H3.3K27M Specific Peptide Vaccine Combined With Poly-ICLC With and Without PD-1 Inhibition Using Nivolumab for the Treatment of Newly Diagnosed HLA-A2 (02:01)+ H3.3K27M Positive Diffuse Intrinsic Pontine Glioma (DIPG) and Newly Diagnosed HLA-A2 (02:01)+ H3.3K27M Positive Gliomas
Phase: PHASE1
Conditions: Diffuse Intrinsic Pontine Glioma, Glioma, Diffuse Midline Glioma, H3 K27M-Mutant
Sponsor: Sabine Mueller, MD, PhD

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H3.3K27M Specific Peptide Vaccine Combined with poly-ICLC with and without PD-1 
inhibition using Nivolumab for the Treatment of newly diagnosed HLA-A2 (02:01)+ 
H3.3K27M Positive Diffuse Intrinsic Pontine Glioma (DIPG) and newly diagnosed HLA-
A2 (02:01)+ H3.3K27M Positive Gliomas
Protocol Number: PNOC 007 (CC# 150819)
IND Number: 17070 
BMS Protocol #: CA209-8TX
Study Intervention: H3.3K27M Peptide Vaccine plus Tetanus Toxoid emulsified in Montanide 
with co-administration of poly-ICLC and Nivolumab
Version Number:  2.0
Version Date:  March 1, 2021
Study Chair
Sabine Mueller, MD, PhD, MAS
University of California, San Francisco (UCSF)
Co-Chair
Hideho Okada, MD, PhD
HDFCC
Mission Bay Campus, Room HD 
472
Co-Chair
Michael Prados, MD
University of California, San 
Francisco
 
Statistician
Annette Molinaro, PhD
UCSF Department of Neurosurgery
Study Nurse
Primary Nurse
Shannon Raber, RN, MS, CPNPAC
UCSF Benioff Children’s Hospital
   
Study Nurse
Secondary Nurse
Carly Hoffman, RN, MS, CPNPAC,
CPON
UCSF Benioff Children’s Hospital
 
Coordinating Center
Pacific Pediatric Neuro-Oncology 
Consortium
Sandler Neurosciences Building
Telephone: (415) 502-1600
PNOC_Regulatory@ucsf.edu
NCT02960230

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Pacific Pediatric Neuro-Oncology Consortium Institutions
Ann & Robert H. Lurie Children’s Hospital of 
Chicago
PI: Angela Waanders, MD, MPH
 
Children’s Hospital Los Angeles
PI:  Ashley Margol, MD
Co-PI: Tom Belle Davidson, MD
Children’s National Medical Center
PI: Lindsay Kilburn, MD
Co-PI: Roger Packer, MD
Dana-Farber Cancer Institute, Harvard 
University
PI: Susan Chi, MD
Co-PI: Tabitha Cooney, MD
Doernbecher Children’s Hospital
Oregon Health & Science University
PI:  Linda Stork, MD
Co-PI: Matthew Miller, MD
Johns Hopkins Hospital
PI: Kenneth Cohen, MD MBA
Co-PI: Eric Raabe, MD
Nationwide Children’s Hospital
PI:  Diana Osorio, MD
Co-PI: Maryam Fouladi, MD, MSc, FRCP
 
Rady Children’s Hospital
University of California, San Diego
PI: John Crawford, MD, MS
Co-PI: Jennifer Elster, MD
Seattle Children’s Hospital
University of Washington, Seattle
PI:  Sarah Leary, MD
Co-PI: Nicholas Vitanza, MD
  
St. Jude Children’s Research Hospital
PI: Amar Gajjar, MD
Co-PI: Christopher Tinkle, MD
 
St. Louis Children’s Hospital
Washington University in St. Louis
PI: Mohamed Shebl Abdelbaki, MD
Co-PI: Josh Rubin, MD, PhD
Texas Children’s Hospital
PI: Patty Baxter, MD
Co-PI: Will Parsons, MD PhD

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The Children’s Hospital of Philadelphia
PI:  Cassie Kline, MD MAS
Co-PI: Jane Minturn, MD PhD
  
UCSF Benioff Children’s Hospital 
University of California, San Francisco 
PI:  Sabine Mueller, MD, PhD, MAS
Co-PI: Alyssa Reddy, MD
 
University of Florida
PI: Sri Gururangan, FRCP
Co-PI: Elias Sayour, MD PhD
 
Children’s Minnesota
PI: Anne Bendel, MD
Co-PI: Maggie Skrypek, MD
 
University of Utah
PI: Nicholas Whipple, MD, MPH
Co-PI: Carol Bruggers MD
 
University of Michigan
C.S. Mott Children's Hospital
PI: Andrea Franson, MD MS
Co-PI: Carl Koschmann, MD
 
Pacific Pediatric Neuro-Oncology Participating Sites
Massachusetts General Hospital 
(in connection with DFCI)
PI: David Ebb, MD
 
 
UCSF Benioff Children’s Hospital Oakland 
(in connection with UCSF Benioff San Francisco)
Non-IND Sites
The University Children’s Hospital in 
Zurich
PI: Nicolas Gerber, MD
Co-PI: Ana Guerreiro Stuecklin, MD PhD
 

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Pacific Pediatric Neuro-Oncology International Collaborators
Australia & New Zealand Children’s 
Hematology/Oncology Group (ANZCHOG)
PI: David Ziegler, BSc(Med), MBBS, FRACP, 
MD/PhD 
Co-PI: Nick Gottardo MB ChB FRACP PhD 
The University Children’s Hospital in Zurich
PI: Nicolas Gerber, MD
Co-PI: Ana Guerreiro Stücklin, MD, PhD
 

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Protocol Signature Page
Protocol No.: PNOC 007
Version Date: 3-1-2021
1.
I agree to follow this protocol version as approved by the UCSF Protocol Review Committee (PRC), 
Institutional Review Board (IRB), and Data Safety Monitoring Committee (DSMC). 
2.
I will conduct the study in accordance with Good Clinical Practices (ICH-GCP) and the applicable 
IRB, ethical, federal, state, and local regulatory requirements.
3.
I certify that I, and the study staff, have received the requisite training to conduct this research 
protocol. 
4.
I agree to maintain adequate and accurate records in accordance with IRB policies, Federal, state 
and local laws and regulations.
Study Chair
Printed Name
Signature
Date

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Protocol Signature Page
Protocol No.: PNOC 007
Version Date: 3-1-2021
Participating Site(s)
I have read this protocol and agree to conduct the protocol in accordance with Good Clinical Practices 
(ICH-GCP) and the applicable IRB, ethical, federal, state, and local regulatory requirements.  
Principal Investigator
Site
Printed Name
Institution Name
Signature
Date

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Abstract
Title
H3.3K27M Specific Peptide Vaccine Combined with poly-ICLC and Nivolumab for 
the Treatment of newly diagnosed HLA-A2 (02:01)+ H3.3K27M Positive Diffuse 
Intrinsic Pontine Glioma (DIPG) and newly diagnosed HLA-A2 (02:01)+ H3.3K27M 
Positive Midline Gliomas
Subject 
Population
Children and young adults (ages 3-21) with newly diagnosed DIPG or newly 
diagnosed other midline gliomas, positive for HLA-A2 (02:01)+ and H3.3K27M.
Rationale for 
Study
Currently, there are no effective therapies for pediatric malignant gliomas. Gliomas 
located within midline structures – such as DIPG – have a particularly poor 
prognosis.  Immunotherapy, such as active vaccinations, has the potential to 
develop as an effective and safe modality for these patients.  Vaccines using 
specific peptides, in comparison to whole glioma-derived antigens, are expected to 
be more feasible because these vaccines may induce glioma-specific immune 
responses without theoretical concerns of auto-immune encephalitis.  In addition, 
these vaccines can be generated “off the shelf” owing to the use of synthetic 
antigen peptides and Montanide ISA-51.  Use of modified peptides (peptides in 
which amino acid residues are replaced from the wild-type sequence) may allow us 
to induce more efficient T cell responses than natural antigens in whole glioma 
cells.  Furthermore, based on recently published laboratory data, administration of 
poly-ICLC along with the synthetic peptides remarkably enhances the induction of 
anti-peptide cytotoxic T lymphocyte (CTL) responses and trafficking of antigen-
specific T cells to the brain tumor sites.
Programmed cell death protein 1 (PD-1) plays an important role in suppressing the 
immune system by inhibiting T cell inflammatory activity and has been shown to 
play a role in tumor evasion of the immune system. PD-1 allows tumor cells to “turn 
off” T cell mediated immune response and prevent immune-mediated attack on the 
tumor. We hypothesize that the combination of PD-1 inhibition with the H3.3K27M 
specific peptide vaccine will improve activity of the peptide vaccine, by amplifying 
the response of peptide-primed T cells against the tumor. 
Utilizing the H3.3K27M peptide as monotherapy, we have shown that the peptide 
vaccine approach is reasonably well tolerated in patients with newly diagnosed 
DIPG (Stratum A) or newly diagnosed other midline gliomas (Stratum B), positive 
for HLA-A2 and H3.3K27M. Based on these initial safety results, we will now 
assess the combination of the peptide vaccine with PD-1 inhibition, using 
nivolumab (Stratum C). 
We will conduct a multicenter study evaluating the safety and immune activity of a 
synthetic peptide vaccine specific for the H3.3.K27M epitope given in combination 
with poly-ICLC and the H3.3.K27M epitope given in combination with poly-ICLC 
and the PD-1 inhibitor, nivolumab, in HLA-A2 (02:01)+ children with newly 

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diagnosed DIPG or other midline gliomas that are positive for H3.3K27M.
Primary 
Objectives

Stratum A 
o
To determine the overall survival at 12 months (OS12) in HLA-A2 
(02:01)+ children with DIPG that are treated with repeated administration 
of the H3.3K27M peptide.
o    To assess the safety of repeated administration of the H3.3K27M 
epitope specific vaccine in HLA-A2 (02:01)+ children with H3.3K27M 
positive DIPGs.

Stratum B
o
To assess the safety of repeated administration of the H3.3K27M 
epitope specific vaccine in HLA-A2 (02:01)+ children with H3.3K27M 
positive midline gliomas other than DIPG.

Stratum C
o
To assess the safety of repeated administration of the H3.3K27M 
epitope specific vaccine in combination with nivolumab in HLA-A2 
(02:01)+ children with H3.3K27M DIPG and positive midline gliomas 
other than DIPG (excluding primary spinal cord tumors).
Exploratory 
Objectives
Stratum A: 

Induction of the H3.3K27M epitope-specific CTL response in post vaccine 
PBMCs in HLA-A2 (02:01)+ children with H3.3K27M positive gliomas other than 
DIPG

Assessment of H3.3K27M infiltrates in subjects with evidence of progression 
that undergo tissue collection as part of their standard of care. Tumor tissue will 
be analyzed for H3.3K27M expression status and infiltration of H3.3K27M 
specific T cells

To archive tumor and normal DNA from each subject at time of initial diagnosis 
along with serial blood draws following therapy to determine whether circulating 
tumor DNA (ctDNA) sequences in the subject’s blood serve as biomarkers of 
tumor burden, response to therapy, or development of drug resistance.
Stratum B: 

Induction of the H3.3K27M epitope-specific CTL response in post vaccine 
PBMCs in HLA-A2 (02:01)+ children with H3.3K27M positive gliomas other than 
DIPG

Assessment of H3.3K27M infiltrates in subjects with evidence of progression 
that undergo tissue collection as part of their standard of care. Tumor tissue will 

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be analyzed for H3.3K27M expression status and infiltration of H3.3K27M 
specific T cells

To archive tumor and normal DNA from each subject at time of initial diagnosis 
along with serial blood draws following therapy to determine whether circulating 
tumor DNA (ctDNA) sequences in the subject’s blood serve as biomarkers of 
tumor burden, response to therapy, or development of drug resistance.
Stratum C: 

To determine the OS12 in HLA-A2 (02:01)+ children with H3.3K27 positive 
DIPGs and midline gliomas (excluding primary spinal cord tumors) that are 
treated with repeated administration of the H3.3K27M peptide and nivolumab.

Induction of the H3.3K27M epitope-specific CTL response in post vaccine 
PBMCs in HLA-A2 (02:01)+ children with H3.3K27M DIPG and other positive 
gliomas other than DIPG (excluding primary spinal cord tumors).

To archive tumor and normal DNA from each subject at time of initial diagnosis 
along with serial blood draws following therapy to determine whether circulating 
tumor DNA (ctDNA) sequences in the subject’s blood serve as biomarkers of 
tumor burden, response to therapy, or development of drug resistance.

To assess Quality of Life (QoL) and cognitive measures in HLA-A2 (02:01)+ 
children with H3.3K27M positive DIPG or other midline gliomas.
Study Design
This is 3-arm, multicenter study that will be conducted through the Pacific Pediatric 
Neuro-oncology Consortium (PNOC). 
Stratum A consists of HLA-A2 (02:01)+ positive subjects with newly diagnosed 
H3.3K27M positive DIPG. 
Stratum B consists of HLA-A2 (02:01)+ positive subjects with newly midline 
diagnosed H3.3K27M positive gliomas that are not classified as DIPG, including 
spinal cord tumors. 
Stratum C consists of newly diagnosed DIPG or newly diagnosed other midline 
gliomas (excluding primary spinal cord tumors), positive for HLA-A2 (02:01) and 
H3.3K27M.
Once we have completed accrual onto strata A and B (subjects who have received 
vaccine peptide + poly-ICLC alone), we will enroll subjects onto stratum C (subjects 
will receive the combination of nivolumab and vaccine peptide + poly-ICLC).
Number of 
subjects
This trial will enroll a total of:
Stratum A - 19 evaluable HLA-A2 (02:01)+ positive subjects with newly diagnosed 
H3.3K27M positive DIPG.
Stratum B - 10 evaluable HLA-A2 (02:01)+ positive subjects with newly diagnosed 
midline H3.3K27M positive gliomas, including spinal cord tumors, 

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Stratum C - 20 newly diagnosed H3.3K27M and HLA-A2 (02:01)+ positive subjects 
with newly diagnosed DIPG or other midline H3.3K27M positive gliomas (excluding 
primary spinal cord tumors).
Duration of 
Therapy
In the absence of tumor progression, subjects may continue treatment for 96 weeks 
or about ~24 months from the time of study entry. 
Duration of 
Follow up
Subjects will be followed for 24 months after completion of treatment, or until 
removal from study or death, whichever occurs first.  
Duration of 
study
Enrollment into strata A, B and C will be completed in approximately 4 years and 
the primary efficacy endpoint is OS12. We therefore anticipate that we will 
complete the study in approximately 6 years. 
Study Drugs
The synthetic H3.3K27M peptide and helper peptide (Tetanus Toxoid) will be 
included in the vaccine formulation. The combined H3.3K27M and Tetanus Toxoid 
will be referred to as K27M/TT peptide. These will be emulsified in Montanide prior 
to administration.         
Poly-ICLC is a synthetic complex of polyinosinic and polycytidylic acid, stabilized 
with polylysine and carboxymethyl cellulose. This will be co-administered with 
K27M/TT peptide to improve therapeutic efficacy.   
Nivolumab is an anti-PD-1 monoclonal antibody, which has received FDA approval 
for treatment of metastatic melanoma, non-small cell lung cancer, and other adult 
malignancies, but has not received approval for pediatric brain tumors.     
Safety 
Assessments
Analyses will be performed for all subjects having received at least one course of 
study therapy, which constitutes K27M/TT peptide and poly ICLC treatment (Strata 
A and B) as well as K27M/TT peptide, poly ICLC plus nivolumab (Stratum C). The 
safety parameters include all laboratory tests and imaging evaluations, physical 
findings, and spontaneous reports of adverse events reported to the investigator by 
subjects.
Each subject will be assessed for the development of any toxicity or adverse event 
as outlined in the Study Calendar.  The study will use the CTCAE v 5.0 for 
assessing all adverse events. 
The Study Chair is responsible for the overall conduct of the study and for 
monitoring its safety and progress at all participating sites.
Efficacy 
Assessments
Overall Survival at 12 months for stratum A and stratum C.
Unique Aspects 
of this Study
This is the first study to evaluate the safety and efficacy of specific synthetic 
peptide for the H3.3.K27M epitope alone and in combination with PD-1 inhibition 
with nivolumab in HLA-A2 (02:01)+ children with newly diagnosed H3.3K27M 

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positive DIPG or other H3.3K27M positive midline gliomas.
Therapy Schema
 

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List of Abbreviations
AE
adverse event
ALP
alkaline phosphatase
ALT
alanine aminotransferase
ANC
absolute neutrophil count
AST
aspartate aminotransferase
BUN
blood urea nitrogen
CBC
complete blood cell (count)
CR
complete response
CRC
Clinical Research Coordinator
CRF
case report form
CSF
cerebral spinal fluid
CTCAE
CTL
Common Terminology Criteria for Adverse Events
Cytotoxic T Lymphocyte
CTMS
DIPG
Clinical Trial Management System
Diffuse intrinsic pontine glioma
DLT
dose limiting toxicity
DSMC
Data and Safety Monitoring Committee
DSMP
Data and Safety Monitoring Plan
FDA
GAA
GBM
Food and Drug Administration
Glioma associated antigens
Glioblastoma multiforme
GCP
GMP
Good Clinical Practice
Good Manufacturing Practice
HDFCCC
Helen Diller Family Comprehensive Cancer Center
HGB
HGG
HLA
IFA
IHC
IM
Hemoglobin
High grade glioma
Human leukocyte antigen
Incomplete Freund’s adjuvant
immunohistochemistry
intramuscular
IND
investigational new drug application
IRB
Institutional Review Board
IV
K27M/TT
Intravenous
H3.3K27M/Tetanus Toxoid vaccine

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List of Abbreviations
MRI
NABTC
NABTT
magnetic resonance imaging
North American Brain Tumor Consortium
New Approaches for Brain Tumor Therapy
NCI
National Cancer Institute
ORR
OSR
OS12
PBMC
overall response rate
overall survival rate
Overall survival at 12 months
Peripheral blood mononuclear cell
PD
PD-1
Poly-ICLC
Progressive disease
Programmed cell death protein 1
Polyinosinic-Polycytidylic acid with polylysine and carboxymethylcellulose
PR
partial response
PRC
Protocol Review Committee (UCSF)
RLT
RT-PCR
SAE
SD
Regimen limiting toxicity
Reverse transcriptase polymerase chain reaction
Serious adverse event
stable disease
SD
standard deviation
SGOT
serum glutamic oxaloacetic transaminase
SGPT
SOP
Th
TIL
TLR3
TT
serum glutamic pyruvic transaminase
standard operating procedure
T helper cell
Tumor infiltrating lymphocytes
Toll-like receptor 3
Tetanus Toxoid
ULN
upper limit of normal
WBC
white blood cell (count)

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Table of Contents
Pacific Pediatric Neuro-Oncology Consortium Institutions......................................................2
Protocol Signature Page (Study Chair)............................................................................................5
Protocol Signature Page...................................................................................................................6
Abstract……
................................................................................................................................7
Therapy Schema ............................................................................................................................11
List of Abbreviations .....................................................................................................................12
Table of Contents...........................................................................................................................14
1
Introduction ............................................................................................................................17
1.1
Background on Indication.............................................................................................17
1.2
Background on the Compounds....................................................................................19
1.3
Rationale for the Proposed Study..................................................................................23
2
Objectives of the Study ..........................................................................................................24
2.1
Primary Objectives........................................................................................................24
2.2
Exploratory Objectives, Other Assessments.................................................................24
3
Study Design ..........................................................................................................................25
3.1
Number of Subjects.......................................................................................................26
3.2
Eligibility Criteria .........................................................................................................26
3.2.1
Inclusion Criteria...................................................................................................26
3.2.2
Exclusion Criteria..................................................................................................28
3.3
Duration of Therapy......................................................................................................29
3.4
Duration of Follow Up..................................................................................................29
3.5
Study Timeline..............................................................................................................29
3.6
Study Completion..........................................................................................................29
4
REGISTRATION PROCEDURES........................................................................................29
4.1
General Guidelines........................................................................................................29
4.2
Reservation and Registration Process ...........................................................................30
5
Study Drugs............................................................................................................................30
5.1
Description, Supply and Storage of Investigational Drugs...........................................30
5.1.1
H3.3K27M peptide................................................................................................30
5.1.2
Tetanus Toxoid......................................................................................................31
5.1.3
K27M/TT Peptide..................................................................................................31
5.1.4
Poly-ICLC .............................................................................................................33
5.1.5
Summary of Common AEs ...................................................................................35
5.1.6
Nivolumab.............................................................................................................35
5.2
Drug Accountability......................................................................................................37
5.3
Drug Ordering ...............................................................................................................37
6
Treatment Plan........................................................................................................................37
6.1
Dosage and Administration...........................................................................................38
6.1.1
Dosage...................................................................................................................38

