Pilot Study of Mesenchymal Stromal Cells in Patients With Xerostomia After Radiation Therapy for Head and Neck Cancer
Phase: PHASE1
Conditions: Xerostomia Following Radiotherapy
Sponsor: University of Wisconsin, Madison

Protocol Version 8, 9/13/2023 
 
 
 
 
 
 
Pilot Study of Mesenchymal Stromal Cells in 
Patients with Xerostomia after Radiation 
Therapy for Head and Neck Cancer 
NCT04489732 

Protocol Version 8, 9/28/2023 
 
 
 
i
 
 
 
 
 
 
 
 
Pilot Study of Mesenchymal Stromal Cells in Patients with 
Xerostomia after Radiation Therapy for Head and Neck 
Cancer 
 
 
 
 
Protocol Number: UW20025  
IRB Protocol Number 2020-1290 
Principal Investigator: Randall Kimple MD, PhD 
 
 
IND #: 23026 
IND Sponsor: Jacques Gallipeau MD 
 
 
 
This document is confidential. 
No part of it may be transmitted, reproduced, published, or used by other persons without prior 
authorization from the Sponsor or Principal Investigator. 
 
 
 
Protocol Version History 
 
Protocol 
Version 
Version 
Date 
Summary of Revisions 
Made 
Rationale 
1.0 
06/22/2020 
Initial version 
 
2.0 
09/08/2020 
 
 Modifications made in response to FDA review 
and IND Application 
3.0 
10/26/2020 
 
Modifications made in response to HS-IRB review 
of initial IRB application  
4.0 
10/7/2021 
Change to “Pilot” Study 
 
6.0 
5/2/2022 
Change to protocol  
Modification made after patient #1 injection for 
study calendar, updated needle gauge from 23 to 
22  
7.0 
3/27/2023 
Change to protocol 
A second injection will be offered for injection into 
each subject’s contralateral submandibular gland 
8.0 
9/28/2023 
Change to protocol 
FDA requested changes 
 
 
 

Protocol Version 8, 9/28/2023 
 
 
 
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TABLE OF CONTENTS 
1.0 
STATEMENT OF COMPLIANCE .......................................................................................................................... 1 
2.0 
LIST OF ABBREVIATIONS ................................................................................................................................... 2 
3.0 
STUDY SUMMARY ................................................................................................................................................ 4 
 
SYNOPSIS ..................................................................................................................................................................... 4 
 
SCHEMATIC OF STUDY DESIGN .................................................................................................................................... 6 
4.0 
KEY ROLES ............................................................................................................................................................ 7 
5.0 
INTRODUCTION ..................................................................................................................................................... 9 
 
RADIATION-INDUCED XEROSTOMIA AND SALIVARY GLANDS BACKGROUND .............................................................. 9 
 
CURRENT STANDARD OF CARE.................................................................................................................................... 9 
 
MESENCHYMAL STEM CELLS ....................................................................................................................................... 9 
 
RATIONALE ................................................................................................................................................................. 10 
 
RATIONALE FOR INJECTION OF SECOND SUBMANDIBULAR GLAND........................................................................... 11 
 .......... THIS AMENDMENT WILL BE FORWARDED TO THE FDA FOR REVIEW PRIOR TO IMPLEMENTATION.
 ............................................................................................................................................................................................ 11 
6.0 
STUDY OBJECTIVES AND ENDPOINTS .......................................................................................................... 11 
7.0 
STUDY DESIGN.................................................................................................................................................... 12 
 
GENERAL DESIGN ....................................................................................................................................................... 12 
 
END OF STUDY DEFINITION ........................................................................................................................................ 13 
8.0 
SUBJECT SELECTION........................................................................................................................................ 13 
 
INCLUSION & EXCLUSION CRITERIA ........................................................................................................................... 13 
 
STUDY POPULATIONS ................................................................................................................................................. 14 
 
LIFESTYLE CONSIDERATIONS ..................................................................................................................................... 14 
 
SUBJECT IDENTIFICATION ........................................................................................................................................... 14 
Identification in Clinical Practice ..................................................................................................................................... 14 
Self Identification ............................................................................................................................................................... 14 
Electronic Medical Record Query ................................................................................................................................... 15 
Department Database ...................................................................................................................................................... 15 
 
SUBJECT RECRUITMENT ............................................................................................................................................ 15 
 
REMUNERATION AND RETENTION STRATEGIES ......................................................................................................... 15 
 
EARLY TERMINATION AND WITHDRAWAL ................................................................................................................... 15 
9.0 
STUDY TREATMENT ........................................................................................................................................... 16 
 
DESCRIPTION OF THE INVESTIGATIONAL MEDICINAL PRODUCT (IMP) ..................................................................... 16 
 
PREPARATION OF THE IMP ........................................................................................................................................ 16 
 
PACKAGING, LABELING AND STORAGE OF THE IMP .................................................................................................. 17 
Packaging .......................................................................................................................................................................... 17 
Labeling .............................................................................................................................................................................. 17 
Storage ............................................................................................................................................................................... 17 
 
TRANSPORT OF IMP ................................................................................................................................................... 17 
 
IMP ACCOUNTABILITY ................................................................................................................................................ 17 
 
RETENTION SAMPLES, IF AVAILABLE, WILL BE CRYOPRESERVED AND STORED IN A VAPOR PHASE OF LN2 STORAGE 
DEWAR WITHIN THE GMP CELL MANUFACTURING FACILITY. RETENTION SAMPLES WILL BE KEPT FOR A MINIMUM OF 2 
YEARS. RETENTION SAMPLES MAY THEN BE DISCARDED ACCORDING TO APPLICABLE REGULATIONS FOR DISPOSAL OF 
BIOLOGICAL PRODUCTS. THE PACT GMP CELL MANUFAUCTURING FACILITY HAS ASSESSED EACH PATIENT’S MSC IMP 
TO ENSURE THE CRYOPRESERVED PRODUCT IS STABLE AND APPROPRIATE FOR SECOND INJECTION (SEE APPENDIX 19.4 

Protocol Version 8, 9/28/2023 
 
 
 
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FOR STABILITY DATA). THE MSC IMP ADMINISTERED FOR THE SECOND INJECTION WILL UNDERGO THE SAME QUALITY 
CONTROL TESTING DETAILED IN SECTION 9.2 PRIOR TO INJECTION.  ..................................................................................... 18 
 
ADMINISTRATION OF IMP ........................................................................................................................................... 18 
 
DOSE-REDUCTION SCHEDULE ................................................................................................................................... 18 
 
SUPPORTIVE CARE ..................................................................................................................................................... 20 
 
DOSE DELAYS/MODIFICATIONS.................................................................................................................................. 20 
 
STUDY PROCEDURAL INTERVENTION(S) DESCRIPTION ............................................................................................. 20 
Pre-Intervention Bone Marrow Biopsy for MSC Collection ......................................................................................... 20 
MSC IMP Administration .................................................................................................................................................. 20 
 
METHOD FOR ASSIGNING TO TREATMENT GROUPS .................................................................................................. 21 
 
UNBLINDING PROCEDURES ........................................................................................................................................ 21 
 
STUDY INTERVENTION COMPLIANCE .......................................................................................................................... 21 
 
CONCOMITANT THERAPY ........................................................................................................................................... 21 
Permitted Concomitant Therapy ..................................................................................................................................... 21 
Prohibited Concomitant Therapy .................................................................................................................................... 21 
10.0 
STUDY VISITS AND PROCEDURES ................................................................................................................. 22 
 
STUDY CALENDAR ...................................................................................................................................................... 22 
 
SCREENING AND ENROLLMENT .................................................................................................................................. 23 
Informed Consent ............................................................................................................................................................. 23 
Enrollment/Registration .................................................................................................................................................... 24 
Screening ........................................................................................................................................................................... 24 
 
ON-STUDY/FOLLOW-UP VISITS .................................................................................................................................. 25 
Baseline (may occur over 1-2 visits) .............................................................................................................................. 25 
Bone Marrow Aspiration for MSC Collection ................................................................................................................ 25 
MSC IMP Administration .................................................................................................................................................. 25 
Three Day Telephone Call  (3 days + 2 days) .............................................................................................................. 25 
One Week Telephone Call  (7 days + 2 days) ............................................................................................................. 25 
One Month Follow-up Visit  (30 days + 10 days) ......................................................................................................... 25 
Three Month Follow-up Visit  (90 days + 14 days) ...................................................................................................... 26 
Six Month Follow-up Visit  (180 days + 21 days) ......................................................................................................... 26 
Twelve Month Follow-up Visit  (365 days + 21 days) .................................................................................................. 26 
Twenty Four Month Follow-up Visit  (730 days + 56 days) ........................................................................................ 26 
Screening/MSC IMP Administration in Contralateral Gland ....................................................................................... 26 
Seven Day Telephone Call After Contralateral Injection  (7 days + 2 days) ............................................................ 27 
Thirty Day Follow-up Visit After Contralateral Injection  (30 days + 10 days) ......................................................... 27 
Ninety Day Follow-up Visit After Contralateral Injection  (90 days + 14 days) ........................................................ 27 
Twelve Month Follow-up Visit After Contralateral Injection  (12 months + 3 months) ............................................ 27 
 
UNSCHEDULED VISITS ................................................................................................................................................ 27 
 
EARLY TERMINATION/WITHDRAWAL VISIT ................................................................................................................. 28 
11.0 
COLLECTION AND PROCESSING OF PATIENT REPORTED OUTCOMES, BIOSPECMENS, AND 
IMAGING ............................................................................................................................................................................ 28 
 
PAIN MEASUREMENT .................................................................................................................................................. 28 
 
QUALITY OF LIFE ASSESSMENTS ............................................................................................................................... 28 
 
SALIVARY FLOW RATE ASSESSMENTS ...................................................................................................................... 28 
 
SALIVARY COMPOSITION ANALYSES .......................................................................................................................... 29 
 
SALIVARY BIOBANKING ............................................................................................................................................... 29 
 
ULTRASOUND IMAGING ASSESSMENT ........................................................................................................................ 29 
 
BIOBANKING OF BLOOD SAMPLE ................................................................................................................................ 30 
12.0 
DATA COLLECTION, HANDLING, SHARING, AND RECORD KEEPING .................................................... 30 

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DATA COLLECTION ..................................................................................................................................................... 30 
Data Collection Forms ...................................................................................................................................................... 30 
Data Capture Methods ..................................................................................................................................................... 30 
 
CONFIDENTIALITY AND PRIVACY ................................................................................................................................ 30 
 
RETENTION FOR FUTURE RESEARCH: DATA & BIOSPECIMEN BANKING .................................................................. 31 
Purpose of Storage ........................................................................................................................................................... 31 
Data and/or Biospecimens Being Stored ...................................................................................................................... 31 
Location of Storage .......................................................................................................................................................... 31 
Duration of Storage .......................................................................................................................................................... 32 
Access to Data, Images, Recordings and/or Biospecimens and Security Measures ............................................. 32 
Procedures to Release Data or Biospecimens ............................................................................................................ 32 
Process for Returning Results ........................................................................................................................................ 32 
Process for Tracking Subject Consent and Authorization .......................................................................................... 32 
 
PROTOCOL DEVIATIONS ............................................................................................................................................. 32 
 
PUBLICATION AND DATA SHARING POLICY ................................................................................................................ 32 
13.0 
STUDY ANALYSIS ............................................................................................................................................... 32 
 
GENERAL CONSIDERATIONS ...................................................................................................................................... 32 
 
DETERMINATION OF SAMPLE SIZE ............................................................................................................................. 33 
 
ANALYSIS SETS .......................................................................................................................................................... 33 
Eligibility, Protocol Deviations ......................................................................................................................................... 33 
Definitions .......................................................................................................................................................................... 34 
 
DEMOGRAPHICS AND BASELINE CHARACTERISTICS ................................................................................................. 34 
 
TREATMENT AND STUDY COMPLIANCE ...................................................................................................................... 34 
 
HANDLING OF MISSING DATA ..................................................................................................................................... 34 
 
ANALYSES OF THE PRIMARY ENDPOINTS .................................................................................................................. 34 
 
ANALYSES OF THE SECONDARY ENDPOINTS ............................................................................................................. 35 
 
INTERIM ANALYSES ..................................................................................................................................................... 36 
14.0 
RISK/BENEFIT ASSESSMENT .......................................................................................................................... 36 
 
POTENTIAL BENEFITS TO THE SUBJECTS .................................................................................................................. 36 
 
KNOWN POTENTIAL RISKS ......................................................................................................................................... 36 
Known Procedural Risks .................................................................................................................................................. 36 
Known Interventional Risks ............................................................................................................................................. 36 
 
RISK/BENEFIT ANALYSIS ............................................................................................................................................ 37 
15.0 
ADVERSE EVENTS REPORTING REQUIREMENTS ...................................................................................... 37 
 
OVERVIEW OF ADVERSE EVENT REPORTING ............................................................................................................ 37 
 
COMMON TERMINOLOGY CRITERIA FOR CRITICAL ADVERSE EVENTS (CTCAE) .................................................... 38 
 
DEFINITION OF ADVERSE EVENT ................................................................................................................................ 38 
 
GRADING THE SEVERITY OF ADVERSE EVENTS ........................................................................................................ 38 
 
CAUSALITY/ATTRIBUTION ........................................................................................................................................... 38 
 
SERIOUSNESS OF ADVERSE EVENT ........................................................................................................................... 39 
 
DETERMINATION OF EXPECTEDNESS ......................................................................................................................... 39 
 
RECORDING ADVERSE EVENTS ................................................................................................................................. 39 
 
BASELINE ADVERSE EVENTS ..................................................................................................................................... 39 
 
EXPEDITED REPORTING ......................................................................................................................................... 40 
 
REQUIRED REPORTING .......................................................................................................................................... 40 
 
FOLLOW-UP OF ADVERSE EVENTS ........................................................................................................................ 40 
16.0 
DATA AND SAFETY MONITORING PLAN ....................................................................................................... 40 
 
OVERSIGHT AND MONITORING PLAN ......................................................................................................................... 40 

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MONITORING AND REPORTING GUIDELINES .............................................................................................................. 41 
 
REVIEW AND OVERSIGHT REQUIREMENTS ................................................................................................................ 41 
 
EXPEDITED REPORTING OF SERIOUS ADVERSE EVENTS.......................................................................................... 43 
 
STUDY STOPPING RULES ........................................................................................................................................... 44 
17.0 
STUDY FEASIBILITY ........................................................................................................................................... 45 
 
ECONOMIC BURDEN TO SUBJECTS ............................................................................................................................ 45 
 
FACILITIES AND LOCATIONS ....................................................................................................................................... 45 
 
FEASIBILITY OF RECRUITING THE REQUIRED NUMBER OF SUBJECTS ...................................................................... 45 
 
PRINCIPAL INVESTIGATOR CONSIDERATIONS ............................................................................................................ 45 
Time Devoted to Conducting the Research .................................................................................................................. 45 
Process for Informing Study Teams ............................................................................................................................... 45 
 
AVAILABILITY OF MEDICAL OR PSYCHOLOGICAL RESOURCES .................................................................................. 46 
18.0 
REFERENCES ...................................................................................................................................................... 46 
19.0 
APPENDICES ....................................................................................................................................................... 49 
 
XEQOL........................................................................................................................................................................ 49 
 
MDADI QUESTIONNAIRE ........................................................................................................................................... 51 
 
VAS XEROSTOMIA QUESTIONNAIRE .......................................................................................................................... 54 
 
STABILITY DOCUMENTATION ...................................................................................................................................... 55 
 
 
 
 

 
 
 
 
 
Protocol Version 8, 9/28//2023 
 
 
1 
1.0 
STATEMENT OF COMPLIANCE 
I confirm that I have read this protocol. I will comply with the IRB-approved protocol, and applicable 
regulations, guidelines, laws, and institutional policies.  
 
I agree to ensure that all staff members involved in the conduct of this study are informed about their 
obligations in meeting the above commitment.  
 
Name 
Signature 
Date 
 
 
Randall Kimple MD, PhD 
___________________________________________  
Principal investigator 
 
 
 
 
 
 
 
 

Protocol Version 8, 9/13/2023 
 
 
2 
2.0 
LIST OF ABBREVIATIONS 
 
AE 
Adverse Event 
BM 
Bone marrow 
BMI 
Body mass index 
CFR 
Code of Federal Regulations 
cGMP 
Current Good Manufacturing Practice 
CRF 
Case Report Form  
CRT 
Chemoradiation therapy 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTMS 
Clinical Trial Management Software 
DLT 
Dose limiting toxiticy 
DSMC 
Data & Safety Monitoring Committee 
DSMP 
Data & Safety Monitoring Plan 
eCRF 
Electronic Case Report Forms 
EDC 
Electronic Data Capture 
ELISA 
Enzyme-linked immunosorbent assay 
EMR 
Electronic medical record 
EpCAM 
Epithelial cellular adhesion molecule 
FACT 
Foundation for the Accreditation of Cellular Therapy 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GDNF 
Glial cell line-derived neurotrophic factor 
HIPAA 
Health Insurance Portability and Accountability Act 
HNC 
Head and neck cancer 
IB 
Investigator’s Brochure 
ICTR 
Institute for Clinical and Translational Research 
IMP 
Investigational Medicinal Product 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
MAD 
Maximal Administered Dose  
MDADI 
MD Anderson Dysphagia Index 
MHC 
Major histocompatibility complex 
MNC 
Mononuclear cells 
MOP 
Manual of Procedures 
MSC 
Mesenchymal Stem (or Stromal) Cells 
MTD 
Maximal Tolerated Dose 
NCI 
National Cancer Institute 
NED 
No Evidence of Disease 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OnCore 
Online Collaborative Research Environment 
PACT 
Program for Advanced Cell Therapy 
PHI 
Protected Health Information 
phOL 
Pooled human platelet lysate 
QoL 
Quality-of-life 
PI 
Principal Investigator 
RT 
Radiation therapy 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 

 
 
 
 
 
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SMC 
Safety Monitoring Committee 
SMP 
Study Monitoring Plan 
UP 
Unanticipated Problem 
US 
Ultrasound 
UWCCC 
University of Wisconsin Carbone Cancer Center 
VAS 
Visual analogue scale 
XeQOL 
University of Michigan Xerostomia Quality of Life 

 
 
 
 
 
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3.0 
STUDY SUMMARY 
 Synopsis 
 
 
Full Title 
Pilot Study of Mesenchymal Stromal Cells in Patients with Xerostomia after 
Radiation Therapy for Head and Neck Cancer  
Short Title 
Mesenchymal stromal cells (MSCs) for xerostomia 
Protocol Number 
UW 20025 
Number of Sites 
This is a single-site study conducted at the University of Wisconsin  
ClinicalTrials.gov 
Identifier & 
Summary 
To be submitted to clinicaltrials.gov following FDA and UW SMPH regulatory 
approvals. 
 
