urine obtained after the BCG 
instillation is completed and all of the 
BCG is first drained.  
•
Week 17-20 – collect urine prior to 
bladder biopsy.
C. Centrifuge urine at 1200xg (2491 rpm for 20 minutes using our 5810R Eppendorf 
Centrifuge) at 4°C in 50 mL conical tube.
D. Filter the supernatant (cell-free urine) with .45 μm filter to remove large debris.  Save cell 
pellet.
E. Store filtered urine as cell-free, filtered urine in 6 vials (1.8 mL cryovial each) at -80°C 
without any cryopreservative.  
F. Resuspend urine cell pellet in 1 mL of 5% DMSO (95% MEM media) and transfer to 1.8 mL 
cryovial tube.
G. Spin this cryovial at 1200xg for 20 minutes at 4°C and leave cell pellet packed. 
H. Do slow freeze of cell pellet with Mr. Frosty and then store at -80.   
I.
Schematic:

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Urine will be processed at:  
William Linehan, MD
c/o Julian Custer or Quentin Li
Urologic Oncology Branch
10 Center Drive, 1W-5888
Bethesda, MD 20892 For patients at CINJ, research samples consisting of urine (week 0, week 3, 
week 5 and week 17-20) will be obtained and processed as above and then shipped via Fed-Ex to 
the above address.  
Blood Protocol
A. Blood will be collected at various time points before any treatments and in various types of 
tubes and processed as below.
B. Time points for collection
BCG/PANVAC arm
BCG arm
•
Week 0 – 1 purple top tube (contains 
EDTA), total volume 10 mL; 6 green top 
•
Week 0 or at randomization – 1 purple 
top tube (contains EDTA), total 
volume 10 mL

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tubes (contains sodium heparin), total 
volume 60 mL; 2 red top tubes, total 
volume 20 mL
•
Week 3 - 6 green top tubes (contains 
sodium heparin), total volume 60 mL; 2 
red top tubes, total volume 20 mL
•
Week 8 - 6 green top tubes (contains 
sodium heparin), total volume 60 mL; 2 
red top tubes, total volume 20 mL
•
Week 11 - 6 green top tubes (contains 
sodium heparin), total volume 60 mL; 2 
red top tubes, total volume 20 mL
•
Week 15 - 6 green top tubes (contains 
sodium heparin), total volume 60 mL; 2 
red top tubes, total volume 20 mL
•
Week 17-20 - 1 purple top tube (contains 
EDTA), total volume 10 mL; 6 green top 
tubes (contains sodium heparin), total 
volume 60 mL; 2 red top tubes, total 
volume 20 mL
•
Week 3 - 6 green top tubes (contains 
sodium heparin), total volume 60 mL; 
2 red top tubes, total volume 20 mL
•
Week 8 - 6 green top tubes (contains 
sodium heparin), total volume 60 mL; 
2 red top tubes, total volume 20 mL
•
Week 17-20 - 1 purple top tube 
(contains EDTA), total volume 10 mL; 
6 green top tubes (contains sodium 
heparin), total volume 60 mL; 2 red 
top tubes, total volume 20 mL
C. Red Top tubes and Green Top Tubes will be processed as follows:
Clinical Services Program (CSP)
NCI Frederick Cancer Research and Development Center
PO Box B
Frederick MD 21702
301-846-1000
On days samples are drawn, Jen Bangh at CSP should be notified (phone: [301] 846-5893; 
fax [301] 846-6222). She will arrange same day courier delivery of the specimens drawn at 
NIH. For samples drawn at outside sites, please refer to the Research Sample Shipment 
section below.
Once a patient’s treatment schedule has been determined, Caroline Jochems should be 
notified at jochemscm@mail.nih.gov for planning purposes.
D. Purple Top Tubes will be processed in Dr. Linehan’s Lab as follows:
a.
Centrifuge blood at 4,000 rpm for 10-20 minutes using our 5810R Eppendorf 
Centrifuge at 4°C.
b. Transfer plasma to 1.8 mL cryovial tubes. Store the tubes with plasma at -80C.