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6.1.2
Treatment Administration .....................................................................................39
6.2
Dose Modifications and Dosing Delays........................................................................40
6.2.1
Dose Modifications for Poly-ICLC.......................................................................40
6.2.2
Dosing Delay for the Peptide Vaccines (K27M/TT emulsified in Montanide ISA-
51)
41
6.2.3
Dose modification for Nivolumab.........................................................................41
6.2.4
Pseudo-progression (please refer to the flow diagram in Table 7.1).....................41
6.3
Regimen Limiting Toxicity (RLT)................................................................................42
6.4
Suspected Myocarditis ..................................................................................................42
7
Study Procedures and Observations .......................................................................................43
7.1
Schedule of Procedures and Observations ....................................................................43
7.1.1
Eligibility Assessments .........................................................................................43
7.1.2
Treatment Period ...................................................................................................44
7.1.3
Every 3 months (+/- 14 days)................................................................................48
7.1.4
Every 6 months for two years then every 12 months after two years, while on 
treatment (+/- 14 days).......................................................................................................48
7.1.5
End-of-Treatment Study Procedures (-14 days) (all strata, unless otherwise 
indicated)............................................................................................................................48
7.1.6
30 Day Toxicity Check..........................................................................................49
7.1.7
Every 12 months during Follow-up (+/- 14 days).................................................49
7.1.8
Long Term/Survival Follow-up Procedures..........................................................49
7.2
Off Study Criteria..........................................................................................................49
7.3
Dietary Restrictions.......................................................................................................54
7.4
Prohibited Medications .................................................................................................54
8
Quality of Life Surveys ..........................................................................................................54
9
Monitoring of Response .........................................................................................................55
9.1
Immuno-monitoring ......................................................................................................55
9.2
Enzyme Linked Immuno-SPOT (ELISPOT) Assays....................................................55
9.2.1
Tetramer Analysis of K27M-reactive T cells in Participant’s PBMC ..................56
9.2.2
Evaluation of Primary and Recurrent Tumor Tissues...........................................57
9.3
Evaluation of Efficacy (or Activity)..............................................................................57
9.3.1
Antitumor Effect....................................................................................................57
9.4
Evaluation of Safety......................................................................................................62
9.5
Definitions of Adverse Events ......................................................................................62
9.5.1
Adverse Event .......................................................................................................62
9.5.2
Adverse Reaction ..................................................................................................63
9.6
Recording of an Adverse Event ....................................................................................64
9.7
Follow-up of Adverse Events........................................................................................65
9.8
Adverse Event Monitoring............................................................................................65
9.9
SAEs and Expedited Reporting.....................................................................................65
9.10 PNOC Reporting ...........................................................................................................67
9.10.1 Reporting to the UCSF Data and Safety Monitoring Committee .........................67
9.10.2 PNOC Reporting to UCSF Institutional Review Board (IRB)..............................67

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Table of Contents
9.10.3 Sponsor-Investigator (PNOC) Reporting to the Food and Drug Administration 
(FDA) 68
9.10.4 Sponsor-Investigator (PNOC) Reporting to Bristol-Myers Squibb (BMS) ..........69
10 Statistical Considerations and Evaluation of Results .............................................................72
10.1 Study Endpoints ............................................................................................................72
10.1.1 Primary Endpoints.................................................................................................72
10.1.2 Exploratory Endpoints...........................................................................................72
10.1.3 Stratification Factors .............................................................................................73
10.1.4 Design....................................................................................................................74
10.2 Determination of Sample Size and Accrual Rate..........................................................74
10.2.1 Sample Size and Power Estimate ..........................................................................74
10.2.2 Accrual estimates ..................................................................................................75
10.3 Interim Analyses and Stopping Rules...........................................................................76
10.3.1 Analysis Population...............................................................................................77
10.3.2 Analysis of Primary Endpoints..............................................................................77
10.3.3 Analysis of Secondary Endpoints..........................................................................77
10.3.4 Other Analyses/Assessments.................................................................................78
10.4 Evaluation of Safety......................................................................................................78
11 Data Reporting/Regulatory Requirements .............................................................................78
11.1 Data Reporting ..............................................................................................................78
11.1.1 Method...................................................................................................................78
11.2 PNOC Oversight and Monitoring Plan .........................................................................79
11.3 Multicenter Communication .........................................................................................79
11.4 Record Keeping and Record Retention.........................................................................79
11.5 Coordinating Center Documentation of Distribution....................................................80
11.6 Regulatory Documentation ...........................................................................................80
12 Protection of Human Subjects................................................................................................80
12.1 Protection from Unnecessary Harm..............................................................................80
12.2 Protection of Privacy.....................................................................................................81
13 References82
14 Appendices .............................................................................................................................84
Appendix A
Performance Status Criteria .................................................................................84
Appendix B
PNOC Institutions Required Regulatory Documents...........................................85
Appendix C
Required Data and Time Table for Submission...................................................86
Appendix D
 PNOC Data and Safety Monitoring ....................................................................87
Appendix E
 Specimen Collection Immuno-Monitoring .........................................................90
Appendix F Biospecimen Banking................................................................................................91
Appendix G
 Medications Associated With Prolonged QTc....................................................92
Appendix H Quality of Life Measures ..........................................................................................94
Appendix I
 Management Algorithms.....................................................................................99

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1
Introduction
1.1
Background on Indication
Overview
Malignant gliomas, including glioblastoma (GBM) and diffuse intrinsic pontine gliomas (DIPG) are lethal 
brain tumors in both adults and children. Indeed, brain tumors are the leading cause of cancer-related 
mortality and morbidity in children. Children with DIPG have one-year progression-free survival (PFS) 
rates below 25%, and median overall survival (OS) of 9 to 10 months with current treatment.1 
Histological grading plays no part in this disease.2 Recent genetic studies have revealed that malignant 
gliomas in children often show recurrent missense mutations in H3F3A, which encodes the replication-
independent histone 3 variant H3.3.2-4  Approximately 30% of pediatric glioblastoma3 and 70% of DIPG 
5 cases harbor the amino-acid substitution from lysine (K) to methionine (M) at the position 27 of H3.3 
(K27M mutation, hereafter), which is universally associated with shorter survival in DIPG patients 
compared with patients with non-mutated H3.35. 
Recent studies have shown that the phenotypic and molecular features of DIPG are highly similar to 
other pediatric HGG arising in anatomical midline structures (e.g. thalamus, spinal cord – midline HGG) 
and that currently these midline HGG are considered to present a spectrum along a single clinico-
pathological entity 6-8. The defining H3K27M mutation of these tumors has been shown to co-segregate 
non-randomly with specific partner mutations dependent on H3 subtype and anatomical location. 
H3.3K27M mutations are frequently found in conjunction with alterations in the p53 pathway (TP53, 
PPM1D, ATM), along with receptor tyrosine kinase amplification/mutation in PDGFRA (DIPG) or 
FGFR1 (other midline gliomas). By contrast, H3.1K27M mutations are almost exclusively found in 
DIPGs, are p53 wild-type, and instead harbor alterations in the TGF/BMP receptor ACVR1 and 
downstream PI3-kinase pathway genes (PIK3CA, PIK3R1) 2,9-11. The H3K27M mutations appear to be 
early clonal events in midline gliomagenesis, co-segregating mutations are frequently found at 
subclonal frequencies, and may demonstrate evidence of convergent or parallel evolution across 
tempero-spatial disease progression 12,13. The outcome for these tumors is universally poor with OS 
rates similar to DIPGs – overall survival rates of 30-40% at 12 months and less than 10% survival at 2 
years. 
The adaptive immune system, such as T-lymphocytes (T cells hereafter), is often tolerant to normal 
self-proteins, but can recognize mutated amino-acids as non-self. Hence cancer-specific mutations can 
be suitable targets for cancer immunotherapy, such as cancer vaccines and adoptive T cell transfer 
therapy. Dr. Okada and his colleagues at the University of Pittsburgh recently conducted one of the first 
vaccine studies in pediatric patients including DIPG and demonstrated robust and specific T cell 
responses against non-mutated, but immunogenic antigens that are overexpressed in glioma cells.14 
Although these data show safety of vaccines targeting these non-mutated antigens,14 it has also been 
reported that immunotherapy targeting non-mutated, non-cancer-specific antigens can cause fatal 
adverse events due to the off-target effects. Therefore, there is a strong demand for finding cancer-

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specific targets given the availability of powerful technologies for inducing immune responses in 
patients. 
Dr. Okada has recently found that a specific peptide that includes the K27M mutation (H3.3K27M 
epitope, hereafter) can induce specific cytotoxic T lymphocyte (CTL) responses in human leukocyte 
antigen HLA-A2 (02:01)+ donors (please see figure 1 below). Most importantly for the therapeutic 
relevance, induced CTLs recognize the H3.3K27M epitope that is endogenously expressed by HLA-A2 
(02:01)+ glioma cell lines that also harbor the K27M mutation. Therefore, H3.3K27M represents a novel, 
shared neoantigen epitope for T-cell-based immunotherapy.
 
Pediatric Glioma Vaccines
Cancer vaccines are designed to induce systemic immunity against antigens expressed by 
tumor cells. Results were recently published on using a series of glioma associated antigens 
(GAA) for the treatment of children with HGG including DIPG.14 The GAAs were EphA2, 
interleukin-13 receptor alpha and survivin. This study was performed on the basis of 
encouraging results in adult patients with glioma using peptide based vaccines.15-19 In the 
pediatric study, children (n=26: 20 children with DIPG and 6 children with other HGG) were 
treated with a combination of these GAA-derived HLA2 restricted antigens and poly-ICLC. All 
patients underwent focal radiation therapy as primary treatment modality and vaccinations 
were started after completion of radiation therapy. Children received subcutaneous injections 
of GAA restricted peptides, Tetanus toxoid emulsified in Montanide ISA-51 with concurrent 
intramuscular injections of Toll-like receptor ligand poly-ICLC (for details about the rationale 
for these compounds please see below). Within this trial a total of 84 children were screened 
for the HLA-A2 status, of which 42 tested positive. Principal toxicities included grade 1 and 2 
injection site reactions in 100% of patients and flu like symptoms such as fatigue, fever, 
myalgias, chills and headache in 92% of participants. Usually these symptoms resolved with 
acetaminophen and/or ibuprofen within 1-2 days. Grade 1 gastrointestinal symptoms 
occurred in 31% of subjects. No grade 3 or higher systemic toxicities or auto-immune 
reactions occurred in that trial. The median survival was 12.7 months among 20 children with 
DIPG and 25.1 months among those with HGG. Median survival among patients with 
pseudoprogression was 19.5 months versus 10.9 months in those without 
pseudoprogression. Immune responses against at least one of the GAA were present in 13 
out of 21 evaluable patients.14 This study highlights the favorable toxicity profile of peptide-
based vaccination strategies but also highlights the complexity of assessing therapy 
response given the relatively high incidence of pseudoprogression that seem to correlate 
with improved outcome. It will also be critical to investigate tumor tissue at time of 
progression to enhance our understanding of therapy resistance. 
Checkpoint inhibitors for cancer therapy

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Immunotherapy has had significant positive effects on outcomes for some of the most malignant tumors 
such as metastatic melanoma and non-small-cell lung cancer. The anti-PD-1 antibody, nivolumab, is a 
second-generation checkpoint inhibitor that has shown antitumor effects in melanoma, renal cell 
carcinoma and lung cancer among other cancers. Nivolumab is a PD-1 inhibitor that has been tested in 
the children with hematologic, solid, and CNS tumors as single agent as well as in combination with 
CTCL4 antibody ipilimumab (NCT02304458; NCT03130959; NCT02927769). The RP2D of nivolumab 
in the pediatric setting has been reported to be 3mg/kg IV every 2 weeks.  Good tolerability was 
demonstrated in the most recent Children’s Oncology Group trial (ADVL1412; NCT02304458), with 
immune-mediated AEs comparable to adult experience. Nivolumab alone as well as in combination 
therapy with ipilimumab is currently being tested in pediatric high-grade CNS malignancies in an 
ongoing BMS sponsored study (NCT03130959). Details about nivolumab and associated toxicity can 
be found in the Investigator Brochure. 
To enhance the activity of the specific K27M/TT vaccine, we will conduct a multicenter study evaluating 
the safety and immunological activity of a vaccine using a specific synthetic peptide for the H3.3K27M 
epitope in combination with nivolumab in HLA-A2 (02:01)+ children with newly diagnosed DIPG or other 
midline gliomas that are positive for the H3.3K27M mutation.
1.2
Background on the Compounds
K27M peptide: It was recently found that a mutated peptide that includes the K27M mutation (the 
H3.3K27M epitope) can induce specific CTL responses in HLA-A2+ healthy donors (Figure 1).  Most 
importantly, induced CTLs lyse the H3.3K27M epitope that is endogenously expressed by the HLA-
A2.1+ H3.3K27M+ glioma cell line in an HLA-class I-dependent manner (Figure 1C). To our knowledge, 
there is not a similar neoantigen-derived epitope for T-cell-based immunotherapy for gliomas. 
A recent study extended binding analyses to HLA-A*02:01, *02:02, A*02:03, A*02:06, A*02:07, and 
A*02:17, and found that the H3.3K27M peptide most effectively binds to the HLA-A*02:01.20

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Figure 1. HLA-A2+ donor-derived CTLs specifically recognize HLA-A2+ K27M+ glioma cells in an HLA-class I- 
dependent manner. Peripheral blood mononuclear cells from an HLA-A2+ donor were stimulated in vitro with the 
H3.3K27M peptide and evaluated for their reactivity against: (A) HLA-A2/H3.3K27M-specific tetramer and anti-CD8 
mAb, and (B) T2 cells pulsed with the mutant or non-mutated H3.3 peptide by IFN-γ ELISA. In (A), among the 
CD8+tetramer+ population (64.1% of total lymphocyte-gated cells), there is a tetramerhigh subpopulation (2.4% of 
total lymphocyte-gated cells), some of which were used as CTL clones (Aim 2). In (B), the Cap1-6D peptide (tested 
at 5 µg/ml only) is a high avidity HLA-A2.1-binding epitope derived from CEA used as an irrelevant negative control.
(C) The CTL line was evaluated for cytotoxicity against glioma cell lines T98 (HLA-A2+but K27M-negative), HSJD- 
DIPG-07 (HLA-A2-negative but K27M+), and HSJD-DIPG-13 (HLA-A2+ and K27M+) lines. CFSE-labeled target cells 
(10e4/well) were incubated with CTLs at the E/T ratio of 25 for 4 hours. To block the CTL cytotoxicity, anti-HLA-ABC 
10µg/ml was added to one group. At the end of incubation, 7-ADD was added into each well and incubated for 10 
minutes on ice. The samples were analyzed by flow cytometry, and the killed target cells were identified as CFSE+ 
and 7-ADD+ cells. The cytotoxicity was calculated as the percentage of CFSE+ and 7-ADD+ cells in total HLA-A2+ 
CFSE+ cells. (*p<0.05 by Wilcoxon rank-sum tests).
Tetanus Toxoid (TT)-derived helper T cell epitope: A number of studies support the important role of 
CD4+ T-helper (Th) cells in the induction of anti-tumor CD8+ CTLs and memory responses.21-23 Since 
Th cell epitopes have not been well-characterized, we have selected a well characterized Th epitope 
from a Tetanus Toxoid (TT) protein in the first pediatric study, to which the vast majority of the 
population has been sensitized and which is commonly used to induce a Th response to the 
immunizing peptides in peptide-based cancer vaccines.21-23 We will apply a similar strategy to the 
current trial using the specific H3.3K27M specific peptide. 
Montanide ISA-51:  H3.3K27M and TT peptides will be emulsified in the adjuvant Montanide ISA-51 
similar to the GAA peptide-based trial described above. Montanide ISA-51 consists of a mineral oil 
base similar to incomplete Freund’s adjuvant (IFA).  However, the Arlacel A emulsifying agent of IFA, 
which has caused reactions in the past, has been replaced with a purified Mannide monooleate called 
"montanide", which appears to be safer and has been shown to be well tolerated in the pediatric GAA 
peptide based trial.14  Peptide-based vaccines in Montanide ISA-51 have been safely administered in a 
large number of research patients, including pediatric patients with DIPG and HGG, and have induced 
T-cell responses against the immunizing peptides in a majority of patients without major toxicities.14,24,25 
Toxicities most commonly observed include local discomfort, induration, and erythema at the injection 
site as outlined above in detail for the pediatric trial using GAA based peptides.

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Poly-ICLC: Polyinosinic-Polycytidylic acid stabilized with polylysine and carboxymethylcellulose (poly-
ICLC) is a synthetic nucleic acid, and functions as a Toll-like receptor-3 (TLR3) ligand.  We propose to 
combine intramuscular (IM) poly-ICLC administration and H3.3K27M peptide based vaccine because: 
1) data show that IM administration of poly-ICLC remarkably and safely improves the therapeutic 
effects of GAA-based vaccines in mouse models26 and in humans14; and 2) IM poly-ICLC as a single 
agent has been extensively evaluated in patients with malignant glioma in pilot and multi-center studies 
through the two NCI-funded brain tumor consortia, the North American Brain Tumor Consortium 
(NABTC) and the New Approaches for Brain Tumor Therapy (NABTT) consortium.27 The proposed 
dose in this trial (30 g/kg) is based on the safety and biological activity data obtained in these 
preceding trials. Data demonstrates that concurrent IM injection of poly-ICLC at the time of vaccination 
provides the maximal adjuvant effect for the induction of antigen-specific CTL response.26 Based on 
studies with frequent injections (2-3/week), the main toxicity of poly-ICLC is a flu-like reaction that can 
include fever, myalgias, arthralgias, malaise, and possibly nausea and vomiting.  With much less 
frequent injections in our treatment plan, we do not anticipate major toxicities with poly-ICLC in the 
proposed trial, which is well supported by results from the pediatric trial using GAA based epitopes.14
In 1996, a multi-institutional trial of single agent poly-ICLC in pediatric patients with brain tumors was 
initiated. The initial dose studied was 20 micrograms/kg given twice a week IM, which was 
subsequently escalated to 30 micrograms/kg.  The protocol enrolled a total of 46 pediatric patients with 
either: 1) newly diagnosed and recurrent high-grade gliomas; 2) recurrent low-grade gliomas; 3) newly 
diagnosed and recurrent brain stem gliomas; 4) any other recurrent brain tumors, or 5) 
neurofibromatosis-related tumors.  There were 16 incidents of Grade 3 or 4 toxicity, with the majority of 
them not likely related to the therapy.  There were 4 cases of Grade 3 hepatic toxicity and one case of 
Grade 3 fever, which were considered to be possibly or definitely related to the therapy, respectively.  A 
case with Grade 3 and another case with Grade 4 neurological toxicity were noted but both cases 
manifested clinical and radiological signs of tumor progression. One of 14 patients with HGG had a 
partial response (PR).  One of 5 patients with recurrent low-grade gliomas had a PR and two patients 
had prolonged stable disease.  One patient had an improved and prolonged response when the dose of 
poly-ICLC was increased from 20 micrograms/kg to 30 micrograms/kg given twice a week. 
In a recent pilot study of peptide-based vaccination in combination with poly-ICLC in DIPG patients,14 
concurrent (i.e., the same day) administrations of subcutaneous peptide vaccine and intramuscular (IM) 
30 micrograms/kg poly-ICLC safely induced robust vaccine-specific T-cell response. Therefore, we will 
use the same mode of poly-ICLC administration (i.e., 30 micrograms/kg, IM). 
Nivolumab [Bristol-Myers Squibb (BMS)]: Nivolumab is a monoclonal antibody consisting of 4 
polypeptide chains, which include 2 identical heavy chains consisting of 440 amino acids and 2 
identical light chains. Molecular weight is 146,221 Daltons. The recommended phase 2 dose for 
nivolumab in pediatric patients based on ADVL1412 is 3 mg/kg every 2 weeks.28  However, more 
recent communication with BMS supports a standard dosing of Nivolumab every 3 weeks at 4.5 mg/kg 
IV. This is based on PK analysis that supports such a dosing schedule as well as scientific rationale to 

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give nivolumab on the same schedule as the K27M/TT vaccine (communication with BMS). We will co-
administer nivolumab with the K27M/TT vaccine. 
Justification of Nivolumab 4.5 mg/kg every 3 weeks Dosing in Pediatric Patients Nivolumab [Bristol-
Myers Squibb (BMS)]:
The selected nivolumab dose of 4.5 mg/kg every 3 weeks represents the same time-averaged dose as 
3 mg/kg every 2 weeks which has been shown to be safe and efficacious in several adult indications, 
and which is currently being investigated for pediatric indications. The PK of nivolumab is linear, and 
consequently the time-averaged concentration is expected to be the same for the 4.5 mg/kg every 3 
weeks and 3 mg/kg every 2 weeks doses; whereas the peak concentrations are expected to be higher, 
and the trough concentration lower with 4.5 mg/kg every 3 weeks.
The magnitude of the predicted differences in key measures of exposure were assessed by a 
nivolumab population pharmacokinetic model was used to predict the nivolumab concentration time 
profiles after 3 mg/kg every 2 weeks and 4.5 mg/kg every 3 weeks dosing regimens in pediatric 
subjects with solid tumors. The predicted summary measures of exposure were used to compare the 
nivolumab exposures achieved with nivolumab 4.5 mg/kg every 3 weeks relative to 3 mg/kg every 2 
weeks  (Table 1). The difference within exposure measures (Cmin and Cavg) after 4.5 mg/kg every 3 
weeks were within ~13% when compared to the exposure measures after 3 mg/kg every 2 weeks , 
suggesting that efficacy is less likely to be affected from exposure. The comparison of Cmax in 
pediatric patients dosed with 4.5 mg/kg every 3 weeks with that in pediatric patients dosed with 3 mg/kg 
every 2 weeks shows higher Cmax up to ~50%. Although the Cmax of nivolumab was expected to be 
higher with 4.5 mg/kg every 3 weeks compared to 3 mg/kg every 2 weeks , the predicted Cmax with 4.5 
mg/kg every 3 weeks  (82.3 micrograms/mL) was well below the Cmaxss (387 micrograms/mL) 
achieved with 10 mg/kg every 2 weeks , which was considered safe and tolerable.