Phase 
Pilot 
Main Inclusion 
Criteria 
• 
History of histological diagnosis of head and neck cancer (HNC) that was 
treated with radiation therapy and clinically or radiologically NED 
• 
Xerostomia, defined as patient reported salivary function (pre-treatment) ≤ 80% 
of healthy (pre-radiation) 
• 
≥ 18 years of age, ≤ 90 years of age. 
• 
Patients ≥ 2 years from completion of radiation therapy for HNC 
• 
Karnofsky ≥ 70, patient eligible for bone marrow aspirate with wakeful 
anesthesia 
• 
Willing and able to give informed consent 
• 
Radiographically confirmed submandibular gland(s) 
Main Exclusion 
Criteria 
• 
Patients with one submandibular gland 
• 
Salivary gland disease (i.e., sialolithiasis)  
Objective(s) 
Primary Objective  
• 
To evaluate the safety and tolerability of MSCs for subjects with xerostomia 
after radiation therapy for HNC.  
Secondary Objectives  
• 
To evaluate the efficacy of MSCs for treatment of xerostomia and salivary 
hypofunction via quality-of-life (QoL) questionnaires, salivary amount, and 
salivary compositional analysis. 
• 
To assess the imaging characteristics in HNC patients after MSC injection using 
ultrasound. 
• 
To assess the feasibility of a future Phase 1 dose-escalation study. 
Endpoints 
Primary Endpoint 
• 
Recommended starting dose of MSCs for a Phase I dose-escalation study, 
determined by the proportion of subjects experiencing dose-limiting toxicity 
(DLT), where DLT is defined as: submandibular pain > 5 on a standard 10-point 
pain scale of 0-10 at 1-month after MSC injection OR any serious AE OR any of 
the selected toxicities listed in section 9.7 within one-month post-injection. 
 
Secondary Endpoints 

 
 
 
 
 
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• 
Salivary function and subjective dry mouth, determined by mean overall and 
individual salivary amounts, compositional analysis, and QoL xerostomia survey 
scores at 1, 3, 6, 12, and 24 months. 
• 
Shear wave velocity with acoustic radiation force impulse, measured by 
ultrasound (US) of submandibular glands at 3, 6, and 12 months 
• 
Feasibility for a future Phase 1 dose-escalation study will be based on drop-out 
rate. 
Study Design 
This is a single-center pilot study designed to determine the safety and tolerability of 
autologous bone marrow-derived MSCs in patients with xerostomia after undergoing 
radiation therapy for HNC. 
IND Number 
23026  
Study 
Intervention 
Adults with xerostomia after radiation therapy for HNC will undergo one-time 
injection of 10 (8 – 12) x 106 MSCs into one submandibular gland.  
A second injection of 10 (8 – 12) x 106 MSCs will be offered for injection into each 
subject’s contralateral submandibular gland as no DLT’s were noted in any of the 
study participants (sub study).  
Total Number of 
Subjects 
A total of 6-12 subjects will be enrolled from 1 study site. 
Study Population Male and females aged 18 to 90 years with xerostomia 2 years after undergoing 
radiation therapy for HNC. 
Statistical 
Methodology 
The pilot trial with 12 patients total enrolled will allow us to estimate 95% CI of adverse 
events (e.g. 1 of 6 patients results in a 95% CI of 0-64%) . All patients will be analyzed 
for adverse events. 
Estimated 
Subject Duration 
The duration of the study for each subject is approximately 24 months.  
Estimated 
Enrollment 
Period & Study 
Duration 
Study enrollment and follow-up will occur over 6 months with the total expected 
duration of the trial to be 30 months.  
 
 
 

 
 
 
 
 
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 Schematic of Study Design 
 
 
 
 
 
Dose 
Levela 
MSC IMPb,c 
-1 
5 x 106 injected into submandibular gland on Day 1 
0 
10 x 106 injected into one submandibular gland on Day 1 
a Dosing to start at level 0  
b Variance of ± 20% cell dose allowable 
c Subjects at dose level 0 must have two submandibular glands and will have only one submandibular gland 
injected  
$ Staggered enrollment for subjects, with a minimum of 14 days between MSC injection in a subject and MSC 
injection in a subsequent subject, during which time there are no SAEs and no AEs ≥ grade 3 that are 
probably or definitely attributable to MSC injection 
 
 
 

 
 
 
 
 
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4.0 
KEY ROLES 
The following is a list of all key personnel and roles: 
 
Principal-Investigator 
Randall Kimple, MD, PhD 
Associate Professor 
Department of Human Oncology 
University of Wisconsin School of Medicine and Public Health 
3107 Wisconsin Institutes for Medical Research 
111 Highland Avenue 
Madison, WI 53705  
Tel: 608-263-3611 
Email: rkimple@humonc.wsic.edu 
Sponsor 
Jacques Galipeau, MD, FRCP(C) 
Professor of Oncology, Department of Medicine and UW 
Carbone Cancer Center 
Associate Dean for Therapeutics Discovery and Development 
University of Wisconsin School of Medicine and Public Health 
3009 Wisconsin Institutes for Medical Research 
111 Highland Avenue 
Madison, WI 53705 
Tel: 608-263-0078 
Email: jgalipeau@wisc.edu   
Participating Site 
University of Wisconsin School of Medicine and Public Health 
750 Highland Avenue 
Madison, WI  53726 
Co-Investigator 
 
Nicole Pulia 
Assistant Professor  
Geriatrics Faculty  
Veterans Administration Hosp  
2500 Overlook Terrace 
Madison, Wi 53705-2254 
Tel: (608) 265-1901 x11697  
Email: npulia@wisc.edu 
Co-Investigator 
Tiffany Glazer, MD 
Assistant Professor 
Division of Otolaryngology-Head & Neck Surgery  
Department of Surgery 
University of Wisconsin School of Medicine and Public Health 
3009 Wisconsin Institutes for Medical Research 
111 Highland Avenue 
Madison, WI 53705 
Tel: (608) 265-8207  
Email: glazer@surgery.wisc.edu 
Co-Investigator 
Grace Blitzer, MD 
Department of Human Oncology  
PGY 3 Resident  
University of Wisconsin School of Medicine and Public Health 
600 Highland Avenue 
Madison, WI 53792 
Tel: (239) 851-2212   
Pager: 5892 
Email: GBlitzer@uwhealth.org 
Biostatistician 
Richard J. Chappell, PhD  
Professor  
Departments of Statistics and Biostatistics & Medical Informatics 
600 Highland Avenue  
Madison, Wi 53792 

 
 
 
 
 
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(608) 263-1706 
chappell@biostat.wisc.edu 
Data and Safety 
Monitoring Committee 
UWCCC Carbone Cancer Center Data and Safety Monitoring 
Committee 
Email: DSMC@uwcarbone.wisc.edu 
 
 
 

 
 
 
 
 
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5.0 
INTRODUCTION 
 Radiation-Induced Xerostomia and Salivary Glands Background 
Xerostomia, or dry mouth, is a common side effect of head neck radiation. Older, 3D conformal 
radiation results in long-term xerostomia in up to 80% of patients. The use of intensity modulated 
radiation allows the sparing of salivary glands but still results in xerostomia in > 40% of patients1. 
Patients with radiation-induced xerostomia can develop dental caries, impaired swallowing ability, 
difficulty speaking, and diminished taste. These associated symptoms can have a major negative 
impact on the overall quality of life. Current treatment options for radiation-induced xerostomia are 
generally supportive in nature. Patients are encouraged to increase water consumption, consume 
specially prepared food, utilize salivary substitutes or attempt to stimulate salivary production through 
the use of parasympathomimetic drugs, organic acids, chewing gum, or sugar-free mints2-5. Most of 
these supportive interventions do not reverse xerostomia and are palliative in intent.  
 
Salivary glands are composed of two types of epithelial cells. The first type is acinar cells which 
comprise approximately 75% of the glands, secrete exocrine proteins, and are the site of water 
movement6. The second is duct cells which are water impermeable and NaCl absorbing6. Radiation 
results in the death of most acinar cells. Adult stem cells are the ultimate source for replenishment of 
salivary gland tissue, including acinar cells necessary for saliva production. The ductal compartment 
in the salivary gland has been identified as the location harboring rare ductal epithelial cellular 
adhesion molecule (EpCAM)+ cells which express nuclear b-catenin, indicating active Wnt signaling 
as a key driver of adult salivary gland stem cells, allowing extensive expansion and enabling 
restoration of function7. An important role for glial cell line-derived neurotrophic factor (GDNF)-driven 
salivary stem cell function has also been defined8.  
 Current Standard of Care 
Current treatment options for radiation-induced xerostomia are generally supportive in nature. 
Patients are encouraged to increase water consumption, consume specially prepared food, utilize 
salivary substitutes or attempt to stimulate salivary production through the use of 
parasympathomimetic drugs, organic acids, chewing gum, or sugar-free mints2-5. Most of these 
supportive interventions do not reverse xerostomia and are palliative in intent. All interventions 
including gum and salivary substitutions will be allowed while on trial.  
 Mesenchymal Stem Cells 
Marrow-derived mesenchymal stem cells (i.e., mesenchymal stromal cells, MSCs) are a viable cell-
based therapy for xerostomia. MSCs are a cellular product that can be derived from bone marrow 
and propagated ex vivo using established, clinically applicable methods9. According to the 
International Society of Cell Therapy guidelines, MSCs must be plastic-adherent when maintained in 
standard culture conditions, express major histocompatibility complex (MHC) class I molecules as 
well as surface CD105, CD90, CD73 and CD44, lack expression of hematopoietic markers CD45, 
CD34, CD11b, and CD19, and retain the ability to differentiate to osteoblasts, adipocytes and 
chondroblasts in vitro10,11. MSCs are also characterized by a unique transcriptome12.  
 
MSCs have an ability to promote tissue healing in a variety of injurious settings13. At one time, it was 
thought that this was attributable to their stem-progenitor-like character – that is, MSC-derived cells 
might directly repopulate damaged organs. However, the small number of MSCs recovered at tissue 
target sites contradicts this hypothesis and instead supports the alternative hypothesis that MSCs 

 
 
 
 
 
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10
limit cell death secondary to tissue inflammation and providence of tissue promoting morphogens13. 
Thus the healing effects are more likely from the MSC secretome, which has broad 
immunomodulatory and trophic activity14,15. In the gut, MSCs deploy niche cell properties with the 
ability to sustain LGR5+ epithelial stem cells via expression of Wnts, FGFs and R-spondins16. Akin to 
intestinal stem cells, the self-renewal ability of salivary gland stem cells is dependent on extrinsic 
niche signals that could be provided by exogenous administration of MSCs. 
 
After expansion in the laboratory, MSCs are cryopreserved until clinically needed. This 
cryopreservation and thawing can result in cellular injury or senescence17,18. Senescent MSCs have 
less effective immunomodulation17-19. Stimulating the MSCs with interferon gamma prior to 
cryopreservation has been shown to prevent this immune dysfunctionality18-20.  
A review of preclinical studies on MSCs for xerostomia found five preclinical studies using mouse 
models, with 32%-200% increases in salivary flow rate after implantation of MSCs21. Three studies 
examined the effects of MSCs on radiation-induced xerostomia, with two of those studies using 
murine MSCs obtained from bone marrow21. The Coppes Lab has used salivary stem cells from non-
irradiated HNC patients that are transplanted into immunodeficient irradiated mice to improve murine 
salivary function. There remain questions about the relevance of this work due to the atrophic nature 
of irradiated salivary glands in HNC patients22.  Another group has found that after allogenic 
transplantation of bone marrow-derived stem cells there was an increase in saliva production, 
promotion of regenerative activity, and direct differentiation of donor stem cells into salivary epithelial 
cells22,23. We are currently undertaking FDA IND enabling studies to demonstrate the viability of 
MSCs taken from patients who have undergone radiation ± chemotherapy.  
The first human clinical trial (MESRIX) of autologous adipose-derived MSCs to treat radiation-
induced xerostomia had the results published early 201824. In this Danish single-center, phase I/II, 
randomized, placebo-controlled, double-blinded clinical trial, 30 patients were randomized using a 1:1 
ratio and received injected adipose-derived MSC or placebo to the submandibular glands. The 
dosing was based on prior murine studies and ranged from 2.2 x 106 to 4.5 x 107.  No adverse events 
were detected. Unstimulated whole salivary flow rates significantly increased in the MSC-arm at one 
(33%; p=0.048) and four months (50%; p=0.003), but not in the placebo-arm, compared to baseline. 
The MSC-arm also had symptom scores significantly decreased on the xerostomia and VAS 
questionnaires, and significantly improved salivary gland functions of inorganic element secretion and 
absorption. This study did not examine the use of interferon gamma-stimulated MSCs. These data 
strongly support the feasibility and benefit of interferon gamma stimulated MSC autotransplantation 
for treating radiation therapy (RT)-induced xerostomia. Based on a search of clinicaltrials.gov in 
January 2020 there are currently no ongoing trials of MSCs for xerostomia in the US. 
 Rationale 
MSCs have been repeatedly studied in subjects with malignancies without showing increased 
incidences of cancer25,26.  Autologous MSCs have an immediate and obvious advantage to allogeneic 
cells since these are not susceptible to immune rejection, may lead to prolonged clinical effect, and 
can be repeatedly administered. Adipose and marrow derived MSCs share many functionalities, with 
marrow MSCs having a favorable bias towards niche functionalities considering the pivotal role in 
maintaining hematopoietic stem cells throughout life. Additionally, research shows a lower chance of 
an adverse event with a bone marrow (BM) biopsy as compared to liposuction to obtain adipose 
tissue - a 0.07% incidence of adverse events related to bone marrow biopsies, as compared to 1.36-
8.6% adverse events related to liposuction27-29. Multiple preclinical studies have shown an increase in 
murine saliva production after MSC transplantation. The MESRIX trial studied adipose-derived MSCs 

 
 
 
 
 
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without characterizing their secretome profile and excluded patients with severe salivary gland 
hypofunction.  
This trial will be a first-in-human clinical trial of bone marrow-derived, interferon gamma-activated 
MSCs for the treatment of radiation-induced xerostomia. In this pilot study, we will demonstrate the 
feasibility and safety of these MSCs and determine the recommended starting dose of interferon 
gamma stimulated MSCs for a Phase I dose-escalation study. We propose that autotransplantation 
of marrow-derived mesenchymal stromal cells (MSCs) in salivary glands post-RT or post-
chemoradiation therapy (CRT) may provide an innovative remedy to treat xerostomia and restore 
quality of life. 
 Rationale for Injection of Second Submandibular Gland 
We have achieved our primary objective of evaluating the safety and tolerability of injection of 
interferon gama stimulated MSCs into the submandibular gland. No patients have had a DLT within 
one month of injection. Indeed, only 3 patients reported pain (pain scale rating 1/10) with all 3 
paitents having resolution of their pain within 4 days. There were no serious adverse events. Now 
that the safety of this dose level of MSCs has been shown, injection of the contralateral 
submandibular gland at the same dose level will be undertaken. We are opening a phase I clinical 
trial in 2023 in which patients undergo bilateral submandibular gland injection with interferon gamma 
stimulated MSCs. In order to provide the most benefit for patients, bilateral injection is recommended, 
as this will allow for the regeneration of both submandibular glands, which provide the majority of 
unstimulated saliva.  
Additionally, the UW PACT has demonstrated stability of the cryopreserved MSC IMP after storage 
(see Appendix 19.4 for stability data). Each patient’s MSC IMP was cryopreserved, thawed, culture-
rescued, and formulated for injection in the already conducted pilot clinical study. The MSC IMP 
utilized for the second injection is composed of MSCs that were manufactured and cryopreserved at 
the same time as the MSCs for the first injection. 
Each patient has cryopreserved autologous MSCs sufficient to allow for injection of the contralateral 
submandibular gland at dose level 0. We will utilize the cryopreserved MSCs for the contralateral 
gland injection, removing the need for another bone marrow aspiration and culturing of cells. The 
MSC IMP for the second injection will be identical to the first injection with the exception that these 
MSCs have been in cryopreservation longer.  
6.0 
THIS AMENDMENT WILL BE FORWARDED TO THE FDA FOR REVIEW PRIOR TO 
IMPLEMENTATION. STUDY OBJECTIVES AND ENDPOINTS 
Objectives 
Endpoints 
Primary 
To evaluate the safety and tolerability of 
MSCs for subjects with xerostomia after 
radiation for HNC. 
Recommended starting dose of MSCs for a Phase I dose-
escalation study, determined by the proportion of subjects 
experiencing dose-limiting toxicity (DLT), where DLT is 
defined as: submandibular pain > 5 on a standard 10-point 
pain scale of 0-10 at 1-month after MSC injection OR any 
serious AE OR any of the selected toxicities listed in 
section 9.7 within one-month post-injection. 
Secondary 

 
 
 
 
 
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• 
To evaluate the efficacy of MSCs for 
treatment of xerostomia and salivary 
hypofunction. 
• 
Salivary function and subjective dry mouth, determined 
by mean overall and individual salivary amounts, 
compositional analysis, and QoL xerostomia survey 
scores at 1, 3, 6, 12, and 24 months. 
• 
To assess the imaging characteristics 
of submandibular gland after MSC 
injection. 
• 
Shear wave velocity with acoustic radiation force 
impulse, measured by ultrasound (US) of 
submandibular glands at 3, 6, and 12 months.  
• 
To assess the feasibility of a future 
Phase 1 dose-escalation study. 
• 
Feasibility for a future Phase 1 dose-escalation study 
will be based on drop-out rate. 
 