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c.
Collect buffy coat layer (white blood cells) using individually packaged 3 mL transfer 
pipets.
d. Extract DNA from buffy coat layer (white blood cells) with Promega MAXWELL 16 
instrument using the Maxwell Blood DNA Purification Kit as follows:
i. Remove the seal from each cartridge.
ii. Place plunger in well #7 and sample (white blood cells) in well #1.
iii. Open the door. Press “Run/Stop” to extend platform.
iv. Transfer cartridges to platform. Add elution tubes and 400 L elution buffer 
to each tube.
v. Close the door. Press “Run” to perform purification for 50 min.
vi. Run completed. Verify that plungers are clear.
vii. Transfer elution tubes to magnetic elution rack and transfer DNA samples to 
storage tubes. 
viii. Label and store the tubes at -80C.
e.
For patients at CINJ, research samples consisting of 2 purple top tubes (week 
0 and week 17-20) will be drawn, processed as above, and then shipped via 
Fed-Ex to Dr. Linehan’s lab.
Tissue Protocol
Tissue will be collected for diagnostic and therapeutic purposes at the beginning of the trial and 
in weeks 17-20 of the trial following BCG or BCG/PANVAC therapy.  Additional tissue that is 
safely obtained and not needed for pathologic diagnosis can be placed in a sterile container and 
processed in the following manner:
i. Remove samples to be frozen from the container with sterile forceps and 
gently dab on sterile gauze to remove excess fluid.
ii. Once dry, place sample on a piece of tin foil above dry ice to freeze samples
iii. Once frozen, move the samples to empty labeled vial.
iv. If there are enough specimens in the sample to freeze in Tissue Tek O.C.T. 
Compound (OCT), then place one sample on plastic OCT plate instead of tin 
foil 
v. Add OCT medium to the OCT plate. Then place the plate on top of dry ice 
with the plastic side down (the OCT medium and embedded tissue should be 
facing you).
vi. If tissue culture is going to be performed on sample, leave at least one piece of 
tissue in the original container (without freezing it) and deliver this sample to 
the tissue culture lab.
vii. Once labeled and placed on dry ice, store samples in a -80 freezer.
Research Sample Shipment
For samples drawn at outside sites to be sent to the NCI Frederick Repository, please FED-EX 
Overnight to the shipping address below. PBMCs are to be sent on the day of draw; serum is to 
be frozen and batch-shipped at intervals.

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USE NIH/NCI/LTIB FedEx Account Number: 281312103
1. Materials 
Pack blood vials in the shipping kit provided to the site by the NCI research team.
Contents of the kit:
EXAKT-PAK for Vials   Category B  D-pak  MD8702V06 (Accommodates 6 vials) 
Includes Inner pack (Ambient) and Insulated Cooler
With 2 cool packs per cooler, part #CP1003, slightly cooled (refrigerated, not frozen)
2. Address
Leidos Biomedical Research
Attn: Bill Kopp/Theresa Burks
1050 Boyles Street
Bldg. 469/Room 121
Frederick, MD 21702
Phone 301-846-5125, or 301-846-1707
•
Please notify the Frederick laboratory when specimens are being shipped. Please email 
Frederick prior to shipping to notify the lab.
•
Emails should be sent to the following individuals:
      Bill Kopp, koppw@mail.nih.gov
      Theresa Burks, burkst@mail.nih.gov
      Caroline Jochems, jochemscm@mail.nih.gov
     William Linehan, wl3e@nih.gov
     James Gulley gulleyj@mail.nih.gov 
•
Additionally, NO specimens should be shipped on Fridays or the day before a Federal 
holiday. 
3. Labeling of Blood Samples
Please label research tubes with a coding mechanism. List the patient’s enrollment number first 
(will be provided by the Central Registration Office at time of registration), followed by the 
patient’s initials, and lastly followed by the enrollment site.
Example: 01-ABC-CINJ
4. Supply for shipping kits
SHIPPING PAKS to be ordered by the NCI and shipped to participating cancer center.

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Please contact the NCI team for requesting additional shipping kits.
EXAKT Technologies, Inc.
Home office: 7002 N. Broadway Extension
Oklahoma City, OK  73116-9006
405-848-5800

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17.6 APPENDIX F: SAMPLE SHIPPING MANIFEST
Ship From: 
Ship To:  
Address:
Attn: 
 
 
Phone: 
Contact Name:
Phone: 
Clinical Site:
Shipping Manifest 
E-mail:  
Shipping Date: 
Carrier: 
 
 
Clinical Protocol: CTEP 9539
 
 
 
 
In Package 
Unique Patient ID*
Description 
Number of items
Comments
Total number of items =