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1.3
Rationale for the Proposed Study
We will conduct a phase 1/2 multicenter study evaluating safety and immunological activity of a 
vaccine using a specific synthetic peptide for the H3.3K27M epitope alone and in combination with PD-
1 blockade using nivolumab in HLA-A2 (02:01)+ children with newly diagnosed DIPG or other midline 
gliomas that are positive for the H3.3K27M mutation through the Pacific Pediatric Neuro-Oncology 
Consortium (PNOC). Currently, there are no effective therapeutic modalities for pediatric malignant 
gliomas. Gliomas located within midline structures – such as DIPG tumors – have a particularly poor 
prognosis.  Immunotherapy, particularly active vaccinations, has the potential to develop as an effective 
and safe modality for these patients.  Vaccines using specific peptides, in comparison to whole glioma-
derived antigens, are expected to be more feasible because these vaccines may induce glioma-specific 
immune responses without theoretical concerns of auto-immune encephalitis.  In addition, these 
vaccines can be generated “off the shelf” owing to the use of synthetic antigen peptides and Montanide 
ISA-51.  Use of modified peptides (peptides in which amino acid residues are replaced from the wild-
type sequence) may allow us to induce more efficient T cell responses than natural antigens in whole 
glioma cells.  Furthermore, based on recent laboratory data, administration of poly-ICLC along with the 
synthetic peptides remarkably enhance the induction of anti-peptide CTL responses and trafficking of 
antigen-specific T cells to the brain tumor sites 18,26,27. 
PD-1 (CD279) is a cell surface receptor present on T cells and a subset of B cells. It is a member of the 
CD28 family of T-cell co-stimulatory receptors that also includes CD28 and CTLA 4. PD-1 signaling has 
an inhibitory effect in cytokine activation (such as IL-2, IL-10, IL-13, interferon-, and Bcl-xL) that is 
CD28 mediated and has been shown to inhibit T cell activation as well as decrease expansion of 
previously activated cells. Inhibition of PD-1 activity appears to stimulate the immune response and 
enhance T-cell-mediated attack on tumor cells by effector T cell activation and repression of regulator T 

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cell activity.29,30 These data support our hypothesis that PD-1 blockade has the potential to amplify T-
cell responses triggered by the K27M/TT vaccine. 
Safety update from PNOC 007 (phase 1) cutoff date September 8, 2020: We have shown that 
treatment with the vaccine and poly-ICLC is safe in children with DIPG (n=19) as well as other midline 
gliomas including spinal cord tumors (n=10), as of September 8, 2020. With this current amendment, 
we will test the safety and efficacy of combined therapy of K27M/TT and poly-ICLC with nivolumab. Our 
hypothesis is that the combination therapy will be more effective compared to vaccine administration 
alone. We will combine DIPG and other midline glioma in one combined strata given our current 
experience that supports a favorable safety profile for both Strata A and B and that recent studies have 
shown similar outcomes for these entities. However H3K27 mutant spinal cord tumors seem to have 
significantly worse outcome and to date we have very limited safety data in this patient population with 
single agent vaccine (n=2) and therefore we will exclude these from Stratum C 31,32.  
2
Objectives of the Study
2.1
Primary Objectives
Stratum A:

To assess the safety of repeated administration of the H3.3K27M epitope specific vaccine in HLA-
A2 (02:01)+ children with H3.3K27M positive DIPGs. 

To determine the overall survival at 12 months (OS12) in HLA-A2 (02:01)+ children with DIPG that 
are treated with repeated administration of the H3.3K27M peptide.
Stratum B:

To assess the safety of repeated administration of the H3.3K27M epitope specific vaccine in HLA-
A2 (02:01)+ children with H3.3K27M positive midline gliomas other than DIPG, including spinal cord 
gliomas.
Stratum C: 

To assess the safety of repeated administration of the H3.3K27M epitope specific vaccine in 
combination with the PD-1 inhibitor nivolumab in HLA-A2 (02:01)+ children with H3.3K27M positive 
midline gliomas including DIPG and midline gliomas (excluding primary spinal cord tumors).
2.2
Exploratory Objectives, Other Assessments
Stratum A: 

Induction of the H3.3K27M epitope-specific CTL response in post vaccine PBMCs in HLA-A2 
(02:01)+ children with H3.3K27M positive gliomas other than DIPG

Assessment of H3.3K27M infiltrates in subjects with evidence of progression that undergo tissue 
collection as part of their standard of care. Tumor tissue will be analyzed for H3.3K27M expression 
status and infiltration of H3.3K27M specific T cells

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
To archive tumor and normal DNA from each subject at time of initial diagnosis along with serial 
blood draws following therapy to determine whether circulating tumor DNA (ctDNA) sequences in 
the subject’s blood serve as biomarkers of tumor burden, response to therapy, or development of 
drug resistance.
Stratum B: 

Induction of the H3.3K27M epitope-specific CTL response in post vaccine PBMCs in HLA-A2 
(02:01)+ children with H3.3K27M positive gliomas other than DIPG

Assessment of H3.3K27M infiltrates in subjects with evidence of progression that undergo tissue 
collection as part of their standard of care. Tumor tissue will be analyzed for H3.3K27M expression 
status and infiltration of H3.3K27M specific T cells

To archive tumor and normal DNA from each subject at time of initial diagnosis along with serial 
blood draws following therapy to determine whether circulating tumor DNA (ctDNA) sequences in 
the subject’s blood serve as biomarkers of tumor burden, response to therapy, or development of 
drug resistance.
Stratum C: 

To determine the OS12 in HLA-A2 (02:01)+ children with H3.3K27 positive DIPGs and midline 
gliomas (excluding primary spinal cord tumors) that are treated with repeated administration of the 
H3.3K27M peptide and nivolumab.

Induction of the H3.3K27M epitope-specific CTL response in post vaccine PBMCs in HLA-A2 
(02:01)+ children with H3.3K27M positive gliomas including DIPG or other H3.3K27M positive 
midline gliomas, excluding primary spinal cord tumors.

To archive tumor and normal DNA from each subject at time of initial diagnosis along with serial 
blood draws following therapy to determine whether circulating tumor DNA (ctDNA) sequences in 
the subject’s blood serve as biomarkers of tumor burden, response to therapy, or development of 
drug resistance.

To assess Quality of Life (QoL) and cognitive measures in HLA-A2 (02:01)+ children with H3.3K27M 
positive DIPG or other midline gliomas.
3
Study Design
This is a 3 strata multicenter study that will be conducted through PNOC. Stratum A consists of HLA-
A2 (02:01)+, positive newly diagnosed subjects with H3.3K27M positive DIPG, Stratum B consists of 
other HLA-A2 (02:01)+, positive newly diagnosed subjects with H3.3K27M positive midline gliomas, 
including spinal cord tumors, that are not classified as DIPG, and Stratum C consists of other HLA-A2 
(02:01)+, positive newly diagnosed subjects with H3.3K27M positive DIPG and other midline gliomas, 
excluding primary spinal cord tumors. We will enroll subjects onto stratum C once we have completed 
accrual onto strata A and B.

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3.1
Number of Subjects
A total of 19 evaluable H3.3K27M positive HLA-A2 (02:01)+ DIPG patients will be enrolled into stratum 
A. Stratum B will include 10 evaluable HLA-A2 (02:01)+ patients with midline gliomas other than DIPG 
that are positive for the H3.3K27M mutation (including spinal cord gliomas). Stratum C will include 20 
evaluable HLA-A2 (02:01)+ patients with DIPG and other midline gliomas that are positive for the 
H3.3K27M mutation (excluding primary spinal cord gliomas). 
3.2
Eligibility Criteria
Patients must have eligibility evaluations performed prior to enrollment and must meet all inclusion and 
exclusion criteria.  In addition, the patient must be thoroughly informed about all aspects of the study, 
including the study visit schedule and required evaluations and all regulatory requirements for informed 
consent.  The written informed consent must be obtained from the patient prior to enrollment.  The 
following criteria apply to all patients enrolled onto the study unless otherwise specified.
3.2.1
Inclusion Criteria
Stratum A:

Newly diagnosed children (3-21 years old) with DIPG who are positive for the H3.3K27M mutation 
(positive testing from a CLIA or equivalent laboratory required) that underwent standard radiation 
therapy.
Stratum B:

Newly diagnosed children (3-21 years old) with diagnosis of midline glioma other than DIPG who 
are positive for the H3.3K27M mutation (positive testing from a CLIA or equivalent laboratory 
required), including spinal cord gliomas, that underwent standard radiation therapy. 
Stratum C:

Newly diagnosed children 3-21 years of age with diagnosis of DIPG or midline glioma other than 
DIPG (excluding primary spinal cord gliomas) who are positive for the H3.3K27M mutation (positive 
testing from a CLIA or equivalent laboratory required), that underwent standard radiation therapy. 
The following eligibility criteria apply to strata A, B and C: 

The patient must test positive for HLA-A*02:01 (positive testing from a CLIA or equivalent laboratory 
required; only the HLA A*02:01 subtype is eligible; other subtypes are excluded)

The patient must be either off systemic steroids or be on stable dose of dexamethasone or 
equivalent (max 0.1 mg/kg/day; maximum 4mg/day) at time of enrollment.

Patients must not have received any prior chemotherapy, immunotherapy or bone marrow 
transplant for the treatment of their tumor. Prior use of temozolomide during radiation at maximum 
of the standard pediatric dosing (defined as 90 mg/m2 /dose continuously during radiation therapy 
for 42 days) or dexamethasone is allowed. 

Patients must have undergone radiation therapy and surgery as part of their standard of care. 

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o
Stratum A: Radiation therapy must have started within 4 weeks of diagnosis by imaging or 
surgery, whichever is later.
o
Stratum B: For subjects undergoing surgery for more extensive resection, radiation therapy 
should be started within 4-6 weeks from surgery. 
o
Stratum C: Radiation therapy must have started within 4 weeks of diagnosis by imaging or 
surgery, whichever is later. For subjects undergoing surgery for more extensive resection, 
radiation therapy should be started within 4-6 weeks from surgery. 

Karnofsky ≥50 for patients ≥16 years of age, and Lansky ≥50 for patients < 16 years of age 
(See Appendix A). Patients who are unable to walk because of paralysis, but who are up in a 
wheelchair, will be considered ambulatory for the purpose of assessing the performance 
score.

The patient must have adequate organ function defined as:
Adequate Bone Marrow Function Defined as:

Peripheral absolute neutrophil count (ANC) ≥ 1000/mm3 and

Platelet count ≥ 100,000/mm3 (transfusion independent, defined as not receiving platelet 
transfusions for at least 7 days prior to enrollment).
Adequate Renal Function Defined as:

Creatinine clearance or radioisotope GFR ≥ 70mL/min/1.73 m2 or

A serum creatinine based on age/gender as follows:
Age
Maximum Serum 
Creatinine 
(
/dL)
Male
Female
3 to < 6 years
0.8
0.8
6 to < 10 years
1
1
10 to < 13 years
1.2
1.2
13 to < 16 years
1.5
1.4
≥ 16 years
1.7
1.4
The threshold creatinine values in this table were derived from the Schwartz formula for 
estimating GFR utilizing child length and stature data published by the CDC.
Adequate Liver Function Defined as:

Bilirubin (sum of conjugated + unconjugated)  1.5 x upper limit of normal (ULN) for 
age and

SGPT (ALT)  110 U/L and 

Serum albumin ≥ 2 g/dL.
Adequate Pancreatic Function Defined as:

Serum lipase  ULN at baseline.
Adequate Pulmonary Function Defined as:

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
No evidence of dyspnea at rest, no exercise intolerance due to pulmonary insufficiency, and 
a pulse oximetry of > 92% while breathing room air.
Adequate Neurologic Function Defined as:

Patients with seizure disorder may be enrolled if seizure disorder is well controlled. 

The effects of the H3.3K27M vaccine and nivolumab on the developing human fetus are unknown.  
For this reason, females of child-bearing potential and males must agree to use adequate 
contraception. Adequate methods include: hormonal or barrier method of birth control; or 
abstinence prior to study entry and for the duration of study participation.  Should a woman become 
pregnant or suspect she is pregnant while she or her partner is participating in this study, she 
should inform her treating physician immediately.  Males treated or enrolled on this protocol must 
also agree to use adequate contraception prior to the study and for the duration of study 
participation.

Ability to understand a written informed consent document, and the willingness to sign it. Assent will 
be obtained when appropriate based on the subjects age.
3.2.2
Exclusion Criteria

Investigational Drugs
o
Patients who are currently receiving another investigational drug are not eligible.
o
Prior treatment with another investigational drug.

Anti-cancer Agents
o
Patients who are currently receiving other anti-cancer agents are not eligible.
o
Prior treatment with other anti-cancer agents.

Patients who have received a live / attenuated vaccine within 30 days of first treatment.

Patients with evidence of disseminated or leptomeningeal disease

Patients with a known disorder that affects their immune system, such as HIV or Hepatitis B or C, or 
an auto-immune disorder requiring systemic cytotoxic or immunosuppressive therapy are not 
eligible. Note: Patients that are currently using inhaled, intranasal, ocular, topical or other non-oral 
or non-IV steroids are not necessarily excluded from the study but need to be discussed with the 
study chair.

Patients with a ≥ Grade 2 hypothyroidism due to history of autoimmunity are not eligible. (Note: 
Hypothyroidism due to previous irradiation or thyroidectomy will not impact eligibility).

Patients who have received prior solid organ or bone marrow transplantation are not eligible.

Patients with uncontrolled infection. 

Female patients of childbearing potential must not be pregnant or breast-feeding. Female patients 
of childbearing potential must have a negative serum or urine pregnancy test prior to the start of 
therapy (as clinically indicated).

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3.3
Duration of Therapy
Treatment may continue for 24 months or until:

Disease progression

Inter-current illness that prevents further administration of treatment

Unacceptable adverse event(s)

Patient decides to withdraw from the study

Significant patient non-compliance with protocol

General or specific changes in the patient’s condition render the patient unacceptable for further 
treatment in the judgment of the investigator
3.4
Duration of Follow Up
Patients will be followed for 24 months after completion of treatment, or until removal from study or 
death, whichever occurs first.  Patients removed from treatment for unacceptable treatment related 
adverse event(s) will be followed until resolution or stabilization of all treatment related adverse events 
to grade 2 or lower, or a minimum of 24 months after removal from treatment.
3.5
Study Timeline
This study aims to enroll 19 HLA-A2 (02:01)+ children with H3.3K27M positive DIPG (Stratum A), 10 
HLA-A2 (02:01)+ children with H3.3K27M positive midline gliomas other than DIPG, including spinal 
cord tumors (Stratum B) and 20 HLA-A2 (02:01)+ children with H3.3K27M positive DIPG or midline 
gliomas other than DIPG, excluding primary spinal cord tumors (Stratum C). H3.3K27M status needs to 
be confirmed in a CLIA or equivalent approved laboratory. Eligible patients with positive H3.3K27M 
need to also test positive for HLA A*02:01in a CLIA or equivalent approved laboratory.14 We will enroll 
into the 3 strata separately, and the first 3 patients in each stratum will be observed for RLTs for at least 
6 weeks before the next set of patients are enrolled in that stratum. We will enroll subjects onto 
stratum C once we have met total accrual onto strata A and B. See Section 9.3 for further 
information. 
Based on our accrual into this trial we anticipate to enroll an average of 1.8 subjects per month. We 
anticipate that enrollment for strata A, B, and C will be similar and therefore we anticipate that 
enrollment into the K27M glioma strata will be completed in about two years for each stratum.
3.6
Study Completion
Enrollment into strata A, B and C will be completed in approximately 4 years and the primary efficacy 
endpoint is OS12.  We therefore anticipate that we will complete the study in 6 years. 
4
REGISTRATION PROCEDURES
4.1
General Guidelines
Participant must meet all inclusion criteria and no exclusion criteria should apply. The participant or 
their legal parent/guardian must have signed and dated an approved, current version of the applicable 
consent and/or assent forms.  To allow non-English speaking participants to participate in this study, 
bilingual health services will be provided in the appropriate language when feasible.

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The treating physician must complete and sign the eligibility checklist. A clinical team member (nurse or 
clinical research coordinator) must also sign.  The completed eligibility checklist will be submitted to the 
PNOC Operations Office for review. The PNOC Operations Office will review the eligibility checklist to 
ensure that all items on the eligibility checklist are filled out.  
Eligible participants will be registered using the UCSF OnCore® database.  Treatment on protocol 
therapy cannot be initiated prior to receiving the registration confirmation email from the PNOC 
Operations Office.
4.2
Reservation and Registration Process
The wait-list for study slots will be maintained by the PNOC Operations Office.  Investigators can view 
updated information about slot availability and registration process updates on the PNOC Member’s 
SharePoint homepage using their secure login and password, or by emailing a request to 
To place a participant on the waitlist, please complete the Qualtrics survey (link available on 
SharePoint). An automatic screening ID will be generated, and emailed to both the Operations Office 
and the person submitting the form. This screening ID will be used for registration and participant 
tracking purposes.
To register a participant for the study, limited participant information (confirmation of screening ID, 
gender, ethnicity, race, month & year of birth, ZIP or country code, disease site, histology, diagnosis 
date, name of treating physician and study specific information) along with a signed consent form and 
HIPAA authorization (if applicable to your institutional regulatory guidelines) should be emailed to the 
PNOC Operations Office 
. All participant PHI must be redacted, and 
the screening ID included on each source document or consent form page. The participant will be given 
the status of consented in OnCore®.
When the eligibility checklist has been completed, the member institution PI and/or Coordinator will 
upload the completed eligibility checklist into the participant’s OnCore® record.
Once the eligibility checklist has been confirmed as received, the PNOC Operations Office will send a 
confirmation e-mail to the institutional PI(s) and Research Coordinator(s) with the participant’s study ID 
and dose information. 
Detailed participant registration instructions can also be found on the PNOC Member’s SharePoint 
Wiki. 
5
Study Drugs
5.1
Description, Supply and Storage of Investigational Drugs
5.1.1
H3.3K27M peptide
The following synthetic H3.3K27M peptide and helper peptides will be included in the vaccine 
formulation. The combined H3.3K27M and Tetanus Toxoid will be referred to as K27M/TT peptide.               