7.0 
STUDY DESIGN 
 General Design  
This single-center, open-label, non-randomized, non-placebo controlled, single-group assignment, 
pilot study is designed to determine the safety and tolerability of autologous bone marrow-derived 
MSCs in patients with xerostomia after undergoing radiation therapy for HNC. A total of 6- subjects 
will be enrolled at UW-Madison for unilateral gland injection (dose level 0). Subject accrual will occur 
over 0.5 years with the total duration of the trial expected to be approximately 2.5 years.  
 
Following the completion of screening/baseline procedures, and written consent, eligible subjects will 
undergo bone marrow aspirate in order to obtain MSCs. MSCs will be prepared as described in 
Section 9.2.  
 
The MSC IMP (dose level 0) will be injected into one submandibular gland under local anesthesia, in 
the gland that received the lowest radiation dose. Patients with only one submandibular gland will be 
ineligible. All subjects will be called by a study coordinator 3 days (+/- 2 days) after injection to 
assess pain and will have a phone visit  with a physician 1 week (+/- 2 days) after injection during 
which the investigator will assess pain and ask about the area of injection regarding redness and/or 
swelling. All subjects will complete a pain diary with daily entries over the first month to record the 
occurrence and severity of pain using a 0-10 visual analog scale and occurrence and severity of 
other adverse events (e.g., redness, swelling, warmth, tenderness, rash, pruritis, nausea, vomiting, 
fatigue). Patients will also keep a log of all pain medications taken including both narcotic and non-
narcotic medications (e.g. ibuprofen, acetaminophen, etc.) for the first month. Subjects will complete 
5 follow-up visits over the course of 24 months – at 1, 3, 6, 12, and 24 months following the 
intervention. Salivary collection for analysis as well as QoL surveys will be obtained at these visits.  
 
Additional Gland Injection: The 6 subjects will be offered optional contralateral submandibular 
gland MSC injection at dose level 0 upon completion. The primary objective (1 month of follow-up 
after injection of MSCs) without any DLTs has now occurred.       
 
Subjects will also be offered injection of MSCs into the contralateral submandibular gland upon 
completion of the trial’s primary objective (1 month of follow-up after injection of MSCs without any 
DLTs). The MSC IMP (dose level 0, from previously obtained bone marrow aspirate and culture) will 
be injected into the contralateral submandibular gland under local anesthesia. Secondary objectives 
will remain unchanged. Each subject will undergo salivary collection and completion of QoL forms 
just prior to second injection of MSC IMP. All subjects will complete follow up timepoints per the main 
study at 12 months (+/- 3 months) post second injection to analyze the benefit of the second injection 
by assessing secondary objectives including salivary amount and salivary QoL. This 12 month 
timepoint will allow for assement of durable improvement, while not prolonging the overall study 
duration. Additionally, subjects will be monitored for AEs post-injection. All subjects will be called by a 

 
 
 
 
 
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study coordinator or physican 3 days (+/- 2 days) and 7 days (+/- 2 days) after injection to assess 
pain, redness, or other AEs. Subjects will also be seen 30 days (+/- 10 days), 90 days (+/- 14 days), 
6 months  (+/- 28 days), 12 months (+/- 3 months) and 24 months (+/- 3 months)  
after second MSC injection for safety evaluation and blood collection to assess for AEs.  
 End of Study Definition 
A subject is considered to have completed the study if they have completed all visits described in the 
study including the last visit listed in Section 10.1: Study Calendar. 
8.0 
SUBJECT SELECTION 
 Inclusion & Exclusion Criteria   
Eligibility will be determined by inclusion and exclusion criteria below and confirmed by medical 
record review as necessary. 
 
Inclusion Criteria  
1. Willing to provide informed consent. 
2. Willing to comply with all study procedures and be available for the duration of the study. 
3. Histological diagnosis of HNC and ≥ 2 years from completion of radiation treatment for HNC 
(±surgery, ±chemotherapy), either clinically or radiologically NED, as assessed by ENT or 
Radiation Oncologist within 28 days of study registration 
4. Individuals at least 18 years of age and no older than 90 years of age. 
5. Xerostomia defined as ≤ 80% of baseline (pre-radiation) salivary function per patient estimate  
6. Karnofsky performance status ≥ 70, patient eligible for bone marrow aspirate with wakeful 
anesthesia. 
7. Radiographically confirmed bilateral submandibular glands 
8. Females of childbearing potential must agree to have a negative urine or serum pregnancy test 
within 7 days prior to bone marrow biopsy. A female of child-bearing potential is any woman 
(regardless of sexual orientation, having undergone a tubal ligation, or remaining celibate by 
choice) who meets the following criteria: 
• 
Has not undergone a hysterectomy or bilateral oophorectomy; or 
• 
Has not been naturally postmenopausal for at least 12 consecutive months (i.e., has had 
menses at any time in the preceding 12 consecutive months). 
9. Women of childbearing potential in sexual relationships with men must have used an 
acceptable method of contraception§ for 30 days prior to study registration and agree to use an 
acceptable method of contraception§ until 4 weeks after completing study treatment. Males 
must agree to avoid impregnation of women during and for four weeks after completing study 
treatment through use of an acceptable method of contraception. 
§Note: Includes, but is not limited to, barrier with additional spermicidal foam or jelly, 
intrauterine device, hormonal contraception (started at least 30 days prior to study enrollment), 
intercourse with men who underwent vasectomy. 
10. Laboratory values: 
Hgb   ≥ 9 g/dL (5.58 mmol/L)  
Platelets  ≥ 100,000/µL 
ANC ≥ 1000/µL 
PT/INR and PTT within normal limits based on age/sex 
Serum creatinine within normal limits based on age/sex 
 
Exclusion Criteria 
1. History of sialolithiasis  

 
 
 
 
 
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2. Patients with one submandibular gland 
3. History of autoimmune diseases affecting salivary glands, including Sjögren’s syndrome, lupus, 
scleroderma, type I diabetes, sarcoidosis, and amyloidosis 
4. Chronic graft versus host disease 
5. Untreated oral candidiasis  
6. Use of anti-cholinergic medications (e.g. atropine, iptratropium, oxybutynin, scopolamine, 
solifenacin, tiotropium, etc…) while enrolled on study 
7. Malignancy within the past 2 years, except adequately treated stage I lung cancer, low risk 
prostate cancer that has been treated or is undergoing active surveillance, adequately treated 
non-melanoma skin cancer, adequately treated DCIS, or adequately treated stage I cervical 
cancer 
8. Expected life expectancy < 6 months. 
9. Lidocaine allergy  
10. Use of investigational drugs, biologics, or devices within 30 days prior to enrollment. 
11. Women who are pregnant, lactating or planning on becoming pregnant during the study.   
12. Not suitable for study participation due to other reasons at the discretion of the investigators. 
 Study Populations 
Individuals from populations who are under-represented in clinical research (e.g., racial and ethnic 
minorities, women,  individuals from rural/frontier communities, older individuals) will be enrolled with 
a goal of ensuring that all eligible patients are given the opportunity to participate in novel clinical 
trials and that research findings can be generalizable to the entire population. 
 
Pregnant women, those who lack consent capacity, the mentally ill, prisoners, cognitively impaired 
persons, children, and employees will not be included in this research study. 
 Lifestyle Considerations 
During this study, subjects are asked to: 
• 
Refrain from consumption of any food, beverages, gum, saliva substitutes, or smoking for 1 hour 
prior to each salivary collection. Patients will be called the day prior to study visits to remind them 
about these restrictions. 
 Subject Identification 
Identification in Clinical Practice 
Potential subjects may be identified during routine visits to Radiation Oncology and Otolarygology 
clinics. A member of the clinical team will inform potential subjects of the research opportunity and 
explain the study. Potential subjects will be pre-screened through medical record review. Information 
collected from potential subjects who are not enrolled will be destroyed. Potential subjects who meet 
all pre-screening criteria will be invited for a formal consent and baseline visit. If the potential subject 
is interested in learning more, an IRB approved consent will be provided and discussed with the 
potential subject.   
Self Identification 
Potential subjects may self-identify as potential subjects after reading online information about the 
study (clinical trials.gov). Potential subjects who self-identified and contact the UWCCC be referred to 
a member of the clinical trials team. The clinical team member will further discuss the research 
opportunity and complete a pre-screening. Potential subjects who meet all pre-screening criteria will 
be invited for a formal consent and baseline visit.  If the potential subject is interested in learning 
more, an IRB approved consent will be provided and discussed with the potential subject.   

 
 
 
 
 
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15
Electronic Medical Record Query 
Potential subjects may also be identified via EMR query using diagnostic codes for head and neck 
cancer and radiation therapy and other eligibility criteria. The research team will conduct further 
prescreening of individual records to further refine the list of potential subjects.  
Department Database 
The head and neck cancer database (HS IRB #2015-1216), described under a separate protocol 
may be used to identify eligible subjects. 
 Subject Recruitment 
A total of 6 subjects with bilateral submandibular glands for unilateral gland injection will be recruited 
from UW-Madison. Potential subjects will be recruited from clinical practice at UWCCC. If the 
potential subject is agreeable, they will be provided contact information for the study team or the 
research team will initiate contact. 
 Remuneration and Retention Strategies 
Many visits will occur in concert with standard of care followup visits for patients. Patients will be 
contacted 2 weeks prior to each visit to be reminded of the upcoming appointment and the next 
appointment will be made before the patient leaves the clinic. 
 Early Termination and Withdrawal 
Subjects are free to withdraw from participation in the study at any time upon request. 
 
The Principal Investigator (PI) may discontinue or withdraw a subject from the study for the following 
reasons at his/her discretion: 
• 
Pregnancy 
• 
Subject non-compliance with study requirements (e.g., study intervention non-compliance)  
• 
If any clinical adverse event (AE), laboratory abnormality, or other medical condition or situation 
occurs such that continued participation in the study would not be in the best interest of the 
subject 
• 
If the subject is no longer an appropriate candidate for participation   
• 
There is evidence of progressive disease or unacceptable toxicity 
• 
Subject unable to receive MSC injection, either due to subject choice or investigator decision 
based on MSC release guidelines 
 
Subjects who sign the informed consent form but do not receive the the MSC injections will be 
replaced. Subjects who sign the informed consent form and receive the the MSC injections, then 
subsequently withdraw, or are withdrawn or discontinued from the study, will not be replaced. 
 
The following actions will be taken if a subject withdraws, or fails to return for a required study visit: 
• 
The site will attempt to contact the subject and reschedule the missed visit within 2 weeks and 
counsel the subject on the importance of maintaining the assigned visit schedule and ascertain if 
the subject wishes to and/or should continue in the study. 
• 
Before a subject is deemed lost to follow-up, the investigator or designee will make every effort to 
regain contact with the subject where possible, 3 telephone calls and, if necessary, a certified 
letter to the subject’s last known mailing address. These contact attempts shall be documented in 
the subject’s study file.  
• 
If the subject continues to be unreachable, they will be considered to be lost to follow-up.  
 

 
 
 
 
 
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16
If a subject is prematurely withdrawn from the study for any reason, the investigator will under all 
circumstances try to perform all evaluations described for the early termination visit 
9.0 
STUDY TREATMENT  
 Description of the Investigational Medicinal Product (IMP) 
Drug Substance: 
Autologous bone marrow-derived MSCs at a concentration of 10x106 cells/mL 
Drug Product (IMP): 
Suspension of autologous bone marrow-derived MSCs suspended in a solution of Plasmalyte A 
containing 0.5% human serum albumin. Cells will be administered at one dose level, Dose 0, with a 
possible lower dose if the DLT criterion is reached. For each cell dosage we have set a 20% 
acceptable deviation. Dose levels and acceptable ranges (in parentheses) are as follows: 
• 
Dose -1: 5 (4 – 6) x106 MSCs (into one submandibular gland; to be used only if Dose level 0 is 
not tolerated)  
• 
Dose 0: 10 (8 – 12) x 106 MSCs (into one submandibular gland) 
If the MSC IMP is not administered to the patient due to a failure of the MSCs to expand to achieve 
the required dose/ or the MSC IMP does not pass QA testing, the subject will be withdrawn from 
study, and  followed for 1 month post the aspiration procedure to ensure AE/SAEs are appropriately 
recorded. These subjects will be replaced in the study by the recruitment of another subject.  
Route of administration: injection into one submandibular gland (must have 2 glands present). The 
gland selected will be the gland that received the lower radiation dose. The contralateral gland of 
each interested subject will be injected with autologous MSC IMP at Dose level 0 following 
completion of the primary objective with no DLTs reported.  
 Preparation of the IMP 
Up to 30 cc of bone marrow will be aspirated from the posterior superior iliac crest of each subject 
under aseptic conditions and local anesthesia by a qualified UW medical personnel. The bone 
marrow aspirate will then be hand delivered to the UW PACT GMP Cell Manufacturing Facility. UW 
PACT staff member will document receipt of the bone marrow aspirate and commence the 
processing according to the standard operating procedure. Mononuclear cells (MNCs) will be isolated 
by using Ficoll-Paque PREMIUM 1.073 g/mL medium (GE Healthcare) and density gradient 
centrifugation. Cells will be washed in CTSTM DPBS (GIBCO®) and re-suspended in culture medium 
supplemented with Gentamicin, USP at 5 µg/mL. The culture medium will consist of MSC NutriStem® 
XF Medium (Biological Industries), 5% PLTMax® human platelet lysate (Mill Creek Life Sciences), 
1% CTSTM GlutaMAXTM I (GIBCO®), and Heparin Sodium, USP at 2 U/mL. The MNCs will then be 
placed into tissue culture flasks at 100,000 – 200,000 cells/cm2 density. After 72 hours in 5% 
CO2/37˚C humidified incubator, culture medium will be aspirated, non-adherent cells will be washed 
off with CTSTM DPBS (GIBCO®). Adherent cells will be returned into the incubator with fresh culture 
medium for additional 4-7 days. MSCs will be harvested using CTSTM TrypLETM Select Enzyme 
(GIBCO®) and re-seeded into tissue culture flasks at 3,000 cells/cm2 density for further expansion. 
Cells will reach approximately 70% confluence after 3 days in culture. Additional passage may be 
necessary in order to generate clinically relevant number of MSCs. Once desired number of cells and 
confluence is achieved, MSCs will be subjected to cytokine licensing by replacing spent medium with 
fresh culture medium supplemented with recombinant human IFN-gamma GMP Protein (R&D 

 
 
 
 
 
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17
Systems) at 1200 IU/mL. One flask will receive no IFN-gamma and serve a negative control. MSCs 
will augment their immunomodulatory properties after 24 hours of exposure to IFN-gamma. 
Stimulated MSCs will be analyzed via flow cytometry for upregulation of PD-L1, MHC I, MHC II, IDO, 
and Icam markers, which are indicative of the immunosuppressive phenotype. In addition, cell 
identity will be confirmed using Miltenyi Biotec MSC Phenotyping Kit. MSCs will be expected to stain 
positive for CD73, CD90, CD105 and negative for CD14, CD19, CD34, CD45 markers. IFN-gamma 
stimulated MSCs will then be cryopreserved at 5,000 cells/mL in 20% Plasma-Lyte A (Baxter), 20% 
Human Serum Albumin (FLEXBUMIN, Shire), 10% dimethyl sulfoxid (CryoMACS® DMSO Miltenyi 
Biotec). Cryovials will be stored in a vapor phase of LN2 storage dewar within UW PACT GMP Cell 
Manufacturing Facility. In preparation for injection, vials will be thawed using ThawSTAR automated 
cell thawing system (BioLife Solutions). Cells will be washed twice in the MSC culture medium and 
seeded into flasks at 25,000 cells/cm2 for 16 hours of culture-rescue, at which point cells have been 
shown to fully restore their immunomodulatory properties. MSCs will be harvested and re-suspended 
at 10 x 106 cells/mL in Plasma-Lyte A containing 0.5% human serum albumin. The suspension is 
then transferred into appropriately sized syringe. One milliliter of the suspension will be dispensed for 
the quality control testing. If the remaining volume in the syringe exceeds the pre-determined cell 
dose, the surplus will be allocated to the retention sample. The IMP will be released upon meeting 
the following specifications: viability >70%, endotoxin < 5 EU/mL, stat gram stain negative, dose level 
within 20% deviation of the target dose. Mycoplasma test results and 14 day sterility culture results 
will not be available on the day of injection.  
 Packaging, Labeling and Storage of the IMP 
Packaging  
The autologous bone marrow-derived IFN-gamma stimulated MSC product will be delivered in a 10 
mL Becton Dickinson Luer-Lok™ Syringe(s) sterile, single use (Product Number 302995). This 
product is sourced from hospital inventory and deployed within the University of Wisconsin Hospital 
and Clinics.  
Labeling 
Labeling of IMP is compliant with FDA regulations and includes the patient’s unique identifiers 
(medical record number, date of birth), product name, batch number, date and time of manufacture, 
expiration date and time, identification of the processing lab.  
Storage 
The IMP is intended for direct administration after preparation. The IMP containing autologous bone 
marrow-derived MSCs re-suspended at a concentration of 10x106 cells/mL  in a solution of Plasma-
Lyte A containing 0.5% human serum albumin has been shown to maintain viability >70% for 24 
hours at room temperature.  However, to maintain highest viability the product will be injected as 
soon as clinically possible. Until injection, the IMP will be stored at room temperature. 
Packaging, labeling and storage of the IMP will follow UW PACT SOPs developed and qualified 
according to cGMP standards.  
 Transport of IMP 
The IMP will be transported from the GMP Cell Manufacturing Facility to the clinical site (ENT clinic) 
in a qualified temperature controlled cooler at 20-25˚C according to the UW PACT SOP.  
 IMP Accountability 
The PI is responsible for maintaining accurate accountability records throughout the study. The 
administration of the IMP will be documented in the patient’s medical file in a procedure note. 