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H3.3K27M is a linear, decapeptide containing eight (8) natural amino acids. The product is isolated as 
its acetate salt form with some residual water as a natural constituent of the drug substance. Figure 2 
shows the structure 
Figure 2: Structure of H3.3K27M
H2N
O
N
H
O
N
N
H
O
H
N
N
H
O
O
N
H
O
H
N
O
H
N
O
N
H
OH
O
O
NH
NH2
HN
S
OH
OH
OH
5.1.2
Tetanus Toxoid
Tetanus Toxoid is a linear, hexadecapeptide containing twelve (12) natural amino acids; both the N- 
and the C-terminus of the sequence are unmodified. The product is isolated as its acetate salt form with 
some residual water as a natural constituent of the drug substance. Figure 3 shows the structure of 
Tetanus Toxoid.
Figure 3: Structure of Tetanus Toxoid
H2N
H
N
N
H
H
N
N
H
H
N
N
H
H
N
N
H
H
N
N
H
H
N
O
O
O
O
O
O
O
O
O
O
O
N
H
H
N
N
H
O
O
O
OH
NH2
O
OH
NH2
O
NH2
OH
NH2
H
N
O
O
OH
OH
O
For more information about the K27M/TT peptide vaccine, please see the Investigator’s Brochure.
5.1.3
K27M/TT Peptide
5.1.3.2 Availability
The H3.3K27M and Tetanus Toxoid peptide will be synthesized under good manufacturing practice 
(GMP) conditions by Polypeptide Inc. (San Diego, CA).  Recombinant vectors in bacteria or viruses will 
not be used.  The synthetic peptide will be purified by HPLC.  The identity of the synthetic peptide will 
be confirmed by verifying their mass and amino acid sequences by mass spectrometry.  Each lot of 
peptide will be evaluated as required by the FDA for identity, purity, sterility and pyrogenicity. An 
investigator-sponsored IND application has been filed 
 
 incorporating the clinical protocol and chemistry, manufacturing and control (CMC) 

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information.  Details of the synthesis, certificates of analysis, and technical summaries are included in 
the Chemistry and Manufacturing section of the IND applications.  The bulk peptide has been sent to 
the University of Pittsburgh Immunologic Monitoring and Cellular Products Laboratory (IMCPL), for 
vialing and combination with TT helper peptide. Enrolling sites will request the K27M/TT peptide 
through the PNOC Operations office 
 Please refer to the PNOC secure 
SharePoint Member Website for details on how to request study drug.
5.1.3.3 Agent Ordering and Distribution (K27M/TT Peptide Vaccine)
Final reconstitution with Montanide ISA-51 will occur at each PNOC site’s pharmacy after each site has 
completed training on how to reconstitute K27M/TT with Montanide. The standard operating procedure 
(SOP) for the final preparation (i.e., reconstitution) has been established to meet the defined 
specifications of strength, quality and purity as outlined in the CMC section of the IND application. Each 
site will request Montanide through the PNOC Operations office around the time of enrollment together 
with the peptide and Poly ICLC (Hiltonol ®). Please refer to the PNOC secure SharePoint Member 
Website for details on how to request Montanide as well as the SOP for reconstitution. 
5.1.3.4  Storage & Stability (Peptides)
The peptides will be vialed under GMP conditions and saved at ≤ -70°C. Stability of lyophilized 
peptides will be tested annually by mass spectroscopy.  Based on data from peptides used in other 
trials at the University of Pittsburgh, lyophilized peptides are typically stable at least for three years.   
Lyophilized peptides in unit dosage vials will be reconstituted with saline/10% DMSO, and aliquoted as 
1 ml vials as the mixture of the two peptides (750 micrograms/ml K27M peptide and 500 micrograms/ml 
TT peptide) at the University of Pittsburgh and sent to each PNOC site after a patient has been accrued 
and enrolled in the trial.  The vials will be stored at a temperature ≤ -70°C and protected from light.  
Vials with reconstituted peptides in saline/10%DMSO expire 6 months from time of reconstitution.  Data 
from Pittsburgh for past peptide-vaccine trials indicate reconstituted peptides are stable for at least 6 
months (less than 8% oxidized).  For each vaccination, one vial will be thawed and mixed with the 
same volume of Montanide ISA-51 at the enrolling PNOC site’s investigational pharmacy.  Once mixed, 
the vaccine must be administered within 6 hours.  The standard operating procedure (SOP) for the final 
preparation (i.e., reconstitution) has been established to meet the defined specifications of strength, 
quality and purity as outlined in the CMC section of the IND applications. Please refer to the PNOC 
secure SharePoint Member Website for details on how to request Montanide as well as the SOP for 
reconstitution.
5.1.3.5 Other Commercially Available Agents in the Vaccines
Montanide ISA-51 will be purchased from SEPPIC Inc. (www.seppic.com) and stored at UPMC IMCPL. 
Each enrolling site will receive Montanide from UPMC IMCPL once a patient is enrolled. Please refer to 
the PNOC secure SharePoint Member Website for details on how to request Montanide as well as for 
the SOP on how to prepare the final peptide emulsion that will be administered to the patient. 
5.1.3.6 Toxicities (K27M/TT Vaccine)
Chronic inflammatory reactions are expected to occur in all patients at their vaccine sites.  Induration 
may persist for months, but is not expected to require additional therapy.  Sterile abscesses may occur 

Versi o n 2. 1, Versi o n D ate: 3/ 1/ 2 0 2 1         
 
Pr ot oc ol P N O C 0 0 7/ C C # 1 5 0 8 1 9
Pa ge 3 3  of 1 0 7
i n s o m e p ati e nt s.  T h e s e ar e n ot a b a si s f or di s c o nti n u ati o n of t h e v a c ci n e s. H o w e v er, if t h e 
i nfl a m m at or y r e a cti o n s ar e s e v er e, s u b s e q u e nt v a c ci n e s m a y b e a d mi ni st er e d i n a dj a c e nt s ki n ( < 2 c m 
fr o m pri or i nj e cti o n sit e) r at h er t h a n i n t h e s a m e l o c ati o n( s), t o mi ni mi z e a d diti o n al m or bi dit y. I n t h e 
e v e nt t h e v a c ci n e c a n n ot b e a d mi ni st er e d wit hi n 2 c m of t h e d e si g n at e d sit e( s), v a c ci n ati o n sit e( s) will 
b e a s si g n e d o n t h e c orr e s p o n di n g l o c ati o n of t h e c o ntr al at er al si d e. P ol y-I C L C will b e a d mi ni st er e d 
i ntr a m u s c ul arl y o n t h e s a m e si d e a s t h e v a c ci n e o n t h e s a m e d a y t h e v a c ci n e i s a d mi ni st er e d. 
C o m pl et e a n d u p d at e d a d v er s e e v e nt i nf or m ati o n i s a v ail a bl e i n t h e I n v e sti g at or’ s Br o c h ur e.
5. 1. 4
P ol y-I C L C
P ol y-I C L C i s cl a s sifi e d a s a n i n v e sti g ati o n al dr u g.  It i s a s y nt h eti c c o m pl e x of p ol yi n o si ni c a n d 
p ol y c yti d yli c a ci d, st a bili z e d wit h p ol yl y si n e a n d c ar b o x y m et h yl c ell ul o s e.  T h e t h er m al d e n at ur ati o n 
p oi nt i s 8 9. 5° C, a b o ut 4 0° C a b o v e t h at of pl ai n P ol y-I C L C; t h e r e si st a n c e t o h y dr ol y si s i s s e v er al ti m e s 
t h at of t h e p ar e nt c o m p o u n d, a n d it i n d u c e s p e a k l e v el s of a b o ut 1 0 0 0- 2 0 0 0 I U of i nt erf er o n-p er m L 
of s er u m i n m o n k e y s gi v e n 1 m g/ k g i ntr a v e n o u sl y.
5. 1. 4. 2 A v ail a bilit y ( P ol y-I C L C)
P ol y-I C L C i s pr e p ar e d a n d p a c k a g e d i n t h e G M P f a cilit y of Bi o s er v, C or p.  It i s t h e n t e st e d f or a cti vit y 
a n d p yr o g e ni cit y b y O n c o vir, I n c.  E a c h sit e will r e q u e st p ol y-I C L C fr o m U P M C-I M C P L t hr o u g h t h e 
P N O C O p er ati o n s offi c e aft er a p ati e nt h a s b e e n e nr oll e d i nt o t h e tri al. T o or d er p ol y-I C L C pl e a s e r ef er 
t o t h e s e c ur e P N O C S h ar e P oi nt m e m b er w e b sit e. 
5. 1. 4. 3 St or a g e & St a bilit y ( P ol y-I C L C)
P ol y-I C L C i s s u p pli e d i n vi al s c o nt ai ni n g 1 m L of tr a n sl u c e nt s ol uti o n wit h a c o n c e ntr ati o n of 1. 8 m g/ m L. 
It i s st a bl e at r o o m t e m p er at ur e f or s e v er al d a y s, b ut i s b ett er st or e d r efri g er at e d at a b o ut 4 0° F ( n ot 
fr o z e n).  
5. 1. 4. 4 T o xi citi e s of P ol y-I C L C
Fl u-li k e s y m pt o m s:
T h e m ai n t o xi cit y of p ol y-I C L C i s a fl u-li k e r e a cti o n i n cl u di n g f e v er, m y al gi a s, art hr al gi a s, m al ai s e, a n d 
p o s si bl y n a u s e a a n d v o miti n g.  T h e s e v erit y i s d e p e n d e nt o n d o s e, r o ut e of i nj e cti o n a n d o v er all h e alt h 
of t h e p arti ci p a nt.  E arl y P h a s e I st u di e s w er e d o n e t o d et er mi n e t h e m a xi m u m t ol er at e d d o s e ( M T D) 
u n d er t h e a s s u m pti o n t h at t hi s w a s al s o t h e m o st eff e cti v e d o s e.  I n t h e s e st u di e s of c a n c er p ati e nt s, it 
w a s f o u n d t h at t h e M T D w a s a b o ut 1 2 m g/ m 2  I V i n p ati e nt s w h o w er e n ot t er mi n all y ill.  P ati e nt s 
t y pi c all y s h o w e d f e v er s of 4 0° C, m y al gi a s, art hr al gi a s, m al ai s e, a n d n a u s e a a n d v o miti n g.  F e v er w a s 
t h e pri m ar y d o s e-li miti n g f a ct or.  At t hi s d o s e, t h e m e a n s er u m I F N l e v el w a s 2 0 0 0 I U/ m L.  W hil e gi vi n g 
e x o g e n o u s I F N r ar el y att ai n s t hi s l e v el, l e v el s of 1 0 0 I U/ m L i n r e s p o n s e t o e x o g e n o u s I F N ar e 
a s s o ci at e d wit h t h e s a m e t y p e s a n d d e gr e e of a d v er s e eff e ct s a s s e e n wit h hi g h d o s e p ol y-I C L C.  I n 
m o st of t h e e arl y c a n c er tri al s, a b o ut 6 m g/ m
2  p ol y-I C L C I V w a s g e n er all y u s e d.  
It w a s s u b s e q u e ntl y s h o w n t h at l o w d o s e s (i. e., l o w d o s e p ol y-I C L C) w er e s u p eri or t o hi g h er o n e s f or 
e n h a n ci n g i m m u n e eff e ct s, a n d t h at t h e hi g h er d o s e a ct u all y i n hi bit e d a n u m b er of c ell- a s s o ci at e d 
i m m u n e f u n cti o n s.  It w a s al s o f o u n d t h at i ntr a m u s c ul ar i nj e cti o n pr o d u c e d mil d er si d e eff e ct s t h a n I V 

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administration 33.  The most common symptom has been mild, transient discomfort at the injection site.  
On occasion, 8 to 12 hours after doses of 10 to 50 micrograms/kg IM, patients may also develop a mild 
flu-like syndrome with fever of less than 38ºC, which may last for another 12 hours, but responds 
readily to acetaminophen or aspirin.  Mild myalgias, arthralgias, sometimes nausea, and malaise are 
present during this period of time.  This flu-like syndrome typically diminishes markedly after the first 
few poly-ICLC treatments.  
Hematologic:
Poly-ICLC has been associated with a coagulopathy in dogs, but not in other species (including 
primates); and there has been no change in the expected incidence of deep venous thrombosis, 
pulmonary embolus, or coagulopathy in multiple sclerosis, AIDS or malignant glioma patients on low 
dose IM poly-ICLC.  One paralyzed multiple sclerosis participant treated with 100 micrograms/kg 
suffered a fatal pulmonary embolus which was not confirmed to be related to the drug-administration.  
Transient leucopenia, lymphopenia, or granulocytopenia has been reported in malignant glioma 
patients on poly-ICLC.  In the completed North American Brain Tumor Consortium trials (n=76 
patients), in which patients received IM poly-ICLC three times/week (20 micrograms/kg), of 786 events 
reported, there were 23 grade 1 or 2 granulocytopenias, 32 grade 1 or 2 leukopenias, and 17 grade 1 
or 2 lymphopenias.  Three patients had grade 3 leukopenia.  Animal studies demonstrated that a major 
portion of IFN-induced leucopenia is related to transient sequestering of WBC in lymphoid organs.30 
Hepatic enzyme elevation:
Mild (grade 1), transient (<7 days) hepatic enzyme elevations were described in a trial of 100 
micrograms/kg poly-ICLC given intravenously in multiple sclerosis patients.  In three patients this was 
prolonged >7 days, but in all patients the enzymes returned to normal after temporary discontinuation 
of the poly-ICLC. 
Seizures:
Three glioma patients with epilepsy had seizures during the febrile episode after poly-ICLC, but 
recovered uneventfully.  Whether this reaction represented inadvertent IV injection on those occasions 
is uncertain.  
Pseudo-Tumor Progression:
In the malignant glioma pilot trial in adults27 a few patients showed increased contrast enhancement 
with or without increased edema 2-4 months after the initiation of poly-ICLC administration, followed by 
an apparent tumor response at 6-12 months.  Dexamethasone was used if clinically indicated during 
the time of pseudo-tumor progression.  In a more recent NABTC study, in adult patients with advanced 
recurrent gliomas, several patients have shown a similar phenomenon after several weeks of poly-ICLC 
therapy, which resolved with or without concomitant steroids (patients continued their poly-ICLC 
administration during this time).  Biopsy of a tumor demonstrating increased contrast enhancement in 

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one patient receiving dendritic cell-based vaccines showed inflammation rather than recurrent tumor27.  
These findings raise the possibility that vaccines and poly-ICLC may at times be facilitating a relatively 
early immunologic anti-tumor response, manifested by increased edema and/or contrast enhancement 
on MRI.  Once treatment is started, patients will be closely monitored with serial MRI scans and 
neurologic evaluations to assess for treatment response as well as pseudo-tumor progression.  
To minimize the likelihood that the timing of radiotherapy-induced swelling or increased enhancement 
may coincide with the pseudo-tumor progression caused by poly-ICLC, we will defer the initiation of 
poly-ICLC/vaccine for up to 12 weeks post-RT in strata A, B and C in those patients that experience 
clinically symptomatic radiographic worsening (i.e. increased enhancement/mass effect on MRI scan) 
immediately following irradiation, to allow this response to resolve.  
Experience in pediatric patients with glioma:
As reviewed in Section 1.2, a multi-institutional trial of poly-ICLC in pediatric patients with brain tumors 
enrolled a total 46 patients.  An improved and prolonged response was seen in one patient in whom the 
poly-ICLC dose was increased from 20 micrograms/kg to 30 micrograms/kg given twice a week IM, so 
that a dose of 30 micrograms/kg was used in subsequent patients and well tolerated.  There were 16 
incidents of Grade 3 or 4 reported adverse events but most of them were unlikely to be related to the 
therapy.  There were 4 cases of Grade 3 hepatic toxicity and one case of Grade 3 fever, which were 
considered to be possibly or definitely related to the therapy, respectively.  A case with Grade 3 and 
another case with Grade 4 neurological toxicity were noted but both cases manifested clinical and 
radiological signs of tumor progression (personal communication Oncovir).
In the pediatric trial using GAA specific peptides, poly-ICLC (Hiltonol, Oncovir, Washington DC) was 
also used at a dose of 30micrograms/kg and this dose was well tolerated. Based on these 
observations, we will also use poly ICLC at 30micrograms/kg in the current protocol14.
5.1.5
Summary of Common AEs 
The most common AEs from the combination of K27M/TT, Montanide and poly-ICLC (≥ 25% of 
patients) include injection site reaction, white blood cell decreased, vomiting, fatigue, alanine 
aminotransferase increased, aspartate aminotransferase increased, lymphocyte decreased, headache 
and skin induration.
Update: As of 12/31/18, treatment with the K27M/TT vaccine and poly-ICLC has been proven to be well 
tolerated with one RLT in the total 29patients treated on strata A and B, 19 and 10 patients in each 
stratum, respectively. 
5.1.6
Nivolumab
Structure and molecular weight

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Nivolumab is a monoclonal antibody consisting of 4 polypeptide chains, which include 2 identical heavy 
chains consisting of 440 amino acids and 2 identical light chains. Molecular weight is 146,221 Daltons. 
Supplier
Nivolumab will be supplied by Bristol-Myers Squibb (BMS). Do NOT use commercially available supply. 
Formulation
The agent is a clear to opalescent, colorless to pale yellow liquid, with light (few) particulates. It is 
available in a 100 mg/10 mL vial containing a sterile, non- pyrogenic, single-use, isotonic aqueous 
solution formulated at 10 mg/mL in sodium citrate, sodium chloride, mannitol, diethylenetriamine 
pentaacetic acid (pentetic acid) and polysorbate 80 (Tween® 80) to a pH of 6.0. A small amount of 
overfill (0.7 mL) is included with each vial to account for VNS (vial, needle, syringe) loss. The 10 mL 
type I flint glass vials are stoppered with butyl rubber stoppers and sealed with aluminum seals. 
Storage
Nivolumab vials for injection must be stored at 2°– 8°C (36°– 46°F) and protected from light, freezing 
and shaking. 
Solution Preparation
Nivolumab injection can be infused undiluted (10 mg/mL) or diluted with 0.9% Sodium Chloride 
Injection, USP or 5% Dextrose, USP to a final concentration of 1 – 10 mg/mL. Vial contents from 
different lots should not be mixed in the same infusion. 
Stability
The administration of undiluted and diluted nivolumab must be completed within 24 hours of 
preparation. If not used immediately, the infusion solution of nivolumab injection prepared for dosing 
may be stored for up to 24 hours in a refrigerator at 2°-8°C (36°-46°F) and a maximum of 8 hours of the 
total 24 hours can be at room temperature (20°-25°C, 68°-77°F) and under room light. The maximum 8-
hour period under room temperature and room light conditions for nivolumab injection in IV bag 
includes the product administration period (30 minutes). Vials of nivolumab for injection do not contain 
preservatives or bacteriostatic agents and should be prepared as soon as possible prior to 
administration using aseptic technique. 

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5.2
Drug Accountability
Each PNOC site Investigational Pharmacist will manage drug accountability records per site standards.
5.3
Drug Ordering
The K27M/TT peptide vaccine will be ordered from UPMC -IMCPL through the PNOC Operations 
office. Please refer to the PNOC SharePoint Member Website for detailed order instructions and an 
order request form. 
The poly-ICLC will be ordered by each PNOC site directly through PNOC Operation’s Office and 
shipped from UPMC -IMCPL- please refer to the PNOC SharePoint Member Website for detailed order 
instructions and an order request form.
Each investigational pharmacy will order Montanide (Seppic, Inc.) from UPMC -IMCPL through the 
PNOC Operation’s Office to generate the K27M/TT peptide-based vaccine per SOP just prior to 
administration of the vaccine. Please refer to the PNOC SharePoint Member Website for detailed order 
instructions and an order request form.
Nivolumab: Nivolumab will be ordered via manual drug order form. Drug supply will be shipped by BMS 
vendor Fisher Scientific. More detailed instructions are available via the PNOC SharePoint Member 
Website.
6
Treatment Plan
Eligible patients will undergo focal radiation therapy after initial diagnosis as part of their standard of 
care per institutional guidelines. Stratum A patients must begin radiation therapy within 4 weeks of 
diagnosis by imaging or pathology, whichever is later. Stratum B patients must begin radiation therapy 
within 4-6 weeks from surgery (for those subjects undergoing surgery for more extensive resection). 
Stratum C: Patients with DIPG must begin radiation therapy within 4 weeks of diagnosis by imaging or 
pathology, whichever is later. Patients with other midline gliomas, excluding primary spinal cord tumors, 
must begin radiation therapy within 4-6 weeks from surgery (for those subjects undergoing surgery for 
more extensive resection).
Treatment should start 2-8 weeks after completion of radiation therapy for all strata. Children will 
receive subcutaneous injections of synthetic peptides of the H3.3.K27M epitope and tetanus toxoid-
derived helper epitope (K27M/TT) emulsified in Montanide ISA-51 along with concurrent intramuscular 
injections of immunoadjuvant poly-ICLC every 3 weeks for a total of 8 doses (please see Therapy 
Schema for trial design). Stratum C patients will also receive nivolumab.
Strata A & B: If the subject demonstrates stable to improved disease to the vaccine therapy and 
tolerates the therapy well (defined as not having any regimen related toxicities RLT; see below), 
patients may receive additional vaccinations every 6 weeks after the 8th dose starting at Week 30 for a 
total of 96 weeks (approximately 2 years).

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Stratum C: On the same day (+/- 3 days) as the vaccination with K27M/TT and poly-ICLC, stratum C 
patients will receive nivolumab 4.5 mg/kg IV, every 3 weeks, through week 21 of the study procedures. 
If the subject demonstrates stable to improved disease to the vaccine therapy and nivolumab 
combination therapy and tolerates the therapy well (defined as not having any regimen related toxicities 
RLT; see below), stratum C patients may continue to receive nivolumab every 3 weeks after the 8th 
dose for a total of 96 weeks (approximately 2 years). Patients may receive additional vaccination with 
K27M/TT and poly-ICLC combined with nivolumab every 6 weeks after the 8th dose and will resume 
combination therapy, starting at Week 27, for a total of 96 weeks (approximately 2 years). 
Because the peptide vaccine is sequestered locally and the immune response occurs primarily locally, 
the dose of the vaccine does not need to be scaled up proportionately to weight or body surface area; 
however, nivolumab will be based on the weight measured within 7 days prior to each infusion. With 
regard to the dose of poly-ICLC we will use a fixed amount of 30 micrograms/kg, which was used 
previously and demonstrated good tolerability with only grade 1-2 adverse events (injection site 
reactions, flu like and GI symptoms)14. The K27M/TT specific peptide will be emulsified in the adjuvant 
Montanide ISA-51, which consists of a mineral oil base, which has demonstrated to be well tolerated in 
previous studies14. 
6.1
Dosage and Administration
6.1.1
Dosage 
6.1.1.2 Poly-ICLC
Justification for the proposed dose of poly-ICLC (30 micrograms/kg IM) is provided in Section 1.2 and 
Section 5.1.4.4 (Experience in pediatric patients with glioma). The first course of poly-ICLC 
administration (30 micrograms/kg IM) will be administered on the day of the first K27M/TT vaccine, 
unless the patient has evidence of radiation induced pseudoprogression as outlined in  Section 5.1.4.4 
(Pseudo-tumor progression). If that is the case, administration of poly-ICLC can be deferred for up to 12 
weeks.  For each of the following repeated vaccinations, poly-ICLC (30 micrograms/kg IM) will be 
administered on the day of the vaccine.  This design is based on a recent pilot study of peptide-based 
vaccines in DIPG patients, in which the combination of peptide-vaccine and IM administration of poly-
ICLC (30 micrograms/kg) administered on the same day induced robust antigen-specific T-cell 
responses.14
Dose should be verified with each administration as per standard chemotherapy procedures. Dose 
adjustments should be done if there is a ≥ 10% weight change from the prior dose. 
Pretreatment with acetaminophen or with any NSAID should be given before each poly-ICLC dose.   
Reported adverse events and potential risks are detailed in Section 5.1.4.4. Appropriate dose 
modifications for poly-ICLC are described in Section 6.2.1.

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6.1.1.3 K27M/TT Peptide Vaccine
Because the peptide vaccine is sequestered locally, and the immune response occurs primarily locally 
and in the draining lymph nodes, the dose of the vaccine does not need to be scaled up proportionately 
to the size (by weight or body surface area) of the recipient, as might be done for a drug whose effect is 
related to its distribution in body fluid.  Because direct toxicity of the peptide is not expected, dose 
escalation is not as meaningful as it would be with a drug with a narrow therapeutic index.  The 
proposed dose is based on past trials, in which up to 1 mg for each of tumor-antigen peptide emulsified 
in Montanide ISA-51 were safely administered.  The 1 ml K27M/TT solution ordered by each site 
contains 750 micrograms/ml K27M peptide and 500 micrograms/ml TT peptide. Eight hundred (800) 
microliters (µL) of that aqueous solution, which corresponds to 600 micrograms K27M peptide and 400 
micrograms TT will be mixed 1:1 with Montanide ISA-51 to form one water-in-oil emulsion. The injection 
volume is 800 microliters (µL), which contains a final peptide amount of 300 micrograms and 200 
micrograms of the TT. Ideally, the vaccine should be administered within 2 hours after mixing, however 
it is stable up to 6 hours at room temperature.  If the vaccine is not administered within 6 hours after 
mixing, it should be discarded.
6.1.1.4 Nivolumab
Nivolumab will be given intravenously every 3 weeks at 4.5 mg/kg per dose over 30 minutes.  
Premedication is not required as infusion reactions are rare, but anaphylactic precautions should be 
observed during each infusion with nivolumab. If grade ≥ 2 infusion reaction occurs, the infusion should 
be stopped and supportive care given based on institutional guidelines. Please refer to Section 6.2.3 for 
dose modifications for nivolumab. The drug dose should be adjusted based on the patient’s actual 
weight in kilograms measured within 7 days prior to the beginning of each infusion. 
6.1.2
Treatment Administration
Treatment will be administered on an outpatient basis. Patients will be vaccinated subcutaneously in 
the upper arm or thigh.  Since we mix the K27M peptide and the TT-helper peptide in one emulsion (0.8 
mL), there will be one injection for the peptide vaccination and one intramuscular (IM) injection for poly-
ICLC. Poly-ICLC is expected to enhance the antigen-presentation process in the draining lymph nodes, 
and therefore poly-ICLC should be administered intramuscularly (IM) within close vicinity to the peptide-
injection site (less than 3 cm from the center of the peptide injection sites). 
   
In each vaccination, the location of vaccination will remain at the same site. Numbing measures such 
as creams, ice or mechanical devices are not permitted. Per Section 5.1.3.6, if the skin reaction from 
the previous vaccine does not allow the next administration at the same site, the vaccine may be 
administered in adjacent skin (< 2 cm from the prior injection site). If the vaccine cannot be 
administered within 2 cm of the designated site, the vaccine site will be administered on the 
contralateral side. Poly ICLC will be administered intramuscularly on the same side and on the same 
day as the K27M/TT vaccine was administered. 
The K27M/TT vaccine will be administered every three weeks starting 2-8 weeks following the 
completion of radiation therapy. Vaccine will be administered every 3 weeks up to and including Week 

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21 (8 doses). For strata A and B, vaccination will resume on Week 30 and every 6 weeks thereafter.  
For stratum C, vaccination will resume on Week 27 and every 6 weeks thereafter.  
Poly-ICLC is administered IM using sterile technique, as supplied from the vial and in the amount 
prescribed for the participant’s weight (typically, one vial is sufficient for one dose).  The poly-ICLC 
treatments will be administered on the same day as the vaccine, sequentially after K27M/TT 
administration.  Vital signs will be monitored before and for at least 20 minutes after each treatment.    
Nivolumab should be given intravenously on the same day as the vaccine or within 3 days (+/- 3 days) 
of vaccination. It can be given before or after the vaccination but should ideally be given on the same 
day as vaccination with K27M/TT and poly-ICLC. 
Nivolumab  Injection, 100 mg/10 mL (10 mg/mL) and 40 mg/4 mL (10 mg/mL) nivolumab injection is 
to be administered as an IV infusion through a 0.2-micron to 1.2-micron pore size, low-protein 
binding in-line filter at the protocol-specified doses. It is not to be administered as an IV push or 
bolus injection; any programmable infusion pump may be used. Nivolumab injection can be infused 
undiluted (10 mg/mL) or diluted with 0.9% Sodium Chloride Injection, USP or 5% Dextrose 
Injection, USP to protein concentrations as low as 0.35 mg/mL. Dilution and infusion of nivolumab 
should be carried out per institutional standard and as per section 5.1.5. Care must be taken to 
assure sterility of the prepared solution as the product does not contain any antimicrobial 
preservative or bacteriostatic agent. Nivolumab infusions are compatible with polyvinyl chloride 
(PVC) or polyolefin containers and infusion sets, and glass bottles.
6.2
Dose Modifications and Dosing Delays
The following dose modification rules will be used with respect to potential toxicity.  Toxicity will be 
assessed according to the NCI Common Terminology Criteria for Adverse Events Version  5.0 
(CTCAE v5.0).
6.2.1
Dose Modifications for Poly-ICLC
For grade 2 or greater constitutional symptoms (see Section 5.1.4.4) that are considered related to 
treatment that persist for greater than 48 hours after the injection, the next poly-ICLC dose should be 
given at two-thirds of the original dose (20 micrograms/kg).  If further dosing is well tolerated, the 
original dose may be subsequently re-instituted at the discretion of the investigator.  All dosage 
changes will be recorded in Advarra.  If grade 2 or greater symptoms again occur despite one dose 
reduction and last > 48 hours, the patient will not receive any more poly-ICLC but can continue to 
receive the K27M/TT peptide if patient is stable. 
In the case of treatment-related hepatic enzyme elevation > 5x baseline (grade 3 or greater), or any 
related, intolerable grade 2 or greater non-hematologic toxicity that lasts for > 7 days, poly-ICLC will be 
held until that toxicity has reduced to Grade 1 or less.  Poly-ICLC will then be re-administered at two-
thirds of the original dose (20 micrograms/kg), and the participant will be closely observed.  If the same 
dose-limiting toxicity again recurs despite the dose reduction, the participant will continue to receive the 
K27M/TT peptide without poly-ICLC if patient is stable. 

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For treatment-related grade 3 or greater hematologic toxicity, the next dose should be reduced to two 
thirds of the original dose (20 micrograms/kg) as long as the toxicity has resolved to grade 1 or less by 
the time the next dose is due.  If the toxicity has not resolved by the time the next dose is due, the 
patient is off treatment with poly-ICLC but can continue with the K27M/TT peptide vaccination per 
schedule.  
See Section 6.2.4 below for pseudo-tumor progression guidelines (presumed or proven) that require a 
temporary discontinuation of treatment.
6.2.2
Dosing Delay for the Peptide Vaccines (K27M/TT emulsified in Montanide ISA-51)
Possible adverse events by Montanide ISA-51-based peptide vaccines are summarized in Section 
6.1.1.3.  The toxicity profile may partially overlap with that of poly-ICLC, though the attribution to either 
or both of these agents may be apparent if the reactions/events are localized to the administration site 
or follow specific timings after the administration (e.g. fever after poly-ICLC administration).  In 
circumstances where poly-ICLC administration is suspended, if the event is not attributable to the 
peptides/Montanide ISA-51 vaccine, vaccine administration should continue on schedule.  In 
circumstances where assessment of an adverse event is limited, such as by intercurrent illness, or 
when laboratory studies are required to assess for other causes of toxicity, the vaccine schedule may 
be interrupted for up to 6 weeks.  If vaccine administration is delayed by longer than 6 weeks due to an 
adverse event other than for pseudo-tumor progression, regardless of attribution, treatment must be 
discontinued.  
6.2.3
Dose modification for Nivolumab
See Appendix I for management algorithms.
6.2.4
Pseudo-progression (please refer to the flow diagram in Table 7.1)
If pseudo-tumor progression is suspected, i.e., increased contrast enhancement with or without 
increased edema of the primary tumor approximately ≤ 6 months following the initiation of protocol 
treatment, the patient may be placed on dexamethasone or equivalent, and/or the dose increased up to 
0.3 mg/kg/day, maximum of 12 mg/day, or started on Avastin or equivalent (10mg/kg every 2 weeks for 
a total of 3 doses) if clinically symptomatic. The recommendation is not to start steroids/Avastin or 
equivalent if the patient is clinically stable and to continue peptide vaccination. If there is evidence of 
clinical deterioration, the peptide vaccination will be discontinued and only restarted if the child is on 
Decadron less than max 0.1 mg/kg/day; maximum 4mg/day and if patient stabilizes within 8 weeks. If 
the repeat MRI scan is unchanged or worse, and/or the patient’s clinical status has not improved 
despite the maximum allowed steroid dose, a biopsy (or resection, if clinically indicated) should be 
performed to differentiate between pseudo- and true tumor progression.  If for some reason (e.g., 
patient refusal or medical/surgical contraindication), a biopsy (or resection) cannot be performed, the 
patient will be taken off study due to presumed tumor progression.  When a biopsy or resection is 
performed, the histopathological specimen will be carefully examined for evidence of: 
inflammatory/lymphocytic infiltration (pseudo-tumor progression). If inflammatory/ lymphocytic 

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infiltration and/or necrosis comprise the majority of the specimen, patients may remain on study and 
restart treatment following resolution of toxicity to grade 1 or less at the discretion of the study chair. 
Such patients should restart treatment at two-thirds of the poly-ICLC dose (20 micrograms/kg).  If the 
majority of the resected specimen consists of persistent/recurrent tumor, the patient will be considered 
to have true tumor progression and will be taken off study.
Patients with suspected pseudoprogression should be discussed with the study chair.
Please refer to Section 9.3.1.4 for details regarding assessment of progressive disease. 
Prior to any therapy decision, any cases of suspected tumor progression or pseudo-tumor 
progression should be reviewed by the study chair/co-chair to determine whether the subject 
should remain in the trial.   
6.3
Regimen Limiting Toxicity (RLT) 
Each patient receiving K27M/TT peptide vaccination and poly-ICLC or K27M/TT peptide vaccination 
and poly-ICLC in combination with nivolumab will be evaluable for safety.  The safety parameters 
include all laboratory tests and hematological abnormalities, physical findings, and spontaneous reports 
of adverse events reported to the investigator by patients.
RLT includes any of the following events that occur during the first 8 vaccine doses (the entirety of the 
time from the 1st vaccine administration through the 8th vaccine administration) and up to 30 days after 
the 8th vaccine administration and are considered either possibly, probably, or definitely to the vaccine:

Any grade 2 or greater autoimmune reaction.

Any grade 3 or greater hematologic or non-hematologic toxicity with the exception of 
lymphopenia.

Any life-threatening event.

Any other unexpected Grade 2 or greater neurological deficit, which is possibly, 
probably, or definitely related to the vaccine therapy that does not respond within 21 
days trial of 0.3mg/kg day dexamethasone or equivalent (max 12mg/day) or Avastin 
equivalent (10mg/kg every 2 weeks for a maximum of 3 doses)
6.4
Suspected Myocarditis
Given the potential risk of immune-mediated myocarditis (inflammation of the heart) from check point 
inhibitor, patients will be evaluated by CPK and cardiac troponins from baseline and throughout 
treatment. Should myocarditis be suspected or as otherwise clinically indicated, treatment should be 
held and patient evaluated with a cardiology consult and TDI-derived strain echocardiography or 
cardiovascular magnetic resonance imaging should be considered.

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7
Study Procedures and Observations
7.1
Schedule of Procedures and Observations
The study-specific assessments are detailed in this section and outlined in Table 6.1 and Table 6.2.  
Screening assessments must be performed within 14 days prior to enrollment unless otherwise noted 
or in the case of H3.3K27M and HLA confirmation. Treatment or visit delays for public holidays or 
weather conditions do not constitute a protocol violation.
A written, signed, informed consent form (ICF) and a Health Insurance Portability and Accountability 
Act (HIPAA) authorization must be obtained before any study-specific assessments are initiated.  A 
copy of the signed ICF will be given to the subject, and a copy will be filed in the medical record.  The 
original will be kept on file with the study records.  
All patients who are consented will be registered in OnCore®, the UCSF Helen Diller Family 
Comprehensive Cancer Center Clinical Trial Management System (CTMS) that is being used for PNOC 
related trials.  The system is password protected and meets HIPAA requirements.
7.1.1
Eligibility Assessments
The Eligibility procedures and assessments must be completed within 14 days prior to enrollment 
unless otherwise noted. 
Strata A & B:

Complete medical history, including history of prior treatments and initial and/or other pre-
radiotherapy MRIs

Performance status

Brain MRI; spine MRI only if clinically indicated

Concomitant medications

Complete blood count (CBC) with differential and platelet count

Blood chemistry assessment, including:
o
Aspartate aminotransferase/alanine aminotransferase (ALT/AST), total bilirubin, 
creatinine and albumin

Females of child-bearing potential will have a serum or urine beta-HCG pregnancy test 
 Stratum C:

Complete medical history, including history of prior treatments  

Brain MRI; spine MRI only if clinically indicated

Performance status

Pulse oximetry

Concomitant medications 

Complete blood count (CBC) with differential and platelet count

Blood chemistry assessment, including:
o
Aspartate aminotransferase/alanine aminotransferase (ALT/AST), total bilirubin, 
creatinine, lipase, amylase, albumin, and C-reactive protein (CRP)

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
TSH (if TSH is abnormal also measure free T4)

Urine analysis (UA)

Females of child-bearing potential will have a serum or urine beta-HCG pregnancy test.
7.1.2
Treatment Period
7.1.2.2 Study Procedures: After enrollment and prior to vaccination

PNOC Health Related Quality of Life & Neurocognitive Measures (+7 days after registration; 
see Appendix H) – for Stratum C only.

Brain MRI; spine MRI only if clinically indicated – within 14 days of treatment start.
7.1.2.3 Study Procedures Day 1 of Week 0 (all strata, unless otherwise indicated)
Laboratory assessments do not need to be repeated if completed within 7 days prior.
Prior to Vaccination:

Baseline toxicity assessment including assessment of any residual toxicity relating to prior 
radiation therapy.

Physical examination including neurological examination

Vital signs 

Pulse oximetry (Stratum C only)

Performance status

Concomitant medications

CBC with differential and platelet count

Blood chemistry assessment, including:

ALT/AST, total bilirubin, calcium, phosphorus, BUN, creatinine, albumin, glucose, 
potassium, sodium, chloride, bicarbonate

Lipase, amylase, and CRP (Stratum C only)

CPK and cardiac troponins (Stratum C only)

TSH (if TSH is abnormal also measure free T4) (Stratum C only)

Urine analysis (UA) (Stratum C only)

Correlative immune monitoring assessments

Circulating tumor DNA

Serum or urine pregnancy test for females of childbearing age (within 24 hours prior to the 
initial administration of study drug)
Vaccination:
Vaccination with K27M/TT

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IM injection of poly-ICLC (if evidence of pseudo-progression after radiation therapy on Eligibility 
MRI, poly-ICLC can be held for up to 12 weeks)
Post Vaccination:

All patients will be closely observed for adverse events for at least 20 minutes following each 
vaccination.  Any time thereafter, patients should report any adverse events to the research 
coordinator or research clinician.
Nivolumab (+/- 3 days; Stratum C only):
Infusion of nivolumab on the same day as K27M/TT vaccination and poly-ICLC injection or 
within 3 days (+/- 3 days) of vaccination. Infusion can occur before or after vaccination. 
7.1.2.4 Study Procedures Day 1 of Weeks 3, 6, 9, 12, 15, 18, 21 (- 3 days) (all strata, unless 
otherwise indicated)
Laboratory assessments do not need to be repeated if completed within 7 days prior. 
Prior to vaccination:

Physical examination including neurological examination

Vital signs

Pulse oximetry (Stratum C only)

Performance status

Evaluation of adverse events

Concomitant medications

CBC with differential and platelet count

Blood chemistry assessment, including:

Alkaline phosphatase, ALT/AST, total bilirubin, calcium, phosphorus, BUN, creatinine, 
total protein, albumin, glucose, potassium, sodium, and chloride, bicarbonate

Lipase, amylase, and CRP (Stratum C only)

CPK and cardiac troponins (Stratum C only)

TSH (if TSH is abnormal also measure free T4) (Stratum C only)

UA (Stratum C only)

Serum or urine pregnancy test for females of childbearing age 

ECHO and ECG, as clinically indicated (Stratum C only)
Vaccination:

Vaccination with K27M/TT

IM injection of poly-ICLC
Post Vaccination:

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
All patients will be closely observed for adverse events for at least 20 minutes following each 
vaccination.  Any time thereafter, patients should report any adverse events to the research 
coordinator or research clinician.
Nivolumab (+/- 3 days; Stratum C only):
Infusion of nivolumab on the same day as K27M/TT vaccination and poly-ICLC injection or within 3 
days (+/- 3 days) of vaccination. Infusion can occur before or after vaccination.
7.1.2.5 Study Procedures Day 1 of Week 24 (- 3 days)
Laboratory assessments do not need to be repeated if completed within 7 days prior.

Physical examination including neurological examination

Vital signs

Pulse oximetry (Stratum C only)

Performance status

Evaluation of adverse events

Concomitant medications

CBC with differential and platelet count

Blood chemistry assessment, including:

Alkaline phosphatase, ALT/AST, total bilirubin, calcium, phosphorus, BUN, creatinine, 
total protein, albumin, glucose, potassium, sodium, chloride, and bicarbonate

Lipase, amylase, and CRP (Stratum C only) 

CPK and cardiac troponins (Stratum C only)

TSH (if TSH is abnormal also measure free T4) (Stratum C only)

UA (Stratum C only)

Serum or urine pregnancy test for females of childbearing age

Echo/ECG, as clinically indicated (Stratum C only)
Nivolumab (+/- 3 days; Stratum C only)
7.1.2.6 Study Procedures Day 1 of Week 27, 30, 33, 36, 39 etc. through Week 96 (- 3 days)
Laboratory assessments do not need to be repeated if completed within 7 days prior.
Stratum C only

Physical examination including neurological examination

Vital signs

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
Pulse oximetry

Performance status

Evaluation of adverse events

Concomitant medications

CBC with differential and platelet count

Blood chemistry assessment, including:

Alkaline phosphatase, ALT/AST, total bilirubin, calcium, phosphorus, BUN, creatinine, 
total protein, albumin, glucose

Lipase, amylase, and CRP 

CPK and cardiac troponins 

TSH (if TSH is abnormal also measure free T4) 

UA 

Serum or urine pregnancy test for females of childbearing age

Echo/ECG, as clinically indicated (Stratum C only)
Nivolumab (+/- 3 days; Stratum C only) 
Vaccination (every 6 weeks, weeks 27, 33, 39, 45, 51, 57, 63, etc. through Week 96:
Vaccination with K27M/TT
IM injection of poly-ICLC
Post Vaccination:

All patients will be closely observed for adverse events for at least 20 minutes following each 
vaccination.  Any time thereafter, patients should report any adverse events to the research 
coordinator or research clinician.
7.1.2.7 Study Procedures Day 1 of Weeks 12, 24, 36, 48, 60, 72, 84, 96 (- 7 days) (All strata)
Laboratory assessments do not need to be repeated if completed within 7 days prior.