 
 
 
 
 
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 Retention samples, if available, will be cryopreserved and stored in a vapor phase of LN2 
storage dewar within the GMP Cell Manufacturing Facility. Retention samples will be kept 
for a minimum of 2 years. Retention samples may then be discarded according to 
applicable regulations for disposal of biological products. The PACT GMP Cell 
Manufaucturing facility has assessed each patient’s MSC IMP to ensure the cryopreserved 
product is stable and appropriate for second injection (See Appendix 19.4 for stability 
data). The MSC IMP administered for the second injection will undergo the same quality 
control testing detailed in section 9.2 prior to injection. Administration of IMP 
MSCs will be supplied in one single use 10 mL Becton Dickinson Luer-Lok™ Syringe sterile, single 
use (Product Number 302995) at the pre-specified dosage levels for each gland to be injected. No 
preparation is required. Administeration by Dr. Glazer will occur as follows: 
• 
Subjects will be placed in a semi-recumbent position 
• 
Injection of 2mL of 1% lidocaine with 1:100,000 epinephrine into the  submandibular gland area. 
• 
Visually inspect the syringe for particulate matter and/or discoloration prior to administration. If 
either of these conditions exist, do not administer 
• 
Gently shake the prefilled syringe  
• 
Identify each submandibular gland with US and cleanse the injection site with chlorhexidine. 
• 
Insert 22 G x 1 ½” needle (Becton Dickinson’s Precisionglide™ hypodermic needle [Product 
Number 305194]) at a 90-degree angle to the skin and inject all of the contents of 1 syringe into a 
submandibular gland under US guidance at a rate of ≤2 mL/min. This rate and needle gauge was 
chosen in part, due to the work published by Mamidi and colleagues, demonstrating that 
repeatedly passing mesenchymal stem cells (MSC) through substantially smaller gauge needles 
(24, 25, and 26G) has no impact on MSC morphology, attachment, viability, phenotype, 
differentiation potential, and in vivo migration abilities30. Do not inject the IMP subcutaneously or 
intravenously. Care should be taken to avoid administering the injection into or near blood 
vessels and nerves.  
o Ultrasound guidance will be used to 1) ensure intraglandular (sub-capsular) injection 
into the submandibular gland and, 2) avoid intravascular injection into branches of 
facial and lingual vessels.  
• 
Monitor the subject for at least 30 minutes post administration. 
 Dose-Reduction Schedule 
The cohort of 6 participants will have staggered enrollment. A minimum interval of 14 days will occur 
between MSC injection of a subject and MSC injection in the subsequent subject, during which time 
there must be no SAEs and no AEs ≥ grade 3 that are probably or definitely attributable to MSC 
injection. The decision to proceed with enrollment of a subsequent subject within a dose cohort will 
be made by the PI based on the criteria stated above.    
For purposes of possible dose reduction from Dose 0 to Dose -1, dose limiting toxicity is defined as a 
submandibular pain score > 5 (on a standard 0-10 pain scle) at one-month post-injection OR any 
serious AE probably or definitely caused by study treatment at any time within one-month post-
injection OR any of the toxicities below within 1 month of injection: 
• 
Grade 4 neutropenia > 5 days 
• 
Grade 4 thrombocytopenia, or grade 3 thrombocytopenia with hemorrhage 
• 
Grade 3-4 non-hematological toxicity except: 
- 
Grade 3 nausea, vomiting, and diarrhea lasting < 72 hrs in the absence of maximal 
medical therapy 
- 
Grade 4 vomiting and diarrhea lasting < 72 hrs in the absence of maximal medical 
therapy 
- 
Grade 3 fatigue < 5 days 
- 
Grade 3 hypertension in the absence of maximal medical therapy 

 
 
 
 
 
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- 
Grade 3 rash < 5 days is included as an exception 
- 
Grade 3 metabolic abnormalities such as hypokalemia, hypomagnesemia, 
hypocalcemia, and hypophosphatemia should only be excepted from the DLT 
definition if they recover to Grade 1 or less within 48 hours. 
- 
Grade 3 fatigue that persists < 7 days. 
- 
Grade 3 rash that resolves to ≤ Grade 1 within 3 weeks.  
- 
Grade 3 or 4 elevation in serum amylase and/or lipase that are not associated with 
clinical or radiographic evidence of pancreatitis. 
- 
≥ Grade 3 electrolyte abnormality that lasts < 72 hours, is not clinically 
complicated, and resolves spontaneously or responds to conventional medical 
intervention.  
- 
Grade 3 nausea or vomiting that lasts < 48 hours, and resolves to ≤ Grade 1 either 
spontaneously or with conventional medical intervention. 
- 
Grade 3 immune related AE (irAE) that resolves to ≤ Grade 1 or to baseline with 
immunosuppressive therapy within 3 weeks. 
 
Additionally, patient enrollment and treatment will be temporarily halted if any of the following occur, 
pending review by the UWCCC DSMC  and FDA if: 
• 
Any death, irrespective of attribution by the investigator within 30 days of MSC injection 
• 
Any (CTCAE v. 5) of grade 4 or higher 
• 
Any hypersensitivity reaction grade 3 or higher at any time 
• 
Any grade 3 SAE in the first 3 subjects 
• 
Any 2 grade 3 or higher of the same SAE at any time during the study 
• 
5 or more grade 3 or higher SAEs that are at least possibly related at any time during the 
study 
 
Dose reduction schedule: 
Dose level 0 (10 x 106 MSCs into one submandibular gland) given to 6 patients: 
- 
If 0 or 1/6 patients experience DLT at dose level 0, then the dose escalation portion of a 
subsequent planned study will begin at dose level 0 (10 (8-12) x 106 MSCs into both 
submandibular glands) and the study will be completed.  
- 
If 2/6 patients experience DLT at dose level 0, then decrease dose to dose level -1 (5 x 106 
MSCs) and continue with unilateral injection at dose level -1. 
 
If needed, Dose level -1 (5 x 106 MSCs) given to 3 patients 
- 
If 0/3 or 1/3 patients experience DLT at this dose level 1 then recruit additional 3 patients at 
this dose. 
o If 2/3 patients experience DLT, then treatment is considered not tolerable and the 
study will be halted. 
- 
If 0/6 or 1/6 patients experience DLT at this dose level, then the dose escalation portion of a 
subsequent planned study will begin at dose level -1 (5 (4-6) x 106 MSCs into both 
submandibular glands).  
o If 2/6 patients experience DLT, then treatment is considered not tolerable and the 
study will be halted. 
 
Part 1 Dose-Reduction Table. 
Dose Level 
MSC IMP 
-1 
5 (4-6) x 106 injected into one submandibular gland on Day 1 
0 
10 (8-12) x 106 injected into one submandibular gland on Day 1 
 

 
 
 
 
 
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 Supportive Care 
Optimal patient care is to be given to all subjects. The subjects will be followed by their head and 
neck oncology team and dentist during the study. 
 
Pain: 
Pain should be managed with over-the-counter analgesics if possible. Recommend scheduling 
acetaminophen 650 mg q 6 hours (maximum < 4,000 mg) or ibuprofen 400 mg q 6 hours (if no 
contraindications such as decreased renal function). Should pain persist at level 6/10 or greater, 
opioid pain medications may be prescribed.   
 
Swelling: 
Subjects with treatment-related swelling should first try supportive measures such as cold packs and 
ibuprofen 400 mg q 6 hours (if no contraindications such as decreased renal function). Should the 
swelling persist, subjects should present to UW clinic for evaluation by medical provider.  
 Dose Delays/Modifications 
Not applicable to this single administration protocol.  
 
Study Procedural Intervention(s) Description  
Pre-Intervention Bone Marrow Biopsy for MSC Collection 
Each subject will undergo a bone marrow (BM) aspirate in order to obtain MSCs. Subjects will 
undergo BM aspiration for the collection of approximately 30 mL of BM aspirate in the UW Oncology 
Clinic by an experienced practitioner. Female subjects will have a urine pregnancy test which must 
be negative to participate. An IV will be placed for conscious sedation, if needed, and for blood 
collection following the aspiration procedure. If conscious sedation is chosen by the patient, IV 
sedative will be administered by a trained nurse who will monitor the subject throughout the 
procedure and recovery from sedation. For the BM collection procedure, the subject will be placed in 
a prone or side-lying position and the area over iliac crest will be anesthetized with a local anesthetic.  
The skin will be scrubbed with chlorhexadine and draped with sterile towels/drapes. Using sterile 
technique, the physician will insert a harvesting needle and aspirate BM into  2-4 10cc syringes, 
previously rinsed with 3000 units of heparin, collecting 5-10 ml at a time.  After the first syringe is 
aspirated, the beveled needle may be turned 90 degree for three more turns and the aspiration 
repeated after each turn.  Each syringe filled with bone marrow will be injected into a tube that has 
been prepared with Na Heparin. The collection tube will be labeled with a unique hMSC bank ID 
number. When all BM has been collected the harvesting needle will be removed and a dressing will 
be placed over the aspiration site. If subjects have received intravenous (IV) sedation, they will be 
observed for at least 1 hour or until fully recovered. In addition, subjects will receive a phone call from 
the research study coordinator within 3 +/- 2 days to review any potential side effects that might be 
attributable to the bone marrow aspiration.  
 
 
MSC IMP Administration 
The injection of the MSC IMP into the subject’s submandibular gland(s) will be done by an 
experienced Otolaryngology physician under ultrasound guidance in the ENT clinic. Should one 
submandibular gland be surgically absent, then MSCs will be injected into only the present gland.  
(Note that patients with only one submandibular gland may not enroll in Part 1, dose level 0). 
Subjects will be in a semi-recumbent position and the skin over the submandibular gland(s) will be 
cleansed with chlorhexidine. The area over the submandibular gland will be anesthetized with an 
injection of 2 mL of 1% lidocaine with 1:100,000 epinephrine. Using sterile technique with US 

 
 
 
 
 
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21
guidance to ensure avoidance of intravascular injection into branches of the facial and lingual 
vessels, the submandibular glands will be injected with 0.5-2 mL of MSCs (depending on dosing 
level) via a 22 gauge, 1 ½ inch needle. The needle will then be removed and a dressing will be 
placed over the site.  
 
 
Method for Assigning to Treatment Groups 
Enrollment will be on a rolling basis per DLT schedule. Patients with only one submandibular gland 
will not be enrolled into this pilot trial. 
 
Unblinding Procedures 
Not applicable. 
 
Study Intervention Compliance 
Pain diary for the first 1 month and QoL surveys, salivary analysis, and submandibular gland US for 
follow-up visits at 1, 3, 6, 12, and 24 months. 
 
Concomitant Therapy 
Permitted Concomitant Therapy 
Any supportive care will be allowed as concomitant therapy including, but not limited to, salivary 
substitutes and stimulatory agents. During the screening and all follow-up visits, data on the use of 
concomitant therapies will be collected. These therapies may affect the study endpoints, as they may 
improve QoL or other study measures. However, as subjects will likely have been previously using 
this, stopping the medications would likely bias the results. Gathering information on the therapies 
they are using prior to the intervention will allow us to analyze the possible effects the concomitant 
therapies may have on our endpoints.  
 
Patients without chronic pain will be instructed to refrain from narcotic pain medication for 3 days 
prior to their scheduled pain assessment. Patients with chronic pain will be instructed not to increase 
their baseline narcotic pain medication for 3 days prior to scheduled pain assessment.    
 
Prohibited Concomitant Therapy 
None 
 
 
 

 
 
 
 
 
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10.0 
STUDY VISITS AND PROCEDURES 
 
Study Calendar 
The procedures performed at each study visit are listed in the table below. 
 
Procedure/Visit 
Screening 
Baseline 
Obtain MSCs,2 
MSC IMP Injection 
3-day phone call,9 
1-week phone 
call,9 
Follow-up visit 
1-month 
3-month   
6-month   
12-month   
24-month  
Visit window 
Day 
± days 
 
- 42 
± 14 
 
- 42 
± 14  
 
- 28 
± 14  
 
0 
 
3 
± 2 
 
7 
± 2 
 
30 
± 10  
 
90 
± 14  
 
180 
± 21  
 
365 
± 21  
 
730 
± 28 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
Review Eligibility Criteria 
X 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
Review Concomitant 
Medications 
X 
 
 
 
X 
X 
X 
X 
X 
X 
X 
Dental Evaluation5 
 
X 
 
 
 
 
 
 
 
 
 
Obtain Medical History 
 
X 
 
 
 
 
 
 
 
 
 
Physical Exam 
 
X 
 
 
 
 
X 
X 
X 
X 
X 
Vital Signs1 
 
X 
 
X3 
 
 
X 
 
 
 
 
Bone Marrow Aspiration  
 
 
X 
 
 
 
 
 
 
 
 
MSC IMP Injection 
 
 
 
X 
 
 
 
 
 
 
 
AE Assessment Including 
Pain 
 
 
X 
X4 
X 
 
X 
X 
X 
X 
X 
X 
Assessment of QoL, 
Salivary Collection 
 
X 
 
 
 
 
X 
X 
X 
X 
X 
Ultrasound of Salivary 
Glands 
 
X 
 
 
 
 
 
X 
X 
X 
 
Collection of Pain Diary6 
 
 
 
 
 
 
X 
 
 
 
 
Blood (for banking) 
 
X 
 
 
 
 
X 
X 
X 
X 
X 
Complete blood count, 
PT/INR and PTT, 
Creatinine 
 
X 
 
 
 
 
X8 
X8 
 
 
 
Pregnancy test (urine or 
serum) 
 
 
X7 
X7 
 
 
 
 
 
 
 
1 – Vitals include body weight, pulse rate, body temperature, blood pressure, and respiration rate. Height 
collected only at baseline. 
2 – Subjects will be contacted via phone 3 days +/- 2 days post bone marrow aspiration to assess for 
toxicities from aspiration by study coordinator 
3 – Vitals to be obtained pre injection and 30 minutes +/- 10 minutes post injection. Weight only obtained 
pre injection. 
4 – Subjects will be asked to verbally rate their pain 30 minutes post MSC administration. 
5 – Dental examination with x-rays within 6 months of enrollment by patient report 
6 – Patients without chronic pain will be instructed to refrain from narcotic pain medication for 3 days prior 
to their scheduled pain assessment. Patients with chronic pain will be instructed not to increase their 
baseline narcotic pain medication for 3 days prior to scheduled pain assessment.  

 
 
 
 
 
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7—Within 7 days prior to MSC collection and confirmation of appropriate contraception prior to injection. 
8—CBC only during follow up 
9-Subjects will be contacted via phone 3 days (+/- 2 days ) and 7 days +/- 2 days post MSC IMP Injection 
to assess for toxicities from injection by study coordinator or physician.  
 
Sub study calendar 
 
Informed 
Consent 
Screen/Injection 
of MSC’s 
Phone 
call (3 
days 
+/- 2 
days)1 
Phone 
call (7 
days 
+/- 2 
days)1 
30 day 
visit 
(+/-10 
days) 
90 
days 
(+/- 
14 
days 
6 
months 
(+/- 28 
days) 
12 
months 
(+/- 3 
months 
24 
months 
(+/- 3 
months 
Review 
Eligibility 
Criteria 
x 
 
 
 
 
 
 
 
Review 
Concomitant 
Medications 
x 
 
 
 
 
 
 
 
Vital Signs2 
x 
 
 
 
 
 
 
 
Physical 
X 
 
 
X 
X 
X 
X 
X 
MSC IMP 
Injection 
(contralateral 
neck) 
X 
 
 
 
 
 
 
 
AE Assessment 
Including Pain 
X3 
X 
X 
X 
X 
X 
X 
X 
Assessment of 
QoL, Salivary 
Collection 
X 
 
 
X 
X 
X 
X 
 
Collection of 
Pain Diary 
 
 
 
X 
 
 
 
 
Complete blood 
count  
X 
 
 
X4 
X4 
 
 
 
 
1Subjects will be contacted via phone 3 and 7 days +/- 2 days post MSC IMP Injection to assess for 
toxicities from injection by study coordinator or physician  
2Vitals to be obtained pre injection and 30 minutes +/- 10 minutes post injection. Weight only obtained 
pre injection. 
3 – Subjects will be asked to verbally rate their pain 30 minutes post MSC administration. Patients without 
chronic pain will be instructed to refrain from narcotic pain medication for 3 days prior to their 
scheduled pain assessment. Patients with chronic pain will be instructed not to increase their 
baseline narcotic pain medication for 3 days prior to scheduled pain assessment 
 
4CBC only during follow up 
 
 
Screening and Enrollment 
The Screening and study visits and procedures are described in detail below. 
Informed Consent 
The informed consent process will be conducted following all federal and institutional regulations 
relating to informed consent. Informed consent will be obtained prior to conducting any research-
related activities. 
 