Brain MRI (-14 days)

Spine MRI if clinically indicated (-14 days)

Circulating tumor DNA

Immuno-monitoring assessments (also to be collected at Week 18)

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7.1.3
Every 3 months (+/- 14 days)

PNOC Health Related Quality of Life & Neurocognitive Measures (PEDs-QL, PROMIS, and 
ADHD; see Appendix H) – Stratum C only.
7.1.4
Every 6 months for two years then every 12 months after two years, while on treatment (+/- 14 
days)

PNOC Health Related Quality of Life & Neurocognitive Measures (ABAS-3 and BRIEF; see 
Appendix H) – Stratum C only.
7.1.5
End-of-Treatment Study Procedures (-14 days) (all strata, unless otherwise indicated)
The following assessments should be completed on the last day of treatment if not assessed within 14 
days prior.

Evaluation of clinical response or deterioration (including MRI, if MRI not done within 30 days 
prior)

Physical examination including neurological examination

Vital signs 

Pulse oximetry (Stratum C)

Performance Status

Evaluation of adverse events; all Adverse Events (AEs) that occur following the subject’s written 
consent to participate in the study through 100 days of discontinuation of dosing, whether 
related or not related to study drug will be recorded.

Concomitant medications

CBC with differential and platelet count

Blood chemistry assessment, including:
o
Alkaline phosphatase, ALT/AST, total bilirubin, calcium, phosphorus, BUN, creatinine, 
total protein, albumin, glucose, potassium, sodium, chloride, and bicarbonate

Lipase, amylase, and CRP (Stratum C only)

CPK and cardiac troponins (Stratum C only)

TSH (if TSH is abnormal also measure free T4) (Stratum C only)

UA (Stratum C only) 

Serum or urine pregnancy test for females of childbearing age

ECHO/ECG, as clinically indicated (Stratum C only)

PNOC Health Related Quality of Life & Neurocognitive Measures (see Appendix H) (Stratum C 
only)
Vaccination (if last day of treatment):

Vaccination with K27M/TT

IM injection of poly-ICLC
Post Vaccination:

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
All patients will be closely observed for adverse events for at least 20 minutes following each 
vaccination.  Any time thereafter, patients should report any adverse events to the research 
coordinator or research clinician.
Nivolumab (+/- 3 days; Stratum C only):

Infusion of nivolumab on the same day as K27M/TT vaccination and poly-ICLC injection or 
within 3 days (+/- 3 days) of vaccination. Infusion can occur before or after vaccination.
7.1.6
30 Day Toxicity Check
To be completed 30 days (+7 days) after last day of treatment; this may be done by telephone contact.

Evaluation of adverse events (All study drug related adverse events must continue to be 
followed until resolution or return to baseline).

Review of concomitant medications
7.1.7
Every 12 months during Follow-up (+/- 14 days)

PNOC Health Related Quality of Life & Neurocognitive Measures (PEDs-QL, PROMIS, ADHD, 
ABAS-3 and BRIEF; see Appendix H) – Stratum C only.
7.1.8
Long Term/Survival Follow-up Procedures
Subjects in the follow up phase will be followed by chart review and/or telephone contact until an off-
study criterion is met to collect survival information (including disease status and any new treatment 
started) every three months (+/- 2 weeks) for 24 months. Any study drug related adverse events will be 
followed until resolution or return to baseline. PNOC Health Related Quality of Life & Neurocognitive 
Measures will also be collected according to the schedule delineated in Appendix H for patients 
enrolled in Stratum C only.
The requested follow-up data is to be submitted quarterly from the date the patient went off treatment. 
This information will be recorded in Advarra® eCRFs due at Follow-up.
7.2
Off Study Criteria
Subjects will be considered Off Study for the following reasons:

Subject determined to be ineligible.

Parent, subject, or guardian withdraws consent for continued participation.

Subject death while on study. 
Subjects who expire without confirmation of disease status will be considered progressive disease at 
the time of death. 
The date and reason for the subject coming off study must be documented in the ‘Follow-Up’ section of 
OnCore® as well as the ‘PNOC End of Treatment eCRF’ in Advarra®. No data will be collected after 
the “off study” date.

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Table 6.1     Schedule of Study Procedures and Assessments (Strata A and B)
Study Day/Visit
Eligibility 
(-14 
days)1
Day 1 on Weeks 0,
3, 6, 9, 12, 15, 18,
21, 24
(-3 days)
Day 1 on Weeks 30,
36, 42, 48, 54, 60, 66,
72, 78, 84, 90, 96
(-3 days)2
End of 
Treatment 
Visit
(-14 days)3
30 Day 
Toxicity 
Check  
(+7 days)4
Follow- 
Up5
Clinical 
procedures
HLA typing
X6
H3.3K27M
mutation status
X6
Consent Form
X1
Physical Exam7
X
X
X
Vital Signs
X
X
X
Medical History8
X
Performance 
Status
X
X
X
X
Adverse Event 
assessment
X9
X
X
X
X
Concomitant 
Medications
X
X
X
X
X
Vaccination10

Vaccine

Poly-ICLC11
X
Evaluation of 
clinical response
X
Survival5
X
Laboratory 
procedures
CBC w/ Diff + plts
X
X12
X12
X12
Blood Chemistry
X13
X12,13
X12,13
X12,13
Pregnancy test14
X
X
X
X
Imaging 
procedures
Brain MRI/Spine 
MRI
X15
X15
X15
X4,15
Specimen 
Collection
Immune 
monitoring tests16
X
X
Blood for ctDNA 17
X
X
Tumor Tissue 
Collection18
X

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1.
Eligibility tests and procedures must be performed within 14 days prior to enrollment. Consent to study therapy 
must be signed.
2.
If the subject demonstrates no evidence of disease progression and tolerates the therapy well (defined as not 
having any regimen related toxicities (RLT); see Section 6.3) after the 8th dose (Week 21), patients may receive 
additional vaccinations starting at Week 30, every 6 weeks, for a total of 96 weeks (approximately 2 years).
3.
End of treatment procedures to occur on last day of treatment. These do not need to be repeated if occurred 
within 14 days prior. Brain/Spine MRI to be repeated if not done within 30 days prior to the end of treatment 
visit.
4.
30-day toxicity check may be done via telephone if needed (+7 days). Related AEs must continue to be 
followed until resolution or return to baseline
5.
Subjects in the follow up phase will be followed by chart review and/or telephone contact until an off- study 
criterion is met to collect survival information every three months for 24 months.
6.
Subjects must be positive for HLA-A2 and H3.3K27M. HLA A*02:01 typing (based on sequencing) and H3.3K27M 
mutation status must be done in a CLIA- or equivalent approved laboratory. If H3.3K27M mutation analysis is to 
be performed at UCSF, pathology and imaging (MRI), and tissue must be submitted.
7.
To include neurological exam.
8.
To include history of prior treatments and any residual toxicity relating to prior radiation therapy and baseline 
conditions assessment.
9.
Adverse assessments to be assessed at all visits following Week 0 vaccine administration.
10. All patients will be closely observed for adverse events for at least 20 minutes following each vaccination. 
Vaccine will not be administered on Week 24 or Week 27. Vaccination will resume on Week 30 and every 6 
weeks thereafter, for a total of 96 weeks (approximately 2 years).
11. If there is evidence of pseudo-progression after radiation therapy on baseline MRI, poly-ICLC can be held for 
up to 12 weeks.
12. Laboratory assessments do not need to be repeated if completed within 7 days prior.
13. Blood chemistry to include: At screening: aspartate aminotransferase/alanine aminotransferase (ALT/AST), total 
bilirubin, creatinine and albumin. Week 0 and beyond: alkaline phosphatase, aspartate aminotransferase/alanine 
aminotransferase (ALT/AST), total bilirubin, calcium, phosphorus, blood urea nitrogen (BUN), creatinine, total 
protein, albumin, glucose, potassium, sodium, chloride, bicarbonate.
14. May be serum or urine pregnancy test; for females of child-bearing potential.
15. Spinal MRI only required if clinically indicated. Post radiation therapy MRI must occur within 14 days of enrollment 
and within 14 days of treatment start date (Day 1 Week 0). MRI(s) to be obtained at baseline and then every 12 
weeks thereafter (-14 days) – at Weeks 12, 24, 36, 48, etc.
16. To be obtained at weeks 0 (prior to vaccine), 12, 18, and 24 and then every 12 weeks thereafter each time a 
MRI is performed (-7 days) (i.e. Week 36, 48, 60, etc.). See Section 9 for further details.
17. To be obtained at baseline (Week 0 Day 1) and then every 12 weeks (-7 days).
18. If a patient has evidence of progressive disease and is undergoing tumor tissue resection as part of standard of 
care, a sample should be sent to UCSF for further analysis to assess antigen loss and immune cell infiltration. 
Please see Section 9.2.2 for further details. Please refer to PNOC SharePoint member website for shipping 
information.

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Table 6.2 Schedule of Study Procedures and Assessments (Stratum C)
Study Day/Visit
Eligibility     
(-14 days)1
Day 1 on Weeks 0, 3, 6, 9, 12, 
15, 18, 21, 24, 27, 33, 39, 45, 
51, 57, 63, 69, 75, 81, 87, 93, 
and 96 (-3 days)2
End of Treatment 
Visit 
(-14 days)3
30 Day Toxicity 
Check 
(+7 days)4
Follow-Up5
Clinical procedures
HLA typing
X6
H3.3K27M mutation 
status
X6
Consent Form
X
Physical Exam7
X
X
Vital Signs
X
X
Pulse oximetry
X
X
X
Medical History8
X
Performance Status
X
X
X
Adverse Event 
assessment9
X
X
X
X
X
Concomitant 
Medications
X
X
X
X
Drug administration

Vaccine10

Poly-ICLC11

Nivolumab20 
(every 3 weeks 
through 96 week 
study)
X
X
Evaluation of clinical 
response
X
Survival5
X
Laboratory 
procedures
CBC w/ Diff + plts
X
X12
X12
Blood Chemistry
X13
X12,13
X12,13
Pregnancy test14
X
X
X
Urinalysis
X
X
X
CPK & cardiac 
troponins
X
X
Imaging/cardiology 
procedures
ECG15
X
X

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ECHO15
X
X
Brain MRI/Spine MRI
X16
X16
Quality of Life 
Assessments
QOL 
Assessments(see 
Appendix H for 
specific timepoints)
X
X
X
X
Specimen Collection
Immune monitoring 
tests17
X
Blood for ctDNA 18
X
Tumor Tissue 
Collection19
X
1.
Eligibility tests and procedures must be performed within 14 days prior to enrollment. Consent to study therapy must 
be signed. H3.3K27M sequencing and HLA typing may be done prior to 14 days within enrollment.
2.
If the subject demonstrates no evidence of disease progression and tolerates the therapy well (defined as not having 
any regimen related toxicities (RLT); see Section 6.3) after the 8th dose (Week 21), patients may continue to receive 
nivolumab every 3 weeks after the 8th dose for a total of 96 weeks. Patients may receive additional vaccination with 
K27M/TT and poly-ICLC combined with nivolumab every 6 weeks after the 8th dose (starting at Week 27) for a total 
of 96 weeks.
3.
End of treatment procedures to occur on last day of treatment. These do not need to be repeated if occurred within 
14 days prior. Brain/Spine MRI to be repeated if not done within 30 days prior to the end of treatment visit.
4.
30-day toxicity check may be done via telephone if needed (+7 days). Related AEs must continue to be followed until 
resolution or return to baseline
5.
Subjects in the follow up phase will be followed by chart review and/or telephone contact until an off-study criterion is 
met to collect survival information every three months for 24 months.
6.
Subjects must be positive for HLA-A*02:01 and H3.3K27M. HLA A*02:01 typing (based on sequencing) and 
H3.3K27M mutation status must be done in a CLIA- or equivalent approved laboratory. If H3.3K27M mutation 
analysis is to be performed at UCSF, pathology and imaging (MRI), and tissue must be submitted.
7.
To include neurological exam.
8.
To include history of prior treatments and any residual toxicity relating to prior radiation therapy and baseline 
conditions assessment.
9.
Adverse assessments to be collected following the subject’s written consent to participate in the study through 100 
days of discontinuation of dosing, whether related or not related to study drug.  
10. All patients will be closely observed for adverse events for at least 20 minutes following each vaccination. Vaccine will 
not be administered on Week 24. Vaccination will resume on Week 27 and every 6 weeks thereafter, for a total of 96 
weeks (approximately 2 years). 
11. If there is evidence of pseudo-progression after radiation therapy on baseline MRI, poly-ICLC can be held for up to 12 
weeks.
12. Laboratory assessments do not need to be repeated if completed within 7 days prior.
13. Blood chemistry to include: At screening: aspartate aminotransferase/alanine aminotransferase (ALT/AST), total 
bilirubin, creatinine, albumin, lipase, amylase, C-reactive protein (CRP), and TSH. Week 0 and beyond: alkaline 
phosphatase, aspartate aminotransferase/alanine aminotransferase (ALT/AST), total bilirubin, calcium, phosphorus, 
blood urea nitrogen (BUN), creatinine, total protein, albumin, glucose, potassium, sodium, chloride, bicarbonate, 
lipase, amylase. CRP, TSH (if TSH is abnormal also measure free T4), urine analysis (UA).

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14. Required within 24 hours prior to the initial administration of nivolumab, then every 3 weeks. May be serum or urine 
pregnancy test; for females of child-bearing potential.
15. Day 1, each visit starting at Week 3 (excluding Week 24): as clinically indicated. End of Treatment: as clinically 
indicated.
16. Spinal MRI only required if clinically indicated. Post radiation therapy MRI must occur within 14 days of enrollment 
and within 14 days of treatment start date (Day 1 Week 0). MRI to be obtained at baseline and then every 12 weeks 
thereafter (-14 days) – at Weeks 12, 24, 36, 48, etc.
17. To be obtained at weeks 0 (prior to vaccine), 12, 18, and 24 and then every 12 weeks thereafter each time a MRI is 
performed (-7 days) (i.e. Week 36, 48, 60, etc.). See Section 9 for further details.
18. To be obtained at baseline (Week 0 Day 1) and then every 12 weeks (-7 days). 
19. If a patient has evidence of progressive disease and is undergoing tumor tissue resection as part of standard of care, 
a sample should be sent to UCSF for further analysis to assess antigen loss and immune cell infiltration. Please see 
Section 9.2.2 for further details. Please refer to PNOC SharePoint member website for shipping information.
20. Nivolumab to be given every 3 weeks. Nivolumab will be given IV before or after vaccine and poly-ICLC injection (+/- 
3 days of vaccination and poly-ICLC injection). 
7.3
Dietary Restrictions
There are no dietary restrictions on this protocol. 
7.4
Prohibited Medications

Interferon therapy (e.g. Intron-A®)

Anti–cancer directed therapy including chemotherapy – with the exception of Avastin 
for treatment of pseudo-progression.

Allergy desensitization injections

Corticosteroid medications administered parenterally with the exception of 
corticosteroids treatment for treatment of pseudo-progression or treatment with 
inhaled, intranasal, ocular, or topical steroids. These cases should be discussed with 
the study chair. 

Growth factors (e.g. Procrit®, Aranesp®, Neulasta®)

Interleukins (e.g. Proleukin®)

Other investigational medications

Illicit drugs

Any live / attenuated vaccine (e.g. varicella, zoster, yellow fever, rotavirus, oral polio 
and measles, mumps, rubella (MMR)) during treatment and until 100 days post last 
dose (Stratum C only).
Medications associated with prolonged QTc should be avoided. Please refer to Appendix G for a list. 
Because the lists of these agents change frequently, it is important to regularly consult frequently 
updated medical references. For the most current list of medications, please refer to the following 
reference: 
Woosley, RL and Romero, KA, www.Crediblemeds.org, QTdrugs List, Accession Date 
December 2nd, 2016, AZCERT, Inc. 1822 Innovation Park Dr., Oro Valley, AZ 85755
8
Quality of Life Surveys

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Health-related quality of life (HRQOL) is a construct based on the impact of health and illness on an 
individual’s QOL, as assessed by dimensions of physical, psychological, and social health 1. Several 
studies have shown that compared to healthy controls or other cancer survivors, survivors of pediatric 
brain tumors have the lowest HRQOL 2,3. For example, children with brain tumors under active therapy 
are frequently viewed as socially isolated and/or often absent from school by their peers 4. Cosmetic 
effects of radiation or chemotherapy treatment (e.g. permanent or temporary alopecia) often occur 5, 
adding to social burdens and contributing to social isolation. Historically though, HRQOL measures 
have rarely been included as clinical trial endpoints 6-9. Fortunately, this trend is slowly changing. 
Several criteria are considered when evaluating the utility of an HRQOL assessment tool. These 
include: reliability and validity of the measure in the population for which it is used, the option for use of 
proxy report, development and age appropriate versions as well as the inclusion of both a generic core 
(i.e. questions relevant in assessing the HRQOL of any sick child) and disease-specific modules (i.e. 
questions specific to brain tumor patients), costs of the study, and availability of forms in parents’ native 
language 1,10.  An important note regarding HRQOL measures is that, though the option for parent or 
proxy reporting is typically necessary, self-report is preferred as parents may view the impact of the 
disease differently than the child 11. Additionally, HRQOL measures should not be too generic. For this 
reason, HRQOL measures should include disease-specific modules to avoid missing clinically 
significant changes that are disease dependent 7. This approach might be particularly important in 
clinical trials where detecting even small changes related to an individual disease or treatment is 
necessary 12. 
There are several cancer-centric assessment tools that satisfy the criteria above 13-20. The Pediatric 
Functional Assessment for patients with Brain Cancer (Peds-FACT-Br) is specific to children with brain 
tumors and English versions are free-of-charge, making this an attractive assessment tool for HRQOL. 
Unfortunately, there have been limited studies assessing its validity among different age groups 19. 
Pediatric brain tumor survivors live with chronic neurocognitive effects. A core set of cognitive 
processes appears particularly affected in these children including attention, information processing 
speed, and working memory. With close monitoring of cognitive development, weaknesses can be 
readily identified so that appropriate interventions and support can be put in place. Within PNOC, we 
will focus on the validated measures described in Appendix H. See Appendix H for the references 
contained within this section.
9
Monitoring of Response
The blood draws performed at weeks 0, 12, 18, 24 and every 12 weeks thereafter at subsequent MRIs 
as part of immune monitoring will be used in the following two analyses.
9.1
Immuno-monitoring
9.2
Enzyme Linked Immuno-SPOT (ELISPOT) Assays
Frequencies of H3.3K27M-responsive T-lymphocyte precursors in peripheral blood mononuclear 
cells (PBMC) prior to and after administration of the K27M-peptide based vaccine can be measured 
by ELISPOT assay.  The biological responses measured by ELISPOT will be done at the same time 
point at least for one individual participant to avoid inter-assay variability.  Successful vaccination 
stimulates clonal populations of T cells that are capable of secreting cytokines in an antigen-specific, 
MHC-restricted fashion.  We will utilize the ELISPOT assay to evaluate H3.3K27M-specific immune 

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responses of CD8+ T-cell populations as well as CD4+ T cells that react against the helper TT 
peptide.  We will evaluate IFN- production to assess Type-1 T-cell response.  Hence, even though 
our plans for peripheral blood drawing should provide us with sufficient PBMC to run both assays, if 
we still encounter a shortage of PBMC, IFN- ELISPOT will be prioritized over tetramer assays. 
ELISPOT Assay: ELISPOT provides a measure of the induction of tumor-specific CD8+ and CD4+ T-
cells by immunization.  Blood specimens from the selected subjects will be obtained pre-, during and 
post-vaccination. ELISPOT assay will be performed to measure the frequency of a population of T cells 
capable of responding to the tumor specific antigen by secreting IFN-.
A subject will be considered to have responded, if at any of post-vaccine time point against the 
H3.3K27M antigen, the number of spots is double that at baseline, and there are at least 10 
spots/20,000 cells, and if the number of the post-vaccine spots is at least three times the standard-
deviation of the pre-vaccine value.  This definition provides some protection against false positive 
response.  
9.2.1
Tetramer Analysis of K27M-reactive T cells in Participant’s PBMC
Tetramer analyses allow us to evaluate the presence of H3.3K27M-specific CD8+ T-cells in peripheral 
blood with a great sensitivity without in vitro re-stimulation of the cells.  It is expected, that significant (a 
log or more) increase in the frequency of peptide-responsive CD8+ T cells will be observed in some, but 
not all, patients immunized with tumor-antigen based vaccines.  In an exploratory manner, these 
PBMCs will also be evaluated for surface expression of an integrin receptor very late antigen (VLA)-4, 
which has been implicated to confer T-cell homing to CNS tumors28 and chemokine receptors (e.g. 
CXCR3 and CCR5).  
CD8+ cells from PBMC will be positively selected on immunobeads (this procedure is established and 
available at UCSF). The enriched CD8+ cell fraction will be tested by flow cytometry for the percentage 
of cells expressing CD8 surface antigen.
In addition to CD8, VLA-4 (41 integrins) and LFA-1 expression on tetramer-positive T cells will be 
examined as markers dictating preferential homing to the brain tumor sites.
Tetramer assays will be done with PBMC samples obtained at baseline and specified time points after 
vaccinations.  We will define a single time-point positive response for a peptide to be (1.5 + B)% of all 
CD8+ cells positive by tetramer assay, where B is the percent positive at baseline, which is usually less 
than 0.1%.  In analogy to the definition of ELISPOT response, a patient will be considered to have 
responded if he/she has two consecutive single time-point responses for the K27M peptide.  Response 
rates will be reported as for ELISPOT.
Flow cytometric analyses of lymphocyte subsets
Number of CD4+, CD8+ T cells as well as CD4+/Foxp3+ T regulatory cells at serial time points pre- and 
post-vaccines will be evaluated. These data will be evaluated in an exploratory manner. 

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9.2.2
Evaluation of Primary and Recurrent Tumor Tissues 
We will evaluate H3.3K27M expression in the patients’ available tumor tissues (either pre-vaccine or 
after progression post-vaccines; or both) by immunohistochemistry (IHC) and reverse transcriptase-
polymerase chain reaction (RT-PCR).    
If tumors recur following vaccinations, it will be critical to evaluate how tumors escape the effects of 
vaccines.  To this end, we will evaluate the following specific issues as much as the tissue-availability 
allows: 

Antigen-loss: We will assess, using IHC and RT-PCR, whether the recurrent tumors express 
H3.3K27M. 

Immune cell infiltration: One reason tumors may escape a vaccine-induced immune response is 
through the failure of reactive T cells to infiltrate the tumor.  To examine this, whenever freshly 
resected tumor tissues (not fixed or frozen) or fresh or flash frozen are available, we will isolate 
tumor infiltrating lymphocytes (TILs) and characterize their numbers, phenotype, and antigen-
specificity using HLA-A2 tetramers for H3.3K27M.  Using multi-color flow-cytometry, we will also 
determine the function and viability of tetramer+ TILs by staining for perforin/IFN- and Annexin-V, 
respectively.  Control tissues will include pre-vaccine tumors (if available) and recurrent tumors from 
patients not in the vaccine trial.  These studies will allow us to evaluate whether vaccine-induced T-
cells efficiently traffic to the brain tumor site and maintain their function and viability.
9.3
Evaluation of Efficacy (or Activity)
Immunotherapeutic approaches for children with gliomas are a relatively new era and therefore we 
have limited experience on how to monitor response.   Recently the Immunotherapy Response 
Assessment in Neuro-Oncology (iRANO) working group has proposed guidelines on how to monitor 
and assess efficacy in adult brain tumor patients treated with immunotherapy as a development of the 
iRANO criteria, that were established to better account for the phenomenon of pseudo-progression in 
adult patients 34,35. The pediatric neuro-oncology working group (RAPNO) is currently working on their 
guidelines for response criteria for pediatric neuro-oncology patients36. Our limited experience with 
immunotherapies have shown that early radiological changes could be misinterpreted as progression 
due to therapy induced inflammation and long-term benefit can still be seen even after initial 
progression or even after the appearance of new lesions 14,37. The response criteria are adapted from 
iRANO. 
9.3.1
Antitumor Effect 
9.3.1.2 Definitions
Evaluable for toxicity
All patients will be evaluable for toxicity from the time of their first treatment with the study therapy.
Evaluable for objective response

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Only those patients who have measurable disease present at baseline, have received at least one dose 
of the vaccine and Poly-ICLC in combination with nivolumab, and have had their disease re-evaluated 
will be considered evaluable for response.  These patients will have their response classified according 
to the definitions stated below.  (Note:  Patients who exhibit objective disease progression prior to week 
12 at the first scheduled MRI will also be considered evaluable.)
9.3.1.3 Disease Parameters
In order to completely document the assessment of response, the two-dimensional tumor 
measurements for all target lesions upon which the assessments of tumor response are based should 
be explicitly noted in the radiology report for the baseline and all subsequent follow-up exams. Reports 
for the follow-up exams should reiterate the measurements obtained at baseline for each target lesion. 
Newly occurring lesions should also be enumerated in these reports, and changes in lesions should be 
described.
Tumor response criteria for this study are to be determined by changes in size using the maximal 2-
dimensional cross-sectional tumor measurements, T x W (product of the longest diameter of the tumor 
[width (W)] and its longest perpendicular diameter [transverse (T)], using either T1 or T2 weighted 
images (which ever gives the best estimate of tumor size).  This will allow comparison with historical 
studies as outlined in the statistical design section, such as CCG-9941, ACNS0126, ACNS0927 and 
ADVL1217 which used cross-sectional measurements in their determination of response status.
 The following section describes the methodology.
 
1.   For MRI imaging, the longest diameter can be measured from the axial plane or the plane in which 
the tumor is best seen or measured, provided the same plane is used in follow ups.
2.   The longest measurement of the tumor (or width, W) should be determined. 
3.   The 2 perpendicular measurements should be determined (transverse (T) measurement-
perpendicular to the width (W) in the selected plane
Measurable disease
Measurable disease is defined as the lesions (or lesions) that can be accurately measured in at least 2 
dimensions by MRI (no less than double the slice thickness).
All tumor measurements will be recorded in millimeters or decimal fractions of centimeters.  
Target lesions
All measurable lesions up to a maximum of 5 lesions total representative of all involved areas should be 
identified as target lesions and recorded and measured at baseline.  Target lesions will be selected on 
the basis of their size (largest) and their suitability for accurate repeated measurements.  
Non-measurable disease 
Non-measurable disease is all other lesions (or sites of disease), including leptomeningeal disease.
Methods for Evaluation of Measurable Disease

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All measurements will be taken and recorded in metric notation using a ruler or calipers.  All baseline 
evaluations will be performed as closely as possible to the beginning of treatment. 
The same method of assessment and the same technique will be used to characterize each identified 
and reported lesion at baseline and during follow-up.  
9.3.1.4 Response Criteria
Complete Response (CR)
Disappearance of all target and non-target lesions, determined by two separate observations 
conducted not less than 4 weeks apart. There can be no appearance of new lesions.
Partial Response (PR)
At least a 50% decrease in the size of target lesions, taking as reference to the baseline MRI.  There 
can be no appearance of new lesions.
Progressive Disease (PD)
At least a 50% increase in the sum of the size of target lesions, taking as reference the smallest target 
size since the treatment started that is confirmed on a 3 month follow up scan as long as the patient is 
NOT experiencing significant neurological decline (defined as CTCAE grade 3 or higher). Please also 
refer to Table 7.1.The confirmatory scan requirement will assure that patients are not 
prematurely assigned to have PD. Also, the appearance of new lesions might be part of an 
immune response and if the patient is clinically stable, these should be confirmed on a 3 month 
follow scan to assess for true progressive disease versus pseudo-progression. This will apply to 
subjects that demonstrate worsening of the MRI within 6 months of start of therapy. Subjects who 
develop worsening radiographic findings > 6 months from start of immunotherapy are expected to have 
a low likelihood of ultimately deriving benefit from the therapy and should be considered PD based on 
imaging if they have a 50% increase in size of the target lesion or if new lesions appear. 
Patients who experience significant clinical decline or those who have radiographic progression on the 
3 month follow up scan should be classified as progressive disease and the date of progression should 
be entered as the first MRI that showed progressive disease.
If the follow up 3 month scan shows stabilization or reduction of tumor size in the setting of stable 
clinical examination and absence of increased steroid use treatment, the patient will be classified as 
having pseudo-progression and will continue on study therapy. 
If feasible, we recommend obtaining tissue if imaging is concerning for progression, as tissue 
evaluation remains the gold standard to differentiate between pseudoprogression versus true 
progression. If pathology mainly consists of recurrent tumor, the subject should be considered to have 
true tumor progression and be taken off study. If the tissue mainly consists of gliosis and inflammation 
(consistent with treatment effect) the subject should be classified has having pseudo-progression and 
should remain on study. Subjects that have tissue available will be centrally reviewed at UCSF. 
In cases for which it remains difficult to differentiate between progression versus pseudo- progression, 
the PI must discuss with the study chair the possibility of continuation of therapy. Images will also be 

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centrally reviewed at UCSF. Continuation of therapy might be considered if the patient derives clinical 
benefit with acceptable toxicity after a review by the study chair. 
Please refer to outline below to assess PD. This is applicable for imaging findings within the first 6 
months since start of immunotherapy. 
Stable Disease (SD)
Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as 
reference the smallest target size since the treatment started.
Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started).  The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria.

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Table 7.1 Response Criteria
# Biopsy requirements: If the repeat MRI scan is unchanged or worse, and/or the patient’s clinical status has not 
improved despite the maximum allowed steroid dose (refer to Section 5.2.4), a biopsy (or resection, if clinically 
indicated) should be performed to differentiate between pseudo- and true tumor progression.  If for some reason 
(e.g., patient refusal or medical/surgical contraindication), a biopsy (or resection) cannot be performed, the patient 
will be taken off study due to presumed tumor progression.  When a biopsy or resection is performed, the 
histopathological specimen will be carefully examined for evidence of: inflammatory/lymphocytic infiltration 
(pseudo-tumor progression). If inflammatory/ lymphocytic infiltration and/or necrosis comprise the majority of the 
specimen, patients may remain on study and restart treatment following resolution of toxicity to grade 1 and if 
steroids were successfully weaned. Such patients MUST be discussed with the study chair and team. Please also 
refer to Section 5.2.4 under Pseudo-progression. 

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Duration of Response
Duration of overall response
The duration of overall response is measured from the time measurement criteria are met for CR or PR 
(whichever is first recorded) until the first date that recurrent or progressive disease is objectively 
documented (taking as reference for progressive disease the smallest measurements recorded since 
the treatment started).
The duration of overall CR is measured from the time measurement criteria are first met for CR until the 
first date that recurrent disease is objectively documented.
Duration of stable disease
Stable disease is measured from the start of the treatment until the criteria for progression are met, 
taking as reference the smallest measurements recorded since the treatment started. 
Progression-Free Survival
Progression-free survival (PFS) is defined as the duration from diagnosis to time of progression.
Overall Survival
Overall survival (OS) is defined as the duration of time of diagnosis to time of death.
9.3.1.5 Imaging Analyses
At the end of the study, images will be evaluated by central review including assessments of standard 
MR imaging parameters. Statistical correlations between these imaging parameters and outcome will 
be performed. Imaging from initial diagnosis, or otherwise prior to radiotherapy, if performed, must be 
submitted for best comparison and analyses.
9.4
Evaluation of Safety
Analyses will be performed for all patients having received at least one course of study therapy.  The 
study will use the CTCAE v5.0 for reporting of all adverse events.
The Study Chair is responsible for the overall conduct of the study and for monitoring its safety and 
progress at all participating sites.
9.5
Definitions of Adverse Events
9.5.1
Adverse Event
An adverse event (also known as an adverse experience) is defined as any untoward medical 
occurrence associated with the use of a drug in humans, whether or not considered drug related.  More 
specifically, an adverse event (can be any unfavorable and unintended sign e.g., an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a drug, without any 
judgment about causality.  An adverse event can arise from any use of the drug (e.g., off-label use, use 

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in combination with another drug) and from any route of administration, formulation, or dose, including 
an overdose. 
9.5.2
Adverse Reaction
An adverse reaction is defined as any adverse event caused by the use of a drug.  Adverse reactions 
are a subset of all suspected adverse reactions for which there is reason to conclude that the drug 
caused the event.
9.5.2.2 Suspected
A suspected adverse reaction is defined as any adverse event for which there is a reasonable 
possibility that the drug caused the adverse event. For the purposes of IND safety reporting, 
“reasonable possibility” indicates that there is evidence to suggest a causal relationship between the 
drug and the adverse event.  A suspected adverse reaction implies a lesser degree of certainty about 
causality than an adverse reaction.
9.5.2.3 Unexpected 
An adverse event or suspected adverse reaction is considered unexpected if it is not listed in the 
investigator brochure or package insert(s), or is not listed at the specificity or severity that has 
been observed, or, if an investigator brochure is not required or available, is not consistent with 
the risk information described in the general investigational plan or elsewhere in the current 
application. 
“Unexpected,” as used in this definition, also refers to adverse events or suspected adverse reactions 
that are mentioned in the investigator brochure as occurring with a class of drugs or as anticipated from 
the pharmacological properties of the drug, but are not specifically mentioned as occurring with the 
particular drug under investigation.
Adverse events that would be anticipated to occur as part of the disease process are considered 
unexpected for the purposes of reporting because they would not be listed in the investigator brochure.  
For example, a certain number of non-acute deaths in a cancer trial would be anticipated as an 
outcome of the underlying disease, but such deaths would generally not be listed as a suspected 
adverse reaction in the investigator brochure.
Some adverse events are listed in the Investigator Brochure as occurring with the same class of drugs, 
or as anticipated from the pharmacological properties of the drug, even though they have not been 
observed with the drug under investigation.  Such events would be considered unexpected until they 
have been observed with the drug under investigation. For example, although angioedema is 
anticipated to occur in some patients exposed to drugs in the ACE inhibitor class and angioedema 
would be described in the investigator brochure as a class effect, the first case of angioedema 
observed with the drug under investigation should be considered unexpected for reporting purposes.
9.5.2.4 Serious

An adverse event or suspected adverse reaction is considered serious if, in the view of either 
the investigator or sponsor, it results in any of the following outcomes: Death

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
Life-threatening adverse event

Inpatient hospitalization ≥ 24 hours or prolongation of existing hospitalization by ≥ 24 hours

A persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
function

Congenital anomaly/birth defect
Important medical events that may not result in death, are life-threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may jeopardize the 
patient or subject and may require medical or surgical intervention to prevent one of the outcomes 
listed in this definition.  Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasias or convulsions that do not 
result in inpatient hospitalization, or the development of drug dependency or drug abuse.
9.5.2.5 Life-threatening
An adverse event or suspected adverse reaction is considered life-threatening if, in the view of either 
the investigator or sponsor, its occurrence places the patient or subject at immediate risk of death. It 
does not include an adverse event or suspected adverse reaction that, had it occurred in a more severe 
form, might have caused death. 
9.6
Recording of an Adverse Event
All clinically significant adverse events will be entered into Advarra®, whether or not the event is 
believed to be associated with use of the study drug.  Data about these events and their severity will be 
recorded using the NCI CTCAE v5.0. All clinically significant Adverse Events (AEs) that occur following 
the subject’s written consent to participate in the study through 100 days of discontinuation of dosing 
must be reported, whether related or not related to study drug.
The Investigator will assign attribution of the possible association of the event with use of the 
investigational drug, and this information will be entered into Advarra® using the classification system 
listed below: 
Relationship 
Attribution 
Description 
Unrelated
The AE is clearly NOT related to the intervention 
Unrelated to investigational 
drug/intervention
Possible
The AE may be related to the intervention 
Probable
The AE is likely related to the intervention 
Related to investigational 
drug/intervention
Definite
The AE is clearly related to the intervention 
 ,Signs or symptoms reported as adverse events will be graded and recorded by the Investigator 
according to the CTCAE.  When specific adverse events are not listed in the CTCAE they will be 

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graded by the Investigator as none, mild, moderate or severe according to the following grades and 
definitions:
Grade 0
No AE (or within normal limits)
Grade 1
Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated
Grade 2
Moderate; minimal, local, or noninvasive intervention (e.g., packing, cautery) 
indicated; limiting age-appropriate instrumental activities of daily living (ADL)
Grade 3:
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-
care ADL
Grade 4:
Life-threatening consequences; urgent intervention indicated
Grade 5:
Death related to AE
9.7
Follow-up of Adverse Events
All adverse events will be followed with appropriate medical management until resolved or return to 
baseline.  Patients removed from study for unacceptable adverse events will be followed until resolution 
or stabilization of the adverse event.  For selected adverse events for which administration of the 
investigational drug was stopped, a re-challenge of the subject with the investigational drug may be 
conducted if considered both safe and ethical by the Investigator.
9.8
Adverse Event Monitoring
PNOC uses the web-based Advarra® Clinical Trials Management System for monitoring and recording 
of Adverse Events (AEs) including all adverse reactions considered “serious” (also called Serious 
Adverse Events, or SAEs).
All Adverse Events entered into Advarra® will be reviewed on a weekly basis by the PNOC Operations 
Office. The PNOC Operations Office will discuss the toxicity, grade, and relationship to study 
intervention for all AEs in question.
In addition, all Serious Adverse Events (SAEs) will be reviewed and monitored by the UCSF DSMC on 
an ongoing basis, and will be discussed at the UCSF DSMC meeting, which take place every six (6) 
weeks. SAEs must be entered into the OnCore clinical trial management system in addition to the 
Advarra EDC for the purpose of the UCSF’s DSMC monitoring. Please see Appendix E PNOC Data 
Safety and Monitoring Plan for more information. 
9.9
SAEs and Expedited Reporting
All Adverse Events which meet the definition of ‘Serious’ as well as other medically significant events 
described below require expedited reporting to PNOC.  Please contact the PNOC Operations Office 
 
with any questions regarding expedited reporting requirements for this 
study. 

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Serious Adverse Events (SAEs) 
An adverse event or suspected adverse reaction is considered serious if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes: 
Death
Life-threatening adverse event
In-patient hospitalization ≥ 24 hours or prolongation of existing hospitalization by ≥ 24 hours
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life 
function
Congenital anomaly/birth defect or cancer
Event that changes the risk/benefit ratio of the study
Important medical events that may not result in death, are life threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may jeopardize the 
subject or subject and may require medical or surgical intervention to prevent one of the outcomes 
listed in this definition.  Examples of such medical events include allergic bronchospasm requiring 
intensive treatment in an emergency room or at home, blood dyscrasias or convulsions that do not 
result in in-patient hospitalization, or the development of drug dependency or drug abuse.
All SAEs (see above definition) on any PNOC trial, regardless of relationship, must be reported 
to PNOC via OnCore, the Advarra EDC system, and Email 
within 
one business day of first PI awareness, even if the SAE is ongoing.  The SAE must be followed 
until resolution:
a) Advarra: All SAEs must be entered into the SAE CRF in the Advarra EDC. The Advarra SAE 
record should be updated immediately as new information becomes available until the SAE is 
resolved.
b) OnCore:  All SAEs must be entered into the Subject Console in OnCore 
(https://oncore.ucsf.edu/ > Subject Console > SAE Tab on left).  The OnCore SAE record 
should be updated immediately as new information becomes available until the SAE is resolved.  
(Toxicity segment MUST be completed.  Don’t forget to click “Add” button.)  Please refer to the 
“PNOC OnCore SAE Entry Guide: Field by Field” found in the PNOC SharePoint Member site 
documents area for more information.
c)
Email:  Please also email 
with the following information: 
In the subject line: “SAE: Patient PNOC ID” (e.g. “SAE: PNOC007-1”)
In the body of the email: registration number, weight, study drug dose with frequency and route, 
dates of use, site PI’s attribution, outcome (ongoing, resolved etc.). Please also provide a 
comprehensive event description (including whether event subsided when treatment was halted, 
and if re-introduction was attempted and if so, if event recurred), pertinent labs or tests with 
dates, concomitant medications, and any other relevant history. The lot number or other unique 
information about the study drug should also be provided. Any information that is not available 
at the time of the initial notification must be provided as soon as possible on an ongoing basis 
until the SAE and all queries have been resolved.

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Site IRB:  Each PNOC site is also responsible for following their own IRB guidelines for 
reporting SAEs.
All Serious Adverse Events (SAEs) that occur following the subject’s written consent to 
participate in the study through 100 days of discontinuation of dosing must be reported to 
PNOC, whether related or not related to study drug.
See additional details for SAE reporting in Section 9.9
SAE Data Entry in AE CRF:
All SAEs must also be entered into the AE CRF for that Cycle (Subject Console > Forms by 
Status/Forms by Visit).  This entry must take place within 10 days of the last day of the Cycle in which 
the SAE occurred, or as soon as possible in the case of an SAE that was discovered late. Please 
reference the “PNOC SAE Reporting and Entry” in SharePoint for more information. 
SAE Deviations:
If the protocol procedures around SAEs are not followed (e.g. reporting timelines or dose 
modifications), a Deviation may also need to be entered in OnCore (Subject Console > Deviation Tab 
on left)/the Advarra EDC.  Please reference the “PNOC Deviation Reporting Guidelines” in SharePoint 
for more information.   
Email notification to PNOC operations office 
 within one business day 
of first PI awareness.
9.10
PNOC Reporting
9.10.1 Reporting to the UCSF Data and Safety Monitoring Committee
If a death occurs during the treatment phase of the study, or within 30 days after the last administration 
of the study drug(s), and is determined to be related either to the investigational drug or to any research 
related procedure, the Study Chair and the PNOC Operations Office must be notified by the member 
institution within 1 business day. The Study Chair or the PNOC Operations Office must then notify the 
UCSF DSMC Chair, or qualified alternate, within 1 business day of this notification.  The contact may 
be by phone or e-mail. Each participating site will follow their institutional reporting guidelines to 
institutional DSMC. 
9.10.2 PNOC Reporting to UCSF Institutional Review Board (IRB)
The PNOC operation office must report events meeting the UCSF IRB definition of “Unanticipated 
Problem” (UP) within 10 business days of awareness of the event. 
Each participating site will follow their institutional reporting guidelines to the IRB.