The informed consent process will be performed as follows: 

 
 
 
 
 
Protocol Version 8, 9/28//2023 
 
 
24
• 
The research coordinator will review the informed consent form and discuss the study in detail 
with the potential research subject. 
• 
The research coordinator will explain the study, its risks and benefits, what would be required of 
the research subject, and alternatives to participation. 
• 
The research subject will be given the opportunity to take the informed consent form home so that 
they may discuss it with family members, friends, clergy or others when possible.   
• 
The subject will have the opportunity to ask questions and have all questions answered by the 
The research coordinator and/or PI. 
• 
The informed consent document must be signed and dated by the research subject and by the 
study team member performing consent procedures. 
• 
The research coordinator will review the informed consent document to ensure that all fields that 
require a response are complete (i.e., checkbox marked yes or no, etc.) as applicable. 
• 
The research subject will be given a copy of the signed and dated informed consent form.  
 
Alternatively remote consenting may occur as described below: 
• 
The participant must receive a copy of the ICF (e.g., in person, via mail, fax, email, or a Part 
11 compliant manner will be used to document consent) in advance of discussion. 
• 
The study coordinator discusses the study with the potential participant via telephone or video 
conferencing. 
• 
The study coordinator must implement a method to ensure the identity of the participant (e.g., 
verification of state identification or other identifying documents or use of personal questions 
such as date of birth or spell first and last name). 
• 
If the potential participant agrees to participation, they must sign and date the ICF and return 
it to the study coordinator via email using a scanner or taking a picture of the signature page 
or using a Part 11 compliant manner to document consent. 
• 
The study coordinator will document the receipt of the signed ICF and the informed consent 
process in the Electronic Medical Record (Healthlink). 
• 
The study coordinator must then email HIS-ScanningCorrec@uwhealth.org a PDF of the 
participant’s signed ICF to be uploaded in Healthlink. As soon as the consent note is written in 
Healthlink and consent form has been emailed for scanning, screening procedures may 
begin. 
• 
No additional signatures are required. 
Enrollment/Registration 
A research subject will be defined as “enrolled” in the study when they meet the following criteria: 
• 
The subject has been consented by study staff.  
• 
The subject has completed all screening procedures. 
• 
The PI has verified subject eligibility by reviewing inclusion and exclusion criteria 
• 
The subject has been enrolled by the protocol staff in the UWCCC ONCORE database. 
The following information will be recorded: 
o Protocol number 
o Patient’s name and initials 
o Patient’s medical record number 
o Patient demographic data 
Screening  
• 
Information from SOC clinic visits may be used if within study window. No research only procedures 
will occur prior to obtaining written informed consent.  
• 
All screening procedures must be performed prior to study enrollment/registration.  
• 
Record data on disease characteristics (e.g., site, stage) and treatment characteristics (e.g., 
radiation dose distributions) 

 
 
 
 
 
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25
• 
Review current medications being taken (SOC) 
• 
Obtain written informed consent 
 
On-Study/Follow-up Visits 
After subjects have been enrolled, the On-Study/Follow-up visit and the procedures performed at 
each visit are described in detail below. 
Baseline (may occur over 1-2 visits) 
• 
Physical exam including weight and height and med history (SOC) 
• 
Vital signs (SOC) 
• 
Ensure patient has undergone dental evaluation with radiographs to exclude dental/oral 
diseases that could cause treatable xerostomia within 6 months of enrollment  
• Salivary collection (research) 
• QoL assessment (research) 
• Collection of blood sample for banking purposes (research) 
• US of salivary glands (research) 
• Review of RT DICOM file of head and neck radiation plan (research) 
• Complete blood count  PT/INR, PTT and creatinine (research) 
 
Bone Marrow Aspiration for MSC Collection  
• Bone marrow aspiration 
MSC IMP Administration  
• Review current medications being taken 
• Vital signs  
• MSC injection (see section 9.6)  
• Patients without chronic pain will be instructed to refrain from narcotic pain medication for 3 days 
prior to their scheduled pain assessment. Patients with chronic pain will be instructed not to 
increase their baseline narcotic pain medication for 3 days prior to scheduled pain assessment. 
 
Assessments after MSC IMP administration 
• Acute toxicity: vital signs (pre and 30 minutes +/- 10 minutes post) and visual inspection of 
injection site after the administration of IMP: 30 minutes post-injection and monitoring of adverse 
events possibly related to acute toxicity including verbal pain assessment. 
Three Day Telephone Call  (3 days + 2 days) 
• Adverse event assessment 
One Week Telephone Call  (7 days + 2 days) 
• Adverse event assessment 
• Obtain description of injection area 
One Month Follow-up Visit  (30 days + 10 days) 
• Review current medications being taken 
• Physical exam including weight  
• Vital signs 
• Salivary collection 
• QoL assessment 
• Adverse event assessment 
• Collection of blood sample for banking purposes  

 
 
 
 
 
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26
• Collection of pain diary 
• Complete blood count, 
Three Month Follow-up Visit  (90 days + 14 days) 
• Review current medications being taken 
• Physical exam including weight  
• Salivary collection 
• US of salivary glands 
• QoL assessment 
• Adverse event assessment 
• Collection of blood sample for banking purposes  
• Complete blood count 
Six Month Follow-up Visit  (180 days + 21 days) 
• Review current medications being taken 
• Physical exam including weight  
• Salivary collection 
• US of salivary glands  
• QoL assessment 
• Adverse event assessment 
• Collection of blood sample for banking purposes  
Twelve Month Follow-up Visit  (365 days + 21 days) 
• Review current medications being taken 
• Physical exam including weight  
• Salivary collection 
• US of salivary glands  
• QoL assessment 
• Adverse event assessment 
• Collection of blood sample for banking purposes  
Twenty Four Month Follow-up Visit  (730 days + 56 days) 
• Review current medications being taken 
• Physical exam including weight  
• Salivary collection 
• QoL assessment 
• Adverse event assessment 
• Collection of blood sample for banking purposes  
 
Screening/MSC IMP Administration in Contralateral Gland 
• Physical exam including weight  
• Salivary Collection 
• QoL assessment 
• MSC injection (see section 9.6)  
• Vital signs 
 
Three Day Telephone Call  (3 days + 2 days) 
• Adverse event assessment 
 

 
 
 
 
 
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27
 
Seven Day Telephone Call After Contralateral Injection  (7 days + 2 days) 
• Adverse event assessment 
 
Thirty Day Follow-up Visit After Contralateral Injection  (30 days + 10 days) 
• 
Physical exam including weight  
• Adverse event assessment 
• Complete Blood Count 
• 
Salivary Collection 
• 
QoL assessment 
 
Ninety Day Follow-up Visit After Contralateral Injection  (90 days + 14 days) 
• 
Physical exam including weight  
• Adverse event assessment 
• Complete Blood Count 
• 
Salivary Collection 
• 
QoL assessment 
 
Six Month Follow-up Visit  (180 days +/- 28 days) 
• Physical exam including weight  
• Salivary collection 
• QoL assessment 
• Adverse event assessment 
 
 
Twelve Month Follow-up Visit After Contralateral Injection  (12 months + 3 months) 
• 
Physical exam including weight  
• Adverse event assessment 
• Salivary collection 
• QoL assessment 
 
Twenty Four Month Follow-up Visit  (730 days +/- 3 months) 
• Physical exam including weight  
• Adverse event assessment 
 
 
Note: This twenty four month visit will be the subject’s final study visit. 
 
Unscheduled Visits 
Notes from unscheduled visits for pain or swelling will be reviewed by the PI to assess for study-
related AE/SAE. Whenever appropriate unscheduled visits will be with a study team member. 

 
 
 
 
 
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28
 
Early Termination/Withdrawal Visit 
If a patient prematurely discontinues the study for any reason after administration of the MSC IMP, all 
assessments planned for the final follow-up visit (24 months) should be performed. The reason for 
premature discontinuation will be documented.  
 
 
11.0 
COLLECTION AND PROCESSING OF PATIENT REPORTED OUTCOMES, BIOSPECMENS, 
AND IMAGING 
 
Pain Measurement  
Subjects will be asked to rate their pain on a scale from 0 -10 (0=not at all to 10=worst pain 
imaginable) by refering to a provided visual analog pain scale.  The pain scale of 0-10 has been 
validated to allow for the discrimination of clinically meaningful differences in pain31,32. They will be 
asked to rate their pain at baseline (screening), 30 minutes after the MSC IMP administration, 3 days 
after administration, one week after administration, 30 days after, and 90 days after MSC 
administration. Subjects will additionally keep a diary with daily entries to record occurrence and 
severity of pain and occurrence and severity of other adverse events (redness, swelling, warmth, 
tenderness, rash, pruritis, nausea, vomiting, fatigue etc.) for the first month after MSC injection. 
Subjects will also keep a log of all pain medications used during the first 30 days, including narcotic 
and non-narcotic medications.  
 
Quality of Life Assessments 
Quality of life will be assessed using three validated tools: the University of Michigan Xerostomia 
Related Quality of Life (XeQOL) scale33, the MD Anderson Dysphagia Index (MDADI)34, and the VAS 
xerostomia questionnaire35. 
The University of Michigan Xerostomia related quality of life scale (XeQOL) is a validated patient-
reported 15-item assessment scale with 4 domains: physical functioning, pain/discomfort, 
personal/psychologic functioning, and social functioning (Appendix 19.1). The score is the average of 
all responses of all domains and can range from 0 to 4. Higher scores indicate increased xerostomia 
burden. This scale has high reproducibility and sensitivity.  
The MDADI is a 20-item questionnaire designed for evaluating the impact of dysphagia on the QOL 
of patients with head and neck cancer. The questionnaire and scoring instructions are in Appendix 
19.2. 
The VAS xerostomia questionnaire is an 8-item questionnaire that provides a validated measure of 
the perception of dry mouth. Subjects will be asked to mark their responses to each item by placing a 
vertical line on the 100-mm horizontal scale. The questionnaire is in Appendix 19.3. 
Subjects will complete the XeQoL, MDADI, and VAS at the screening (baseline) visit and at 3- and 6-
month follow-up visits. Subjects in the dose-escalation cohort will also complete these QoL 
questionnaires at their one-month follow-up visit.  
 
Salivary Flow Rate Assessments 
Whole saliva production rates (sialometry) will be measured under unstimulated and stimulated saliva 
collection conditions, as previously described36,37. Participants will refrain from eating, drinking, and, 

 
 
 
 
 
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29
smoking for one hour prior to collection. Unstimulated saliva production will be measured first by the 
passive drool method over a 5-minute time frame. Participants will allow saliva to pool in the mouth 
and, then, with head tilted forward, gently guide saliva into a saliva collection aid attached to a 
cryovial. Stimulated saliva production will be measured by having participants chew inert gum base to 
the pace of a metronome (70 beats per minute) while expectorating saliva (without swallowing) into 
the saliva collection aid for 5 minutes total38. Cryovials will be weighed before and after collection and 
the difference in weight (g) will represent the amount of saliva produced in 5 minutes for each 
condition. Subjects will complete the salivary flow rate assessments at the screening (baseline) visit 
and at 1-, 3-, 6-, 12-, and 24-month follow-up visits.  
 
Salivary Composition Analyses 
Salivary composition analyses will focus on qualitative aspects of saliva previously found to change 
following radiation treatment: salivary pH39,40, total protein concentration (mg/mL)41,42, amylase 
(mU/mL)39,43, and mucins (MUC5B, mU/mL)43,44. Given that MSCs will be injected into one of the 
submandibular glands which contain both serous and mucous acinar secretory cells, we will measure 
products of both types of cells (both= total protein and pH; serous= amylase; mucous= mucins). 
Salivary pH will be measured using a pH meter (Orion 9810BN, Thermo Scientific). Enzyme-linked 
immunosorbent assays (ELISAs) will be used to quantify total protein, amylase, and mucin levels. 
Saliva composition will be assessed on whole saliva samples collected from subjects at each 
timepoint salivary flow rate is assessed (see Section 11.3). Saliva will be processed, stored at -80C, 
and analyzed in batch at a later date. 
 
Salivary Biobanking 
The remaining saliva will be biobanked in the -80 freezer in the Kimple lab in a secure location. 
Future clinical studies on the biobanked may include investigations in the microbiome or cytokines.   
 
Ultrasound Imaging Assessment 
Salivary gland size will be measured by ultrasound45. Ultrasound imaging is a non-ionizing, 
noninvasive imaging modality that can be quickly obtained in a standard exam room. Three-
dimensional (3D) Bmode data sets will be acquired for gland volume measurements and 
characertization of the gland. 
 
The lower outline of the gland will be used to define the distal (relative to the ultrasound probe) end of 
the gland.  This assessment is necessary to provide a 3D volume.  In a series of six patients imaged 
as part of a pilot study, determination of 3D gland volume was possible in all patients.  Rarely the 
lower, or distal aspect of the gland can be difficult to visualize, particularly after radiation 45.  Under 
this circumstance, 2D measurements will be employed to estimate gland volume for the study 
patient.  The salivary gland volumes will be used to determine if gland volume increases after MSC 
administration. Additionally, the stiffness of the salivary glands will be measured by shear wave 
velocity. Acoustic radiation force impulse imaging is a type of ultrasound technique employed to 
measure elasticity and fibrosis of salivary glands via shear wave velocity. Stiffness, or fibrosis, will be 
assessed at baseline and after MSC injection.  Acoustic radiation force impulse imaging is used in 
multiple salivary gland conditions including Sjogren’s syndrome to measure fibrosis 46,47. The 
evaluators will be blinded to the time point of evaluation (pre- or post- MSC injection).  
 
Ultrasound assessment of salivary glands  will be done at the baseline, 3-month,  6-month, and 12-
month follow-up visits. 

 
 
 
 
 
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30
 
Biobanking of Blood Sample 
Biobanking of participant blood will occur at a baseline visit or the day of the bone marrow aspiration, 
and at the 1 (for those seen at 1 month), 3, 6, 12, and 24 month visits. Approximately 3 mL of blood 
will be placed into an EDTA tube which will be transported to the Kimple lab, in WIMR where it will be 
stored in a secure freezer in a secure location. Future clinical studies on the biobanked blood may 
include measuring inflammatory cytokines or other immune markers.   
12.0 
DATA COLLECTION, HANDLING, SHARING, AND RECORD KEEPING 
 
Data Collection  
Data Collection Forms 
Standardized data collection forms (e.g., source documents, case report forms, standardized 
assessment forms, etc.) are used to ensure data collected are consistent and compliant with the 
protocol and IRB application.  
 
Data collection is the responsibility of study team members under the supervision of the Principal 
Investigator (PI). The PI is responsible for ensuring the accuracy, completeness, legibility, and 
timeliness of the recorded and reported data. 
 
All data collection forms must be completed in a legible manner; any missing data will be explained. 
Data entry errors will be corrected with a single line through the incorrect entry and the correct data is 
entered above/near the correction. All changes will be initialed and dated. 
Data Capture Methods 
This study will utilize 2 different web-based platforms, Oncore (Forte Research) for study registration 
and tracking and REDCap for clinical trial data collection. Both systems are secure web platforms 
that are compliant with Good Clinical Practices and Federal Rules and Regulations.  UW Department 
of Human Oncology Coordinators will coordinate and manage data collection and entry 
Clinical data (including AEs, concomitant medications, and solicited events data) and clinical 
laboratory data will be entered into the following REDCap. Clinical data will be entered directly from 
the source documents. 
 
Shadow research charts with original consent forms and documents specifically created for this study 
will be maintained in the Department of Human Oncology until the study is terminated. The records 
will then be sent to Wisconsin State Records Archiving facility for long term storage (10 years) and 
re-archived as needed.  
 
Confidentiality and Privacy 
Subject confidentiality and privacy are strictly held in trust by the participating investigators, their 
staff, and the sponsor(s) and their agents. This confidentiality is extended to cover testing of 
biological samples and genetic tests in addition to the clinical information relating to subjects. 
Therefore, the study protocol, documentation, data, and all other information generated will be held in 
strict confidence. No information concerning the study or the data will be released to any 
unauthorized third party without prior written approval of the sponsor.  
 
All research activities will be conducted in as private a setting as possible. 
 

 
 
 
 
 
Protocol Version 8, 9/28//2023 
 
 
31
All study staff engaged in the conduct of this project have completed training on the protection of 
human subjects and the Health Insurance Portability and Accountability (HIPAA) Privacy Rule. In 
addition, all key personnel (i.e., Principal Investigator, individuals involved in identifying/recruiting 
subjects, obtaining informed consent, or interacting and intervening with subjects) have undergone 
Good Clinical Practice (GCP) training. 
 
Information about study subjects will be kept confidential and managed according to HIPAA 
requirements. All subjects will sign a combined informed consent and HIPAA authorization form that 
includes specific privacy and confidentiality rights. Study data will be maintained per federal, state, 
and institutional data policies. 
 
The investigator(s) will ensure that the identities of subjects are protected by using coded subject 
information. The log of subject identifying information that links subjects to their study-specific 
identification number will be maintained by the investigator. The log and all study records will be 
maintained in locked rooms and access will be limited to essential study personnel. The log linking 
subject code to identifiers will be stored separately from study data. The PI will have access to the 
log linking code to identifiers, as will authorized study personnel. Electronic study records/files will be 
stored on a department server and accessed via networked computers that are password-protected 
with access provided only to authorized study personnel.  
 
Authorized representatives of the following groups may need to review this research as part of their 
responsibilities to protect research subjects: representatives of the IRB, UWCCC DSMC, UWCCC, 
authorized personnel of the UW PACT, Other groups at the University of Wisconsin tasked with 
Research Oversight and compliance, and federal oversight agencies, such as the Food and Drug 
Administration (FDA).  
 
Records Retention 
It is the investigator’s responsibility to retain study essential documents for a minimum period of 7 
years following completion of the study per UW-Madison institutional policy, or at least 2 years after 
the last approval of a marketing application in their country and until there are no pending or 
contemplated marketing applications in their country or at least 2 years have elapsed since the 
formal discontinuation of clinical development of the investigational product, whichever comes last. 
 
Retention for Future Research: Data & Biospecimen Banking 
Purpose of Storage 
The purpose of collecting and storing biospecimens is to establish a biobank for use by UW-Madison 
researchers to use who are investigating the causes, diagnosis, prevention and treatment of cancer. 
Data and/or Biospecimens Being Stored 
Blood in a 3 mL standard EDTA tube will be collected from each participant on the day of bone 
marrow biopsy, and at the 1(for those seen at 1 month), 3, 6, 12, and 24 month follow-ups. This 
blood will be labeled with a unique subject ID code. All tubes of blood will then be stored in a secure 
freezer in the secured Kimple lab in WIMR.  
 
Saliva will be collected from each participant at the pre-specified timepoints as detailed previously. 
The saliva will be used for clinical endpoints as detailed previously, any remaining saliva will be 
stored in an Eppendorf tube in a secure freezer in the secured Kimple lab in WIMR.  
Location of Storage 
Blood and saliva tubes labelled with coded subject ID number, date, and time point, will be stored in 
the Kimple Laboratory. Data associated with the blood and saliva tubes is on a UW password-
protected server.  

 
 
 
 
 
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32
Duration of Storage 
Biospecimens will be stored until they are used up in their entirety.  
Access to Data, Images, Recordings and/or Biospecimens and Security Measures 
UW researchers who are doing biomedical research may apply for access to coded data and blood 
(no patient identifiers on tube).  
Procedures to Release Data or Biospecimens 
Researchers must have local IRB approval for their study which will include study of the 
biospecimens and accompanying data. 
Process for Returning Results 
There are no plans to disclose results of future testing to research subjects.  
Process for Tracking Subject Consent and Authorization 
In the consent form for this study, subjects are informed of an optional aspect of the study that 
involves donating blood for future biomedical research. Subjects are made aware they do not have to 
donate biospecimens to the Biobank to participate in the study. Subjects must opt into the biobanking 
aspect of the study by checking a box and initialing a line next to the box.  
 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol or investigational plan 
requirements. The noncompliance may be either on the part of the subject, the investigator, or the 
study site staff. Protocol deviations will be assessed for their impact on safety, study operations, and 
data integrity. Appropriate corrective and preventive actions will be implemented if warranted. 
 
It is the responsibility of the Principal Investigator/site investigator/study staff to use continuous 
vigilance to identify and report deviations. The Principal Investigator is responsible for assessing 
whether the deviation constitutes noncompliance as defined by the reviewing IRB and if so, reporting 
it within the required time frame(s) to the UWCCC and the IRB as applicable 
 
Publication and Data Sharing Policy 
This study will be conducted in accordance with the following publication and data sharing policies 
and regulations: This study will comply with the NIH Data Sharing Policy and Policy on the 
Dissemination of NIH-Funded Clinical Trial Information and the Clinical Trials Registration and 
Results Information Submission rule. As such, this trial will be registered at ClinicalTrials.gov, and 
results information from this trial will be submitted to ClinicalTrials.gov. In addition, every attempt will 
be made to publish results in peer-reviewed journals. 
13.0 
STUDY ANALYSIS 
Any deviations from the planned analyses will be described and justified in the final integrated study 
report. Statistical programming and analyses will be performed using SAS® (SAS Institute Inc., Cary NC), 
version 9.4 or higher. A formal statistical analysis plan (SAP) will be developed before the database lock. 
It will include detailed descriptions of summaries and mock-ups of tables, listings, and figures to be 
included in the clinical study report. 
 
General Considerations 
The statistical analyses in this study will be exploratory since the study is not powered to address any 
pre-defined statements but to generate valid hypotheses on safety/tolerability, feasibility, and efficacy 

 
 
 
 
 
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issues. A formal sample size calculation was therefore not done. Thus, all resulting p-values and 
confidence intervals are to be interpreted in the exploratory sense, only. 
Data will be appropriately summarized and analyzed using tabulation and graphs for demographic and 
baseline characteristics, safety and efficacy observations and measurements. Standard descriptive 
summary statistics (i.e., n, arithmetic mean, standard deviation, median, lower/upper quartiles, and 
minimum/maximum values) will be calculated for continuous variables. Categorical data will be 
presented in frequency tables using counts and percentages. For all data collected during the study, 
listings of the individual raw data will be provided. Individual patient data listings will be presented per 
parameter. 
The main analysis will be performed after the 24-month Follow-up Visit, i.e., when all patients have 
either completed the visit, are lost to follow-up or have died within this period.  
 
Determination of Sample Size  
Patients in this pilot trial will undergo unilateral gland injection per FDA request. Associated 95% 
confidence intervals will be provided for the toxicity rate. To describe changes in quality of life or 
salivary function/composition between baseline and post-injection timepoints, separate one-way 
ANOVA models will be fit to the data for each measured outcome. After fitting the models to the data, 
comparisons between the timepoints will be calculated using Tukey’s method. Due to the short time 
frame of intervention, we anticipate that adherence to the intervention will be high (>90% of patients 
will complete all mandatory study components) and that rates of follow-up will be similarly high (i.e., 
low rates of drop outs or lost to follow-up). 
Interim analysis: In this pilot study, there is not a planned interim analysis.   
Sample Size: Six to twelve patients will be accrued, depending on toxicity encountered. If 0/6 or 1/6 
participants experience a DLT at Dose Level 0, sample size would be six. If 2/6 participants 
experience a DLT at Dose Level 0, another cohort would be enrolled at Dose Level -1. Sample size 
would then be up to 12 patients, unless 2 or more patients at Dose Level -1 experience a DLT, at 
which point the study would be stopped. 
Length of follow-up: Patients are observed for DLT after MSC injection, with a follow-up of 4 weeks 
after injection. Secondary outcomes will be assessed at 24 months (end of study for patients). DLT is 
defined as: pain > 5 on a standard pain scale of 0-10 at 1-month after MSC injection OR any serious 
AE within one-month post-injection (probably or definitely caused by study treatment) or other 
toxicities described in section 9.7. 
   
 
Analysis Sets 
Eligibility, Protocol Deviations 
Enrolling an ineligible participant is a protocol violation that is reportable to the IRB. If Protocol 
Deviations are identified, the PI will determine whether the protocol should be modified (to prevent 
further incidents from occurring) and whether the participant should be withdrawn due to safety or other 
concerns. Enrollment in another clinical study possibly interfering with the endpoints of the present 
study will be considered a protocol violation. 

 
 
 
 
 
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Each patient’s allocation to the different analysis sets will be identified prior to database lock. Significant 
deviations from the protocol will lead to the exclusion of a subject from the per-protocol analysis set. 
Listings will be prepared to show the characteristics of all subjects for the different analysis sets and a 
summary will be given on the number of subjects per analysis set. A detailed description of the criteria 
used for data sort out will be provided before start of the evaluations. 
Definitions 
The statistical evaluation will be based on separate, hierarchically organized analysis sets as defined 
below: 
• Intention to Treat (ITT) analysis set: The safety analysis set will consist of all patients enrolled. 
• Safety analysis set: The full analysis set will consist of all patients who received the injection of the 
IMP.  
• Per-protocol analysis set: The per-protocol analysis set will consist of all patients of the ITT 
analysis set for whom no major protocol violations have been recorded.  
Demographic and baseline characteristics will be analyzed for all three analysis sets. General safety 
data will be evaluated using the safety analysis set. Efficacy parameters will be evaluated using the 
full analysis set, the per-protocol analysis set, and based on dose of IMP received.  
 
Demographics and Baseline Characteristics 
Demographics (age, sex, racial, ethnic group based on standard NIH categories) and baseline 
characteristics will be summarized by means of descriptive statistics for continuous data or frequency 
tables for categorical data. Demographic data and other baseline characteristics will be analyzed for 
all three-analysis sets. 
 
Treatment and Study Compliance 
The intervention in this study is a one-time injection that involves a procedure performed by study 
personnel so that there is limited concern with adherence to the intervention. The primary endpoint is 
based upon short-term outcomes and thus study compliance is expected to be good. Patients will be 
called by study coordinator to remind them of all study visits. Secondary endpoints are assessed up to 
24 months after the intervention. To maximize study compliance, patients will receive regular reminders 
of study visits and all visits will be scheduled up to 1 year in advance.  
The number of patients who complete each study visit and assessment will be provided in a CONSORT 
diagram at the time of publication. 
 
Handling of Missing Data 
Guidelines promulgated in the National Research Council report on handling of missing data will be 
followed48,49. 
 
Analyses of the Primary Endpoints 
The primary objective of the study is to evaluate the safety and tolerability of MSCs for subjects with 
xerostomia after radiation for HNC.  
The primary endpoint is the recommended starting dose of MSCs for a Phase I dose-escalation study, 
which will be determined by the proportion of subjects experiencing DLT, where DLT is defined as: 

 
 
 
 
 
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pain > 5 on a standard 10-point pain scale of 0-10 at 1-month after MSC injection OR any serious AE 
OR any of the selected toxicities listed in section 9.7, within one-month post-injection.  
Adverse events will be processed in the statistical analysis after classification into standardized 
medical terminology using the NCI Common Terminology Criteria for Adverse Events, Version 5.0 
(CTCAE v5.0) grouped by grade/severity, attribution/relatedness and expectedness.  
All adverse events data will be listed in the individual patient data listings, including all information 
documented on the adverse event form. Separate listings will be provided likewise for serious 
adverse events, adverse events in subjects who died, and for adverse events leading to 
discontinuation of the study. Concomitant medication documented in relation to the occurrence of a 
serious adverse event after MSC administration on SAE forms will be listed separately as 
‘Concomitant medication as documented on SAE forms after MSC administration’. 
Frequency tabulations of the number and percentage of patients with a pain rating of less than 6 on a 
VAS of 0-10 will be presented and displayed graphically with two-sided 95% confidence intervals 
using the Wilson score method. 
Standard descriptive summary statistics (i.e., n, arithmetic mean, standard deviation, median, 
lower/upper quartiles, and minimum/maximum values) will be calculated for continuous variables. 
Categorical data will be presented in frequency tables using counts and percentages. Graphical 
presentation will be given by means of box and whisker plots and bar charts, as appropriate.  
 
Analyses of the Secondary Endpoints 
Analyses of the secondary endpoints focus on efficacy of the IMP in the treatment of xerostomia and 
hyposalivation. All inferential analyses for the secondary outcome variables will be interpreted in the 
exploratory sense, only.  
Patient-reported outcome measures will be evaluated by comparing the changes in salivary QOL 
from baseline to each follow-up visit and by assessing changes over time, within-group comparisons 
will be performed with the Wilcoxon signed-rank test. 
Salivary flow rate analysis will be analyzed in a manner described by Gronhoj et al. 201824: by 
comparing the changes from baseline to each follow-up visit and changes over time, within-group 
comparisons will be performed with the Wilcoxon signed-rank test. 
Salivary composition analyses will focus on qualitative aspects of saliva previously found to change 
following radiation treatment: salivary pH39,40, total protein concentration (mg/mL)41,42, amylase 
(mU/mL)39,43, and mucins (MUC5B, mU/mL)43,44. Given that MSCs will be injected into one of the 
submandibular glands which contain both serous and mucous acinar secretory cells, we will measure 
products of both types of cells (both= total protein and pH; serous= amylase; mucous= mucins). 
Salivary pH will be measured using a pH meter (Orion 9810BN, Thermo Scientific). Enzyme-linked 
immunosorbent assays (ELISAs) will be used to quantify total protein, amylase, and mucin levels. 
Saliva composition will be assessed on whole saliva samples collected from subjects at the 
screening visit and the in-person follow-up visits.   
 
To assess the imaging characteristics of submandibular gland after MSC injection, salivary gland size 
will be measured by ultrasound45. Ultrasound imaging is a non-ionizing, noninvasive imaging modality 
that can be quickly obtained in a standard exam room. Three-dimensional (3D) Bmode data sets will 
be acquired for tumor volume measurements. If post-RT submandibular glands suppress ultrasound 
waves to prevent the visualization of the lower outline of the gland, a 2D estimate of gland size will be 
made.  

 
 
 
 
 
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Standard descriptive summary statistics (i.e., n, arithmetic mean, standard deviation, median, 
lower/upper quartiles, and minimum/maximum values) will be calculated for continuous variables. 
Categorical data will be presented in frequency tables using counts and percentages. Graphical 
presentation will be given by means of box and whisker plots and bar charts, as appropriate.  
Results from physical examinations will be summarized for each scheduled study visit by means of a 
frequency table. 
Briefly, assessment of feasibility for a future Phase I dose-escalation study will be accomplished by 
analyzing the drop-out rate and reasons for drop-out, time from patient inclusion to administration of 
the IMP and successful production of MSC IMP on an intent to treat basis.  
 
Interim Analyses 
There is no interim analysis for this pilot study. 
14.0 
RISK/BENEFIT ASSESSMENT 
 
Potential Benefits to the Subjects 
The potential benefits to research subjects associated with this study include the possible 
improvement of radiation-induced xerostomia and hyposalivation. If this study is able to demonstrate 
the safety, tolerability, and possible therapeutic benefit of MSCs in radiation-induced xerostomia and 
hyposalivation, the community of HNC patients who undergo radiation would benefit by the 
availability of a treatment option. The MESRIX trial has demonstrated an improvement in salivary 
production and quality of life after MSC injection24.  
 
Known Potential Risks  
Known Procedural Risks 
• 
Injection of MSCs: The risks of MSC injection include pain or discomfort within the salivary gland; 
pain or discomfort at the site of injection; possible bruising and swelling around the injection site; 
rarely an infection, potentially diminished function of the submandibular gland, damage to small 
nerves that are located near the submandibular gland – this risk will be minimized by injection 
with ultrasound guidance. 
• 
Bone Marrow Aspiration: Potential risks from bone marrow aspiration include bruising and mild 
transient pain around the needle site.  There is a small risk of infection around the bone marrow 
access site that could start locally, but spread systemically.   There is also a small risk of severe 
bleeding around the aspiration site or internally. If sedation is performed there is a small risk of 
slowed breathing during the procedure and nausea, headache, or feeling drowsy after the 
procedure.   
• 
Blood Draw: The risks of drawing blood from a vein include discomfort at the site of puncture; 
possible bruising and swelling around the puncture site; rarely an infection; and, uncommonly, 
faintness from the procedure. 
Known Interventional Risks 
At present there has not been a defined dose limiting toxicity of MSCs and to date no serious 
adverse events have been reported following the infusion of either autologous or allogeneic MSCs. 
Of the toxicities noted so far in MSCs trials a minor (i.e. <10%) portion of patients reported a rash 
following infusion which can be directly linked to the cryopreservative (DMSO) used in most MSC trial 
where the cell dose is thawed at the bedside and immediately infused without removal of majority of 

 
 
 
 
 
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DMSO. In our trial the cells will be delivered after being thawed in media and culture rescued for 16 
hours to ensure removal of DMSO and thus we do not expect to see any of these types of reactions. 
Despite the strong safety profile MSC infusion has shown to date there is the slim possibility that 
interferon-gamma activated MSCs could result in certain systemic (acute and delayed) reactions. As 
such each subject will be evaluated and monitored before during and following injection of MSCs 
during the study. 
Systemic reaction is any untoward medical hypersensitivity-like event other than injection site 
reaction, occurring during or after MSCs infusion administration that can be at least possibly 
attributed to the MSC infusion. Systemic reaction is further classified as acute and delayed based on 
timing and presentation of symptoms typical for hypersensitivity reactions. Acute and delayed 
reactions (within the first 7 days) to MSCs will be reported according to the judgment of the 
Investigator, based on the typical clinical features: 
• 
Hypotension 
• 
Urticaria 
• 
Flushing 
• 
Facial or hand edema 
• 
Throat tightness 
• 
Oral cavity or lip edema 
• 
Headache 
• 
Shortness of breath 
 
Risk/Benefit Analysis 
The potential procedural risks and the minimal interventional risk are outweighed by the likely benefit 
of improvement of radiation-induced xerostomia. The procedural risks will be minimized by the use of 
a skilled practitioner injecting all MSCs under ultrasound guidance. The subjects will be observed for 
30 minutes after MSC injection to ensure no acute systemic reaction has occurred.  
 
There have been no SAEs or DLTs occurring within 1 month of MSC injection (primary objective), 
supporting the safety and low risk of MSC injection into a submandibular gland. Additionally, the 
cryopreserved MSCs that will be utilized for the second injection are identical to the MSCs used for 
the first injection. The stability of the cryopreserved MSCs has been validated by the PACT GMP 
facility. MSCs for the second injection will undergo the same quality control process and will have the 
same release criteria as the MSCs for the initial injection. There is a very small risk that the 
crypreserved MSC IMP used for the second injection is not as effective as the MSC IMP used for the 
first injection. Additionally, the second injection should carry with it the exact same, very small, risk 
for infection, bleeding, etc. detailed above. There is no known increased risk in the second injection 
of MSC IMP as compared to the first injection. The likely benefit of an improvement in radiation-
induced xerostomia is increased when MSCs are injected into both submandibular glands to allow for 
optimal tissue recovery. Injecting both submandibular glands has the proposed benefit of allowing 
both salivary glands to recover and repopulate, leading to reduced xerostomia and improved quality 
of life. 
15.0 
ADVERSE EVENTS REPORTING REQUIREMENTS 
 
Overview of Adverse Event Reporting 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in future 

 
 
 
 
 
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studies using similar agents. Adverse events are reported in a routine manner at scheduled times 
during a trial. Additionally, certain adverse events must be reported in an expedited manner to allow 
for optimal monitoring of patient safety and care. The first step is to identify the event using the 
Common Toxicity Criteria for Adverse Events (CTCAE). The severity of the event should then be 
graded using the CTCAE criteria. Next, it must be determined if the adverse event is related to the 
study treatment (attribution). If so, determine whether the adverse event is expected or unexpected. 
Using this information and the adverse event reporting section of the protocol, it can be determined 
whether an adverse event should be reported in an expedited report or a routine report. 
 
Common Terminology Criteria for Critical Adverse Events (CTCAE) 
The CTCAE document provides descriptive terminology for adverse event reporting. A grading 
(severity) scale is provided for each adverse event term. This study will utilize version 5.0 of the 
CTCAE of the National Cancer Institute for toxicity and performance reporting. A copy of the CTCAE 
version 5.0 can be downloaded from the NCI website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm 
 
Definition of Adverse Event 
An adverse event (AE) is defined as any untoward medical occurrence in a patient receiving 
study treatment and which does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the subject’s 
participation in the research, whether or not considered related to the subject’s participation 
in the research. 
 
Grading the Severity of Adverse Events 
Guidance for grading each type of event is found in the CTCAE. Assessment of severity is frequently 
subjective and medical judgment should be used to compare the reported adverse events to similar 
types of events observed in clinical practice. It is important to recognize that severity is not 
equivalent to event seriousness; severity is a measure of intensity; thus, a severe event may not 
necessarily be classified as a serious event. Definitions of the grading categories to assess severity 
of adverse events are as follows:  
• 
Mild (grade 1): the event causes a sign or symptom barely noticeable to the patient without 
disruption of normal daily activities  
• 
Moderate (grade 2): the event causes sufficient discomfort to interfere with normal daily activities 
and may require treatment of symptoms  
• 
Severe (grade 3): an event of sufficient severity to cause the patient severe discomfort and 
leaving the patient unable to perform normal daily activities; Symptoms may be resistant to 
conventional symptomatic treatment.  
• 
Life threatening (grade 4): the patient was at risk of death at the time of the event.  
• 
Fatal (grade 5): the event caused death. 
 
Causality/Attribution 
The causality, or attribution, of AEs refers to the relationship of the AE to the experimental 
intervention (IMP). The investigator, using the following points, makes the assessment of whether 
there is a reasonable possibility of a causal relationship:  
• 
Timing of the event between administration of IMP and the onset of adverse event  
• 
Dose of IMP and evidence, if any, of overdose  

 
 
 
 
 
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• 
A known or expected response pattern to the suspected IMP based on previous experience  
• 
Physiological effects/pharmacological action of the IMP  
• 
Adverse events known to occur with the IMP belonging to the same or a similar class  
• 
Specific genetic predisposition of the patient  
 
Based on the aforementioned points, the PI assigns attribution of the adverse event to the study 
treatment. Attribution categories are as follows:  
• 
Definite: The AE is clearly related to the study treatment  
• 
Probably: 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  
 
Seriousness of Adverse Event 
Adverse events that meet one or more of the following are classified as serious:  
• 
Results in death  
• 
Is life-threatening  
• 
Requires inpatient hospitalization or prolongation of existing hospitalization (for > 24 hours)  
• 
Results in persistent or significant disability or incapacity  
• 
Produces a congenital abnormality or birth defect  
• 
a medical event, based on appropriate medical judgment, that is believed to jeopardize the 
patient and/or requires medical or surgical intervention to prevent one of the outcomes defining a 
SAE. For example: allergic bronchospasm requiring intensive treatment in an emergency room or 
at home, convulsions that may not result in hospitalization.  
 
Determination of Expectedness 
Expected events are those that have been previously identified as resulting from administration of the 
intervention. An adverse event is considered unexpected, for expedited reporting purposes only, 
when either the type of event or the severity of the event is not listed in:  
• 
Current known adverse events listed in this protocol 
• 
Investigator Brochure (for agents provided under an IND)  
 
Recording Adverse Events 
• 
All adverse events regardless of attribuition will be recorded from the time of the research blood 
draw through the 1 month post MSC injection visit.  
• 
Diagnostic and therapeutic non-invasive and invasive (i.e., surgical) procedures will not be 
reported as adverse events. However, the medical condition for which the procedure was 
performed must be reported if it meets the definition of an adverse event, unless the condition 
existed prior to the patient’s MSC IMP injection. 
• 
If an AE is determined to be caused by the IMP (definitely related) or associated with the IMP 
(probably related or possibly related), and is a CTCAE v5.0 grade 3 or higher, it will be reported 
regardless of the timeframe of the occurrence.   
 
Baseline Adverse Events 
An expedited adverse event report will NOT be submitted if a patient is entered on this study with a 
preexisting condition (e.g., elevated laboratory value). If the preexisting condition worsens in severity, 

 
 
 
 
 
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the investigator will reassess the event to determine attribution and whether the event requires 
reporting. If the adverse event resolves and then recurs, the investigator will reassess the event to 
determine if the event will be reported.  
 
Expedited Reporting 
Refer to Reporting Table in Section 16.4.  
 
Required Reporting 
Reporting requirements to the UW Health Sciences Institutional Review Board (HS-IRB)  
The UW HS-IRB website will be referenced for real-time guidance regarding current reporting 
requirements.  
https://irb.wisc.edu/wp-content/uploads/sites/2/sites/2/2021/11/HRP-103-INVESTIGATOR-
MANUAL_2021-10-29.pdf. Pregnancies will be reported to the UWCCC DSMC, IRB. Additionally, 
Dr. Galipeau, in his role as Sponsor, will report pregnancies to the FDA as required.   
Reporting requirements to the FDA  
Any unexpected fatal or unexpected life-threatening event possibly due to the investigational agent, 
will be reported to the FDA by telephone or fax as soon as possible but no later than 7 calendar days 
after notification of the event and followed by a written safety report as complete as possible within 8 
additional calendar days (i.e., full report 15 calendar days total after notification of event).  
Unexpected, non-fatal and non-life-threatening SAEs that are considered due to or possibly due to 
the study intervention, will be reported to the FDA by written safety report as soon as possible but no 
later than 15 calendar days of the notification of the occurrence of the event. Expected SAEs, even 
unexpected fatal SAEs, considered by the PI to be not related to the study, will be reported to the 
FDA in the Annual Review Report along with non-serious AEs. 
 
Follow-up of Adverse Events 
Only grade 3 or 4 Adverse Events (AEs) that are thought to be at least possibly related to the study 
will be followed until the event has resolved or, in the case of a clinically significant abnormal 
laboratory value, it has returned to baseline or stabilized at an acceptable level according to the PI.  
• 
There is a satisfactory explanation for the changes observed, or  
• 
The patient is lost to follow-up or off study  
16.0 
DATA AND SAFETY MONITORING PLAN 
 
Oversight and Monitoring Plan 
The UWCCC Data and Safety Monitoring Committee (DSMC) is responsible for the regular review 
and monitoring of all ongoing clinical research in the UWCCC. A complete IND Study Monitoring Plan 
is located in the electronic records component of the Regulatory Binder for this IND. The IND Study 
Monitoring Plan describes the strategies, responsibilities, and quality management activities in place 
to ensure adequate protection of the rights, welfare, and safety of human subjects and the quality 
and integrity of the resulting data, in compliance with applicable laws, regulations, policies, and 
guidance. Quality management activities include both internal and external quality management 
processes used throught the study, including but not limited to staff training, standardized 

 
 
 
 
 
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procedures, methods for data collection, study and data monitoring, and routine team meetings to 
review the study progress and isolate any complicance issues and/or trends. A summary of UWCCC 
DSMC activities is as follows: 
• Reviews all clinical trials conducted at the UWCCC for subject safety, protocol compliance, and 
data integrity.  
• Reviews all Serious Adverse Events (SAE) requiring expedited reporting, as defined in the 
protocol, for all clinical trials conducted at the UWCCC, and studies conducted at external sites for 
which the UWCCC acts as an oversight body.  
• Reviews all reports generated through the UWCCC DSMS elements (Internal Audits, Quality 
Assurance Reviews, Response Reviews, Compliance Reviews, and Protocol Summary Reports) 
described in Section II of this document.  
• Notifies the protocol PI of DSMC decisions and, if applicable, any requirements for corrective 
action related to data or safety issues.  
• Notifies the CRC of DSMC decisions and any correspondence from the DSMC to the protocol 
Principal Investigator.  
• Works in conjunction with the UW Health Sciences IRB in the review of relevant safety information 
as well as protocol deviations, non-compliance, and unanticipated problems reported by the 
UWCCC research staff.  
• Ensures that notification of SAEs requiring expedited reporting is provided to external sites 
participating in multi-institutional clinical trials coordinated by the UWCCC. 
• The decision to proceed with enrollment of a subject into the next higher dose group will be made 
by the study PI and the statistician after review of the AEs within the dose cohort 
• The DSMC will have oversight of the attribution of SAEs throughout the duration of the protocol.   
 
Monitoring and Reporting Guidelines 
UWCCC quality assurance and monitoring activities are determined by study sponsorship and risk 
level of the protocol as determined by the PRMC. All protocols (including Intervention Trials, Non-
Intervention Trials, Behavioral and Nutritional Studies, and trials conducted under a Training Grant) 
are evaluated by the PRMC at the time of committee review. Based on UWCCC PRMC review, 
monitoring requirements for this trials are as follows: 
 
Intensive Monitoring 
Protocols subject to intensive monitoring generally include UW Institutional Phase I and Institutional 
Trials of any phase involving recombinant DNA/gene transfer.  These protocols undergo continuous 
review of data and subject safety at weekly Disease Oriented Team (DOT) meetings where the 
results of each subject’s treatment are discussed and the discussion is documented in the DOT 
meeting minutes. The discussion includes the number of subjects enrolled, significant toxicities, dose 
adjustments, and responses observed. Protocol Summary Reports are submitted on a quarterly basis 
by the study team for review by the DSMC. 
 
Review and Oversight Requirements 
• 
Serious Adverse Event: Report Within 24 Hours  
o Serious Adverse Events requiring reporting within 24 hours must also be reported to the 
UWCCC Data and Safety Monitoring Committee (DSMC) Chair via an email to 
saenotify@uwcarbone.wisc.edu within one business day.  

 
 
 
 
 
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o The OnCore SAE Details Report must be submitted along with other report materials as 
appropriate (The DSMC Chair will review the information and determine if immediate action is 
required.  
o Within 7 calendar days, all available subsequent SAE documentation must be submitted 
electronically along with a 24-hour follow-up SAE Details Report and a completed UWCCC 
SAE Routing Form to saenotify@uwcarbone.wisc.edu. All information is entered and tracked 
in the UWCCC database.  
o The Principal Investigator notifies all investigators involved with the study at the UWCCC, the 
HS-IRB, and funding agencies and provides documentation of these notifications to the 
DSMC.  
o The PI reviews the event in conjunction with the UWCCC Sponsor Investigator Determination 
Form to determine whether the SAE requires reporting to the FDA.  
 
• 
Serious Adverse Event: Report Within 15 Days 
o Serious Adverse Events requiring reporting within 15 days (as described in the protocol) must 
also be reported to the Data and Safety Monitoring Committee (DSMC) Chair via an email to 
saenotify@uwcarbone.wisc.edu.  
o The OnCore SAE Details Report must be submitted along with other report materials as 
appropriate (FDA MedWatch Form #3500 and/or any other documentation available at that 
time of initial reporting). The DSMC Chair will review the information and determine if further 
action is required. All information is entered and tracked in the UWCCC database.  
o The Principal Investigator notifies all investigators involved with the study at the UWCCC, the 
HS-IRB, and funding agencies and provides documentation of these notifications to the 
DSMC.  
o The PI reviews the event in conjunction with the UWCCC Sponsor Investigator Determination 
Form to determine whether the SAE requires reporting to the FDA and other participating 
investigators.  
o If a patient experiences any serious and unexpected adverse effect that could be attributable 
to receipt of a cellular product that has failed a sterility test, then a report of this information 
will be submitted to the FDA, IRB, DSMC and participating investigators.  
 
• 
Report to FDA Within 30 Calendar Days  
o In the case that a patient receives a product that results in a positive sterility test, a report will 
be submitted to the FDA within 30 calendar days after initial receipt of the positive sterility 
results. The report will include information regarding the sterility failure, results of an 
investigation and any cause if determined, and any corrective or preventative actions.  
 
• 
Principal Investigator and Sponsor Responsibilities for SAE Review  
o Dr. Randall Kimple reviews all reports of serious adverse events occurring on the study and 
makes a determination of 1) attribution and 2) expectedness in the context of this study. Dr. 
Jacques Galipeau, MD FRCP(C), UW Professor in Oncology, Assistant Dean for 
Therapeutics Discovery and Development, and Director of the Program for Advanced Cell 
Therapy, holds the IND for this study and therefore assumes responsibility of the study 
sponsor in accordance with FDA 21 CFR 312.32. He is responsible for reporting SAEs to the 
FDA.  
o SAE with suspected causality to study treatment and deemed unexpected are reported as 
IND Safety Reports by the Sponsor to the FDA and all participating investigators on the study 
within 15 calendar days.  
o All fatal or life-threatening SAE that are unexpected and have suspected causality to the 
study treatment will be reported by Sponsor to the FDA and all participating investigators on 
the study within 7 calendar days.  
 

 
 
 
 
 
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• 
Study Progress Review  
o Protocol Summary Reports (PSR) are required to be submitted to the DSMC in the timeframe 
determined by the risk level of the study (quarterly; semi-annually; or annually). The PSR 
provides a cumulative report of SAEs, as well as instances of noncompliance, protocol 
deviations, and unanticipated problems, toxicities and responses that have occurred on the 
protocol in the timeframe specified. PSRs for those protocols scheduled for review are 
reviewed at each DSMC meeting.  
o Protocol Summary Reports enable DSMC committee members to assess whether significant 
benefits or risks are occurring that would warrant study suspension or closure. This 
information is evaluated by the DSMC in conjunction with other reports of quality assurance 
activities (e.g., reports from Internal Audits, Quality Assurance Reviews, etc.) occurring since 
the prior review of the protocol by the DSMC. Additionally, the DSMC requires the study team 
to submit external DSMC or DSMC reports, and any other pertinent study-related information.  
o In the event that there is significant risk warranting study suspension or closure, the DSMC 
will notify the PI of the DSMC findings and ensure the appropriate action is taken for the 
protocol (e.g., suspension or closure). The DSMC ensures that the PI reports any temporary 
or permanent suspension of a clinical trial to the appropriate agencies. DSMC findings and 
requirements for follow-up action are submitted to the CRC.  
 
Expedited Reporting of Serious Adverse Events 
• 
Depending on the nature, severity, and attribution of the serious adverse event, an SAE report 
will be phoned in, submitted in writing, or both according to the Table below.  
• 
 
• 
Reporting of expedited and final SAE reports will go to: 
• 
1)UWCCC DSMC via email at: saenotify@uwcarbone.wisc.edu 
• 
2) Dr. Jacques Galipeau, MD FRCP(C), UW Professor in Oncology, Assistant Dean for 
Therapeutics Discovery and Development, and Director of the Program for Advanced Cell 
Therapy, via email at: jgalipeau@medicine.wisc.edu______________ 
 
 
Reporting to the UW IRB will be per IRB guidelines. 
 
Determine the reporting time line for the SAE in question by using Table 3 below.  
 
Phase 1 and Early Phase 2 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/Intervention 1,2. 
Table 4. FDA Reporting Requirements.  
FDA Reporting Requirements for Serious Adverse Events (21 CRF Part 312) 
NOTE: Investigators MUST immediately report to the UWCCC DSMC and any other parties 
outlined in the protocol 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 (the patient was at risk of death at the time of the event; it 
does not refer to an event that hypothetically might have caused death if it were more 
severe). 

 
 
 
 
 
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44
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 within 30 days of IMP injection that meet the above criteria MUST 
be immediately reported to the UWCCC within the timeframes detailed in the table below: 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3-5 
Timeframes 
Resulting 
in 
hospitalization  ≥ 
24 hrs 
15 Calendar Days 
24 Hour; 7 Calendar Days 
Not resulting in 
Hospitalization ≥ 
24 hrs 
Not required 
Expedited AE reporting timelines are defined as: 
• 
24-Hour; 7 Calendar Days – The AE must initially be reported within 24 hours of learning 
of the AE, followed by a complete expedited report within 7 calendar days of the initial 24-
hour report. 
• 
15 Calendar Days – A complete expedited report on the AE must be submitted within 15 
calendar days of learning of the AE 
1 Serious adverse events that occur more than 30 days after the last administration of 
investigational agent/intervention and have an attribution of probable or definite require reporting 
as follows: 
Expedited 24-hour notification followed by complete report within 7 calendar days for: 
• 
All Grade 3, 4, and 5 SAEs 
Expedited 15 calendar day reports for: 
• 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
 
 
 
Study Stopping Rules 
 This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable 
cause. If the study is prematurely terminated or suspended, the PI will promptly inform the IRB,  
FDA, and will provide the reason(s) for the termination or suspension.  
 

 
 
 
 
 
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45
Patient enrollment and treatment will be temporarily halted if the following rules occur, pending 
review by the UWCCC DSMC, and FDA if: 
• 
Any death, irrespective of attribution by the investigator  
• 
Any (CTCAE v5.0) of grade 4 or higher 
• 
Any hypersensitivity reaction grade 3 or higher at any time 
• 
Any grade 3 SAE in the first 3 subjects 
• 
Any 2 grade 3 or higher of the same SAE at any time during the study 
• 
5 or more grade 3 or higher SAEs that are at least possibly related at any time during the 
study 
 
Other circumstances that may warrant termination or suspension include, but are not limited to:  
• 
Determination of unexpected, significant, or unacceptable risk to subjects  
• 
Data that are not sufficiently complete and/or evaluable  
 
If the study is suspended, it will not be reopened without prior FDA approval and without protocol 
modifications if recommended by the FDA or UWCCC DMSC. If the study is suspended, all subjects 
will still be followed as specified in the protocol.  
 
Any change to the study stopping rules must first be reviewed by the FDA. 
 
17.0 
STUDY FEASIBILITY  
 
Economic Burden to Subjects 
Subjects will not have to pay for study procedures. The subject will not be billed by the healthcare 
system or their health insurance company for any costs related to a study procedure.  
 
Facilities and Locations 
All activities of the trial will be conducted at the UW Carbone Cancer Center, UW Hospital, Wisconsin 
Institute for Medical Research (WIMR) or UW Otoloaryngology Clinic.  
 
Feasibility of Recruiting the Required Number of Subjects 
The Department of Radiation Oncology sees 2-20 eligible subjects/week for follow-up. Less than five 
percent of the eligible subjects seen would need to be recruited in order to achieve the required 
number of clinical trial subjects.  
 
Principal Investigator Considerations 
Time Devoted to Conducting the Research 
Dr. Kimple has allocated a sufficient amount of time to be devoted to this clinical trial.  
Process for Informing Study Teams 
All research staff interacting with subjects will have completed HIPAA and human subjects 
training. Research staff will have been trained in salivary collection procedures. A board-certified 
otolaryngology physician (Dr. Glazer) from the Division of Otolaryngology-Head & Neck Surgery 
in the Department of Surgery at UW-Madison will administer the MSC IMP to subjects. Dr. Galzer 
has allocated a sufficient amount of time to be devoted to this clinical trial. 

 
 
 
 
 
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46
 
Availability of Medical or Psychological Resources 
Not applicable.  
18.0 
REFERENCES 
 
1. 
Marta GN, Silva V, de Andrade Carvalho H, et al. Intensity-modulated radiation therapy for head 
and neck cancer: systematic review and meta-analysis. Radiother Oncol. Jan 2014;110(1):9-15. 
doi:10.1016/j.radonc.2013.11.010 
2. 
Visvanathan V, Nix P. Managing the patient presenting with xerostomia: a review. Int J Clin Pract. 
Feb 2010;64(3):404-7. doi:10.1111/j.1742-1241.2009.02132.x 
3. 
Gornitsky M, Shenouda G, Sultanem K, et al. Double-blind randomized, placebo-controlled study 
of pilocarpine to salvage salivary gland function during radiotherapy of patients with head and neck cancer. 
Oral 
Surg 
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5. 
Shahdad SA, Taylor C, Barclay SC, Steen IN, Preshaw PM. A double-blind, crossover study of 
Biotene Oralbalance and BioXtra systems as salivary substitutes in patients with post-radiotherapy 
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6. 
Baum BJ. Principles of saliva secretion. Ann N Y Acad Sci. Sep 20 1993;694:17-23.  
7. 
Maimets M, Rocchi C, Bron R, et al. Long-Term In Vitro Expansion of Salivary Gland Stem Cells 
Driven by Wnt Signals. Stem Cell Reports. Jan 12 2016;6(1):150-62. doi:10.1016/j.stemcr.2015.11.009 
8. 
Xiao N, Lin Y, Cao H, et al. Neurotrophic factor GDNF promotes survival of salivary stem cells. J 
Clin Invest. Aug 2014;124(8):3364-77. doi:10.1172/jci74096 
9. 
Sensebe L, Bourin P, Tarte K. Good manufacturing practices production of mesenchymal 
stem/stromal cells. Hum Gene Ther. Jan 2011;22(1):19-26. doi:10.1089/hum.2010.197 
10. 
Dominici M, Le Blanc K, Mueller I, et al. Minimal criteria for defining multipotent mesenchymal 
stromal cells. The International Society for Cellular Therapy position statement. Cytotherapy. 
2006;8(4):315-7. doi:10.1080/14653240600855905 
11. 
Horwitz EM, Le Blanc K, Dominici M, et al. Clarification of the nomenclature for MSC: The 
International Society for Cellular Therapy position statement. Cytotherapy. 2005;7(5):393-5. 
doi:10.1080/14653240500319234 
12. 
Ren J, Jin P, Sabatino M, et al. Global transcriptome analysis of human bone marrow stromal cells 
(BMSC) reveals proliferative, mobile and interactive cells that produce abundant extracellular matrix 
proteins, some of which may affect BMSC potency. Cytotherapy. Jul 2011;13(6):661-74. 
doi:10.3109/14653249.2010.548379 
13. 
Romieu-Mourez R, Coutu DL, Galipeau J. The immune plasticity of mesenchymal stromal cells 
from mice and men: concordances and discrepancies. Front Biosci (Elite Ed). Jan 1 2012;4:824-37.  
14. 
Le Blanc K, Mougiakakos D. Multipotent mesenchymal stromal cells and the innate immune 
system. Nat Rev Immunol. Apr 25 2012;12(5):383-96. doi:10.1038/nri3209 
15. 
Burt RK, Loh Y, Pearce W, et al. Clinical applications of blood-derived and marrow-derived stem 
cells for nonmalignant diseases. Jama. Feb 27 2008;299(8):925-36. doi:10.1001/jama.299.8.925 
16. 
Aoki R, Shoshkes-Carmel M, Gao N, et al. Foxl1-expressing mesenchymal cells constitute the 
intestinal 
stem 
cell 
niche. 
Cell 
Mol 
Gastroenterol 
Hepatol. 
Feb 
1 
2016;2(2):175-188. 
doi:10.1016/j.jcmgh.2015.12.004 
17. 
Galipeau J, Sensebe L. Mesenchymal Stromal Cells: Clinical Challenges and Therapeutic 
Opportunities. Cell Stem Cell. Jun 1 2018;22(6):824-833. doi:10.1016/j.stem.2018.05.004 

 
 
 
 
 
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47
18. 
Chinnadurai R, Copland IB, Garcia MA, et al. Cryopreserved Mesenchymal Stromal Cells Are 
Susceptible to T-Cell Mediated Apoptosis Which Is Partly Rescued by IFNgamma Licensing. Stem Cells. 
Sep 2016;34(9):2429-42. doi:10.1002/stem.2415 
19. 
Chinnadurai R, Rajan D, Ng S, et al. Immune dysfunctionality of replicative senescent 
mesenchymal stromal cells is corrected by IFNgamma priming. Blood Adv. Apr 25 2017;1(11):628-643. 
doi:10.1182/bloodadvances.2017006205 
20. 
Kim DS, Jang IK, Lee MW, et al. Enhanced Immunosuppressive Properties of Human 
Mesenchymal Stem Cells Primed by Interferon-gamma. EBioMedicine. Feb 2018;28:261-273. 
doi:10.1016/j.ebiom.2018.01.002 
21. 
Jensen DH, Oliveri RS, Trojahn Kolle SF, et al. Mesenchymal stem cell therapy for salivary gland 
dysfunction and xerostomia: a systematic review of preclinical studies. Oral Surg Oral Med Oral Pathol 
Oral Radiol. Mar 2014;117(3):335-342.e1. doi:10.1016/j.oooo.2013.11.496 
22. 
Sumita Y, Liu Y, Khalili S, et al. Bone marrow-derived cells rescue salivary gland function in mice 
with 
head 
and 
neck 
irradiation. 
Int 
J 
Biochem 
Cell 
Biol. 
Jan 
2011;43(1):80-7. 
doi:10.1016/j.biocel.2010.09.023 
23. 
Tran SD, Sumita Y, Khalili S. Bone marrow-derived cells: A potential approach for the treatment of 
xerostomia. Int J Biochem Cell Biol. Jan 2011;43(1):5-9. doi:10.1016/j.biocel.2010.10.010 
24. 
Gronhoj C, Jensen DH, Vester-Glowinski P, et al. Safety and Efficacy of Mesenchymal Stem Cells 
for Radiation-Induced Xerostomia: A Randomized, Placebo-Controlled Phase 1/2 Trial (MESRIX). Int J 
Radiat Oncol Biol Phys. Jul 1 2018;101(3):581-592. doi:10.1016/j.ijrobp.2018.02.034 
25. 
Prockop DJ, Brenner M, Fibbe WE, et al. Defining the risks of mesenchymal stromal cell therapy. 
Cytotherapy. Sep 2010;12(5):576-8. doi:10.3109/14653249.2010.507330 
26. 
Casiraghi F, Remuzzi G, Abbate M, Perico N. Multipotent mesenchymal stromal cell therapy and 
risk of malignancies. Stem Cell Rev. Feb 2013;9(1):65-79. doi:10.1007/s12015-011-9345-4 
27. 
Bain BJ. Morbidity associated with bone marrow aspiration and trephine biopsy - a review of UK 
data for 2004. Haematologica. Sep 2006;91(9):1293-4.  
28. 
Kim YH, Cha SM, Naidu S, Hwang WJ. Analysis of postoperative complications for superficial 
liposuction: 
a 
review 
of 
2398 
cases. 
Plast 
Reconstr 
Surg. 
Feb 
2011;127(2):863-71. 
doi:10.1097/PRS.0b013e318200afbf 
29. 
Roustaei N, Masoumi Lari SJ, Chalian M, Chalian H, Bakhshandeh H. Safety of ultrasound-assisted 
liposuction: a survey of 660 operations. Aesthetic Plast Surg. Mar 2009;33(2):213-8. doi:10.1007/s00266-
008-9293-9 
30. 
Mamidi MK, Singh G, Husin JM, et al. Impact of passing mesenchymal stem cells through smaller 
bore size needles for subsequent use in patients for clinical or cosmetic indications. J Transl Med. Nov 21 
2012;10:229. doi:10.1186/1479-5876-10-229 
31. 
Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing Numerical Rating Scales, Verbal 
Rating Scales, and Visual Analogue Scales for assessment of pain intensity in adults: a systematic 
literature 
review. 
J 
Pain 
Symptom 
Manage. 
Jun 
2011;41(6):1073-93. 
doi:10.1016/j.jpainsymman.2010.08.016 
32. 
Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in pain 
intensity measurement? Pain. Sep 1994;58(3):387-92. doi:10.1016/0304-3959(94)90133-3 
33. 
Henson BS, Inglehart MR, Eisbruch A, Ship JA. Preserved salivary output and xerostomia-related 
quality of life in head and neck cancer patients receiving parotid-sparing radiotherapy. Oral Oncol. Jan 
2001;37(1):84-93.  
34. 
Chen AY, Frankowski R, Bishop-Leone J, et al. The development and validation of a dysphagia-
specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia 
inventory. Arch Otolaryngol Head Neck Surg. Jul 2001;127(7):870-6.  
35. 
Pai S, Ghezzi EM, Ship JA. Development of a Visual Analogue Scale questionnaire for subjective 
assessment of salivary dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 
2001;91(3):311-6. doi:10.1067/moe.2001.111551 
36. 
Navazesh M, Kumar SK. Measuring salivary flow: challenges and opportunities. J Am Dent Assoc. 
May 2008;139 Suppl:35s-40s.  
37. 
Navazesh M. Methods for collecting saliva. Ann N Y Acad Sci. Sep 20 1993;694:72-7.  

 
 
 
 
 
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48
38. 
Kaae JK, Stenfeldt L, Eriksen JG. Xerostomia after Radiotherapy for Oral and Oropharyngeal 
Cancer: Increasing Salivary Flow with Tasteless Sugar-free Chewing Gum. Front Oncol. 2016;6:111. 
doi:10.3389/fonc.2016.00111 
39. 
Chitra S, Shyamala Devi CS. Effects of radiation and alpha-tocopherol on saliva flow rate, amylase 
activity, total protein and electrolyte levels in oral cavity cancer. Indian J Dent Res. Jul-Sep 2008;19(3):213-
8.  
40. 
Sim C, Soong YL, Pang E, et al. Xerostomia, salivary characteristics and gland volumes following 
intensity-modulated radiotherapy for nasopharyngeal carcinoma: a two-year follow up. Aust Dent J. Jun 
2018;63(2):217-223. doi:10.1111/adj.12608 
41. 
Richards TM, Hurley T, Grove L, et al. The effect of parotid gland-sparing intensity-modulated 
radiotherapy on salivary composition, flow rate and xerostomia measures. Oral Dis. Oct 2017;23(7):990-
1000. doi:10.1111/odi.12686 
42. 
Valdez IH, Atkinson JC, Ship JA, Fox PC. Major salivary gland function in patients with radiation-
induced xerostomia: flow rates and sialochemistry. Int J Radiat Oncol Biol Phys. Jan 1993;25(1):41-7.  
43. 
Almstahl A, Wikstrom M, Groenink J. Lactoferrin, amylase and mucin MUC5B and their relation to 
the oral microflora in hyposalivation of different origins. Oral Microbiol Immunol. Dec 2001;16(6):345-52.  
44. 
Dijkema T, Terhaard CH, Roesink JM, et al. MUC5B levels in submandibular gland saliva of 
patients treated with radiotherapy for head-and-neck cancer: a pilot study. Radiat Oncol. Jun 15 2012;7:91. 
doi:10.1186/1748-717x-7-91 
45. 
Bialek EJ, Jakubowski W, Zajkowski P, Szopinski KT, Osmolski A. US of the major salivary glands: 
anatomy and spatial relationships, pathologic conditions, and pitfalls. Radiographics. May-Jun 
2006;26(3):745-63. doi:10.1148/rg.263055024 
46. 
Cindil E, Oktar SO, Akkan K, et al. Ultrasound elastography in assessment of salivary glands 
involvement 
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Jul 
- 
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2018;50:229-234. 
doi:10.1016/j.clinimag.2018.04.011 
47. 
Zhang S, Zhu J, Zhang X, He J, Li J. Assessment of the Stiffness of Major Salivary Glands in 
Primary Sjogren's Syndrome through Quantitative Acoustic Radiation Force Impulse Imaging. Ultrasound 
Med Biol. Mar 2016;42(3):645-53. doi:10.1016/j.ultrasmedbio.2015.11.009 
48. 
National Research Council Panel on Handling Missing Data in Clinical T. The Prevention and 
Treatment of Missing Data in Clinical Trials. National Academies Press (US) 
Copyright 2010 by the National Academy of Sciences. All rights reserved.; 2010. 
49. 
Little RJ, D'Agostino R, Cohen ML, et al. The prevention and treatment of missing data in clinical 
trials. N Engl J Med. Oct 4 2012;367(14):1355-60. doi:10.1056/NEJMsr1203730 
 
 
 

 
 
 
 
 
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19.0 
APPENDICES 
 
XeQoL  
 
 
Scoring: Each of the 15 items receive a score of 0 to 4. Items 1-14 are scored as: 0=not at all; 1=a little; 
2=somewhat;3=quite a bit;4=very much. Item 15 is scored as: 0=delighted; 1=mostly satisfied; 2=mixed: 
equally saistifed/dissatisfied; 3= mostly dissatisfied; 4=terrible. Physical functioning is based upon 
responses to items Nos.1, 6, 10, 12. Pain/discomfort issues are based upon responses to items Nos. 2, 
3, 7, 9. Personal/psychological functioning is based upon responses to items Nos. 8, 13, 14, 15. Social 
functioning is based upon responses to items Nos. 4, 5, 11. Each XeQoLS domain score is calculated by 

 
 
 
 
 
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50
averaging the values of all the respective items for that individual domain (maximum score per scale: 4). 
A total average XeQoLS score can also be calculated, if overall XeQoL is of interest. 
Source: Henson BS, Inglehart MR, Eisbruch A, Ship JA. Preserved salivary output and xerostomia-
related quality of life in head and neck cancer patients receiving parotid-sparing radiotherapy. Oral 
Oncology 2001;37(1):84-93.  
 
 

 
 
 
 
 
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MDADI Questionnaire 
 

 
 
 
 
 
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52
 
 
 

 
 
 
 
 
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53
 
 
 

 
 
 
 
 
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54
 
VAS Xerostomia Questionnaire 
 
 
 
 

 
 
 
 
 
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55
 
Stability Documentation  
 
Test 
Criteria 
Specifications 
T=0 
(09FEB2022) 
T=1 
(29JUN2022) 
T=2 
(11JAN2023) 
Purity 
%CD45+ 
≤ 5% 
0% 
1% 
0% 
Identity 
%CD105+ 
≥ 95% 
100% 
100% 
100% 
%CD90+ 
≥ 95% 
100% 
100% 
99% 
%CD73+ 
≥ 95% 
100% 
100% 
100% 
Potency 
Fold 
increase 
in MFI 
after IFNɣ 
stimulation 
≥ 2 for MHC I 
5 
4 
4 
≥ 2 for MHC II 
11 
11 
10 
≥ 2 for ICAM 
70 
67 
50 
≥ 2 for IDO 
17 
14 
13 
≥ 2 for PD-L1 
4 
4 
4 
Viability 
% viable 
cells 
≥70% 
96% 
97% 
98%