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9.10.3 Sponsor-Investigator (PNOC) Reporting to the Food and Drug Administration (FDA)
All SAEs on any PNOC trial, regardless of relationship, must be reported to the PNOC 
Operations Office via OnCore, the Advarra EDC, and Email 
within 
one (1) business day of first PI awareness, even if the SAE is ongoing. The SAE must be followed 
until resolution.
The submitting PNOC site must include as much of the following information as possible in the initial 
notification email and in the entry: registration number, weight, study drug dose with frequency and 
route, dates of use, site PI’s attribution, outcome (ongoing, resolved etc.). Please also provide a 
comprehensive event description (including whether event subsided when treatment was halted, and if 
re-introduction was attempted and if so, if event recurred), pertinent labs or tests with dates, 
concomitant medications, and any other relevant history. The lot number or other unique information 
about the study drug should also be provided. Any information that is not available at the time of the 
initial notification must be provided as soon as possible on an ongoing basis until the SAE and all 
queries have been resolved.   
As this study is being conducted under an IND, the PNOC Operations Office is responsible for 
determining whether or not the suspected adverse reaction meets the criteria for Expedited IND Safety 
Reporting in accordance with Federal Regulations (21 CFR §312.32). 
The PNOC Operations Office will be responsible for IND Safety Reporting to the FDA for any suspected 
adverse reaction at any PNOC site that is determined to be serious, at least possibly related to the 
study drug, and unexpected.  The PNOC Operations Office needs to ensure that the event meets all 
three definitions (as defined below by FDA): Suspected adverse reaction, Unexpected, and Serious.
When the PNOC Operations Office receives notification of an SAE, they will alert the Study Chair and 
Co-Chair as well as the PNOC Lead and Co-Lead (the “study team”) within one (1) business day.  The 
Study Chair/Co-Chair and PNOC Lead/Co-Lead will be required to respond regarding the relationship 
and expectedness of the SAE within one (1) business day of receiving all the information needed to 
make a determination.
If the majority of the study team decides the adverse event does not meet all three of the definitions, 
the SAE will not be submitted as an Expedited IND Safety Report. However, standard PNOC 
procedures for reviewing an SAE will still be followed, as below.
If the majority of the study team decides the adverse event does meet all three definitions, PNOC 
Operations Office will submit MedWatch Form 3500A to the FDA within ten (10) business days of the 
determination for general related, unexpected SAEs, or within three (3) business days for any 
unexpected fatal or life-threatening suspected SAEs. 

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Any relevant additional information that pertains to a previously submitted IND Safety Report will be 
submitted to FDA as a Follow-up IND Safety Report as soon as possible after the information becomes 
available 
9.10.4 Sponsor-Investigator (PNOC) Reporting to Bristol-Myers Squibb (BMS)

All Serious Adverse Events (SAEs) that occur following the subject’s written consent to participate 
in the study through 100 days of discontinuation of dosing must be reported to BMS Worldwide 
Safety, whether related or not related to study drug. If applicable, SAEs must be collected that 
relate to any later protocol-specified procedure (e.g., a follow-up skin biopsy).

Following the subject’s written consent to participate in the study, all SAEs, whether related or not 
related to study drug, are collected, including those thought to be associated with protocol-
specified procedures. The investigator should report any SAE occurring after these 
aforementioned time periods, which is believed to be related to study drug or protocol-specified 
procedure.

An SAE report should be completed for any event where doubt exists regarding its seriousness; 

If the investigator believes that an SAE is not related to study drug, but is potentially related to the 
conditions of the study (such as withdrawal of previous therapy or a complication of a study 
procedure), the relationship should be specified in the narrative section of the SAE Report Form.

If the BMS safety address is not included in the protocol document (e.g., multicenter studies 
where events are reported centrally), the procedure for safety reporting must be 
reviewed/approved by the BMS Protocol Manager. Procedures for such reporting must be 
reviewed and approved by BMS prior to study activation.
An appropriate SAE form (e.g.  ex-US = CIOMS form or USA = Medwatch form) should be used to 
report SAEs to BMS.  If you prefer to use your own Institutional form, it must be reviewed by BMS prior 
to study initiation.  Note:  Please include the BMS Protocol number on the SAE form or on the cover 
sheet with the SAE form transmission.  
o
The CIOMS form is available at: http://www.cioms.ch/index.php/cioms-form-i 
o
The MedWatch form is available at: MedWatch 3500 Form 

For studies with long-term follow-up periods in which safety data are being reported, include the 
timing of SAE collection. 

The Sponsor will reconcile the clinical database SAE cases (case level only) transmitted to BMS 
Global Pharmacovigilance (
). Frequency of reconciliation should be 
every 3 months and prior to the database lock or final data summary. BMS GPV&E will email, 
upon request from the Investigator, the GPV&E reconciliation report. Requests for reconciliation 
should be sent to
. The data elements listed on the GPV&E 
reconciliation report will be used for case identification purposes. If the Investigator determines a 
case was not transmitted to BMS GPV&E, the case should be sent immediately to BMS

In accordance with local regulations, BMS will notify investigators of all reported SAEs that are 
suspected (related to the investigational product) and unexpected (i.e., not previously described in 
the IB). An event meeting these criteria is termed a Suspected, Unexpected Serious Adverse 

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Reaction (SUSAR). Investigator notification of these events will be in the form of a SUSAR 
Report. 
o
Other important findings which may be reported by BMS as an Expedited Safety Report 
(ESR) include: increased frequency of a clinically significant expected SAE, an SAE 
considered associated with study procedures that could modify the conduct of the study, lack 
of efficacy that poses significant hazard to study subjects, clinically significant safety finding 
from a nonclinical (e.g., animal) study, important safety recommendations from a study data 
monitoring committee, or sponsor decision to end or temporarily halt a clinical study for safety 
reasons.
o
Upon receiving an ESR from BMS, the investigator must review and retain the ESR with the 
IB. Where required by local regulations or when there is a central IRB/IEC for the study, the 
sponsor will submit the ESR to the appropriate IRB/IEC. The investigator and IRB/IEC will 
determine if the informed consent requires revision. The investigator should also comply with 
the IRB/IEC procedures for reporting any other safety information. 
o
In addition to the Sponsor Investigator’s responsibility to report events to their local HA, 
suspected serious adverse reactions (whether expected or unexpected) shall be reported by 
BMS to the relevant competent health authorities in all concerned countries according to local 
regulations (either as expedited and/or in aggregate reports).
SAEs, whether related or not related to study drug, and pregnancies must be reported to BMS within 24 
hours \ 1 Business Day of becoming aware of the event. SAEs must be recorded on either CIOMS, 
MedWatch, or approved site SAE form.  
Pregnancies must be reported and submitted to BMS on any of the following form(s):
1. MedWatch or, CIOMS or
2. BMS Pregnancy Surveillance Form or, 
3. Approved site SAE form 
* Note: Reporting requirements will vary by product.  Please check with your ISR Lead for 
applicable reporting timeframe.
SAE Email Address:  
SAE Facsimile Number:  
If only limited information is initially available, follow-up reports are required. (Note: Follow-up SAE 
reports should include the same investigator term(s) initially reported.) 
If an ongoing SAE changes in its intensity or relationship to study drug or if new information becomes 
available, a follow-up SAE report should be sent within 24 hours \ 1 Business Day to BMS using the 
same procedure used for transmitting the initial SAE report. 
All SAEs should be followed to resolution or stabilization.
DEFINITIONS
The protocol must include a definition for Serious Adverse Events (SAE).
SERIOUS ADVERSE EVENTS

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A Serious Adverse Event (SAE) is any untoward medical occurrence that at any dose: 

results in death

is life-threatening (defined as an event in which the participant was at risk of death at the time of 
the event; it does not refer to an event which hypothetically might have caused death if it were 
more severe)

requires inpatient hospitalization or causes prolongation of existing hospitalization (see NOTE 
below)

results in persistent or significant disability/incapacity

is a congenital anomaly/birth defect 

is an important medical event (defined as a medical event(s) that may not be immediately life-
threatening or result in death or hospitalization but, based upon appropriate medical and scientific 
judgment, may jeopardize the subject or may require intervention [eg, medical, surgical] to prevent 
one of the other serious outcomes listed in the definition above.) Examples of such events include, 
but are not limited to, intensive treatment in an emergency room or at home for allergic 
bronchospasm; blood dyscrasias or convulsions that do not result in hospitalization.) 

Suspected transmission of an infectious agent (e.g., pathogenic or nonpathogenic) via the study 
drug is an SAE. 
Although pregnancy, overdose, potential drug-induced liver injury (DILI), and cancer are not always 
serious by regulatory definition, these events must be handled as SAEs.
Any component of a study endpoint that is considered related to study therapy should be reported as 
an SAE (e.g., death is an endpoint, if death occurred due to anaphylaxis, anaphylaxis must be 
reported).
NOTE: (PI determines if this information regarding hospitalizations are considered SAEs and should be 
included in the protocol. This is supplemental information that is included in BMS-sponsored trials)
The following hospitalizations are not considered SAEs in BMS clinical studies: 

a visit to the emergency room or other hospital department < 24 hours, that does not result 
in admission (unless considered an important medical or life-threatening event)

elective surgery, planned prior to signing consent

admissions as per protocol for a planned medical/surgical procedure

routine health assessment requiring admission for baseline/trending of health status (eg, 
routine colonoscopy)

Medical/surgical admission other than to remedy ill health and planned prior to entry into 
the study. Appropriate documentation is required in these cases.

Admission encountered for another life circumstance that carries no bearing on health 
status and requires no medical/surgical intervention (e.g., lack of housing, economic inadequacy, 
caregiver respite, family circumstances, administrative reason).

Admission for administration of anticancer therapy in the absence of any other 
SAEs (applies to oncology protocols)

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The following hospitalizations are not considered SAEs in BMS clinical studies: 

a visit to the emergency room or other hospital department < 24 hours, that does not result 
in admission (unless considered an important medical or life-threatening event)

elective surgery, planned prior to signing consent

admissions as per protocol for a planned medical/surgical procedure

routine health assessment requiring admission for baseline/trending of health status (e.g., 
routine colonoscopy)

Medical/surgical admission other than to remedy ill health and planned prior to entry into 
the study. Appropriate documentation is required in these cases.

Admission encountered for another life circumstance that carries no bearing on health 
status and requires no medical/surgical intervention (e.g., lack of housing, economic inadequacy, 
caregiver respite, family circumstances, administrative reason).

Admission for administration of anticancer therapy in the absence of any other SAEs 
(applies to oncology protocols)
10
Statistical Considerations and Evaluation of Results
10.1
Study Endpoints
10.1.1 Primary Endpoints

Stratum A:
o
OS12 in HLA-A2+ children with H3.3K27M positive DIPG 
o
Safety and toxicity measurements of repeated administration of the H3.3K27M 
epitope specific vaccine using CTCAE version 5.0 in HLA-A2+ children with 
H3.3K27M positive DIPG 

Stratum B:
o
Safety and toxicity measurements of repeated administration with the H3.3K27M 
epitope specific vaccine using CTCAE version 5.0 in HLA-A2 (02:01)+ children with 
other H3.3K27M positive midline gliomas, including spinal cord tumors 

Stratum C:
o
Safety and toxicity measurements of repeated administration with the H3.3K27M 
epitope specific vaccine in combination with nivolumab using CTCAE version 5.0 in 
HLA-A2 (02:01)+ children with H3.3K27M positive DIPG  or other H3.3K27M positive 
midline gliomas, excluding primary spinal cord tumors (Stratum C)
10.1.2 Exploratory Endpoints
Stratum A: 

Induction of the H3.3K27M epitope-specific CTL response in post vaccine PBMCs in HLA-A2 
(02:01)+ children with H3.3K27M positive gliomas other than DIPG

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
Assessment of H3.3K27M infiltrates in subjects with evidence of progression that undergo tissue 
collection as part of their standard of care. Tumor tissue will be analyzed for H3.3K27M expression 
status and infiltration of H3.3K27M specific T cells

To archive tumor and normal DNA from each subject at time of initial diagnosis along with serial 
blood draws following therapy to determine whether circulating tumor DNA (ctDNA) sequences in 
the subject’s blood serve as biomarkers of tumor burden, response to therapy, or development of 
drug resistance.
Stratum B: 

Induction of the H3.3K27M epitope-specific CTL response in post vaccine PBMCs in HLA-A2 
(02:01)+ children with H3.3K27M positive gliomas other than DIPG

Assessment of H3.3K27M infiltrates in subjects with evidence of progression that undergo tissue 
collection as part of their standard of care. Tumor tissue will be analyzed for H3.3K27M expression 
status and infiltration of H3.3K27M specific T cells

To archive tumor and normal DNA from each subject at time of initial diagnosis along with serial 
blood draws following therapy to determine whether circulating tumor DNA (ctDNA) sequences in 
the subject’s blood serve as biomarkers of tumor burden, response to therapy, or development of 
drug resistance.
Stratum C: 

To determine the OS12 in HLA-A2 (02:01)+ children with H3.3K27 positive DIPGs and midline 
gliomas (excluding primary spinal cord tumors) that are treated with repeated administration of the 
H3.3K27M peptide and nivolumab.

Induction of the H3.3K27M epitope-specific CTL response in post vaccine PBMCs in HLA-A2 
(02:01)+ children with H3.3K27M positive gliomas including DIPG or other H3.3K27M positive 
midline gliomas, excluding primary spinal cord tumors.

To archive tumor and normal DNA from each subject at time of initial diagnosis along with serial 
blood draws following therapy to determine whether circulating tumor DNA (ctDNA) sequences in 
the subject’s blood serve as biomarkers of tumor burden, response to therapy, or development of 
drug resistance.

To assess Quality of Life (QoL) and cognitive measures in HLA-A2 (02:01)+ children with H3.3K27M 
positive DIPG or other midline gliomas.
10.1.3 Stratification Factors
This trial will enroll into 3 strata based on disease location and treatment intervention – Stratum A: 
DIPG; Stratum B: any other H3.3K27M positive midline glioma, including spinal cord tumors; and 
Stratum C: DIPG and any other H3.3K27M positive midline glioma, excluding primary spinal cord 
tumors.

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10.1.4 Design
We will enroll into the 3 strata separately: Stratum A consists of HLA-A02:01+ positive newly diagnosed 
patients with H3.3K27M positive DIPG, stratum B consists of other HLA-A02:01+  positive newly 
diagnosed patients with H3.3K27M positive gliomas that are not classified as DIPG, including spinal 
cord tumors and stratum C consists of subjects with HLA-A02:01+ H3.3K27M positive DIPG or other 
HLA-A02:01+ H3.3K27M positive midline gliomas, excluding primary spinal cord tumors. The separation 
of strata A and B is based on anticipation that toxicity of the vaccine and Poly-ICLC could be 
significantly different based on the primary tumor location. Toxicities resulting from pseudoprogression 
or local reaction (such as edema or inflammation) may manifest differently when tumors are located 
within the brainstem (as in DIPG) versus outside the brainstem, such as the spine or other part of the 
brain. Treatment related reaction in the brainstem may be more toxic due to a more restricted space 
and closer proximity to high-risk anatomic structures. The first 3 patients in each stratum will be 
observed at least for 6 weeks before the next set of patients are enrolled. 

If there are no RLTs in the first 3 subjects, enrollment will commence continuously within each 
stratum. 

If 2 or 3 RLTs occur in the first 3 subjects, accrual will be suspended and the investigator, 
PNOC leadership and Sponsor will make decisions regarding continuation of study accrual. 

If a RLT occurs in 1 of the first 3 patients, an additional 3 patients will be enrolled in that stratum 
and observed for at least 12 weeks. In this case:
o
If fewer than 2 of the first 6 patients in each stratum experience RLT with at least 12 
weeks of follow-up, the remaining patients will be enrolled. 
o
If a RLT occurs in ≥ 2 of the first 6 patients accrual will be suspended and the 
investigator, PNOC leadership and Sponsor will make decisions regarding continuation 
of study accrual.
If enrollment commences, all additional patients will be monitored continuously for treatment-related 
adverse events by the study PIs Drs. Okada and Mueller. With six patients, there is an 88% probability 
of detecting 1 or more RLTs with an underlying rate of 30%. There is a 74% probability of detecting 1 or 
more RLTs with an underlying rate of 20%. If all 19 patients are enrolled in Stratum A, there is an 86% 
probability of detecting 1 or more RLTs with an underlying rate of 10% and a 62% probability with an 
underlying rate of 5%. If all 10 patients are enrolled in Strata B, there is a 65% probability of detecting 1 
or more RLTs with an underlying rate of 10% and a 40% probability with an underlying rate of 5%. If all 
20 patients are enrolled in Strata C, there is an 88% probability of detecting 1 or more RLTs with an 
underlying rate of 10% and a 64% probability with an underlying rate of 5%.
Enrollment into Stratum C will start once Strata A and B have completed accrual. 
10.2
Determination of Sample Size and Accrual Rate
10.2.1 Sample Size and Power Estimate
For the primary endpoint for stratum A, we will assess the efficacy endpoint (OS12) in 19 evaluable 
patients with H3.3K27M positive DIPG. Prior research has shown overall survival for children with DIPG 
ranges from 30-40% at 12 months38,39. The most recent Children’s Oncology Group study that treated 
children newly diagnosed with DIPG with a combination of radiation therapy and temozolomide resulted 

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in an OS12 rate of 40% (SD ± 6.5%)1. Review of outcomes of DIPG patients on PNOC studies of 
children and young adults with newly diagnosed DIPG who received standard of care radiation therapy 
revealed an OS12 rate of 50% (PNOC003 - NCT02274987 and PNOC007 - NCT02960230, 
unpublished data). For PNOC003 patients were enrolled prior to the start of radiation therapy - similar 
to the COG study- and none of the enrolled patients came off study due to progression during or at 
completion of radiation therapy making this a reasonable control group for this study.
With a null hypothesis that OS12 is 40%, a sample size of 19 patients achieves 80% power to detect a 
difference of 30% using a one sided exact binominal test40. The target significance level is 5% and the 
actual significance level is 3.5% with this test. If 12 or more patients are alive at 12 months, the null 
hypothesis that OS12 is 40% will be rejected. Patients lost to follow-up before 12 months will be 
considered events. OS12 will be estimated from the Kaplan-Meier method. Two-sided 95% CI will be 
computed based on the Greenwood's formula. If the null hypothesis is truly OS12 = 30% or OS12 = 
50%, a sample size of 19 patients still achieves 80% power to detect a difference of 30%, however, the 
number of patients needed to reject the null changes to n = 10 or n = 14, respectively.
For the secondary endpoint for stratum C, we will assess the efficacy endpoint (OS12) in 20 evaluable 
patients with H3.3K27M positive DIPG or other midline gliomas, excluding primary spinal cord tumors. 
In comparing outcomes to other H3K27M positive midline gliomas, OS rates similar to those for Stratum 
A are reported, although the reference literature is sparser for this patient population31,32. Thus, similar 
to stratum A, a sample size of 20 patients achieves 80% power to detect a difference of 30% using a 
one sided exact binominal test (see above)40. 
At time of data analysis, we will use the most recent published data and PNOC enrollment data in order 
to determine the appropriate null rate for stratum A and stratum C. 
10.2.2 Accrual estimates
This study aims to enroll 19 children with H3.3K27M positive DIPG (Stratum A), 10 children with 
H3.3K27M positive glioma, other than DIPG, including spinal cord tumors (Stratum B) and 20 children 
with H3.3K27M positive DIPG or other midline gliomas, excluding primary spinal cord tumors (Stratum 
C). Eligible patients need to test positive for the HLA-A02:01+ to be eligible. Based on our previous 
study, we anticipate that about 40 children with DIPG and 40 children with other gliomas will need to be 
screened to meet accrual goals14. We anticipate that most of the PNOC sites will open this study and 
that we will be able to screen 2-3 potentially eligible patients per month which would allow us to accrue 
at least one patient per month. To date, we have enrolled an average of 1.4 patients/month on the 
phase 1 portion of PNOC007 with 14 PNOC sites actively accruing. To date, enrollment has been 
similar between the strata. Therefore, we anticipate that enrollment onto Strata A and B will be 
completed in approximately two years. We anticipate that Stratum C will follow a similar pattern, taking 
up to 2 years for enrollment.

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10.3
Interim Analyses and Stopping Rules
The study will be monitored by Drs. Mueller and Okada and the PNOC Operation’s office on a weekly 
basis including a review of all adverse events and deviations entered within Advarra® in concordance 
with the PNOC requirements for phase 1/2 clinical trials. The toxicity monitoring rules for the following 
events will be applied to all patients treated in the study. The regimen limiting toxicity (RLT) will be 
based on the tolerability observed following the vaccine doses following radiation therapy.
RLT includes any of the following events that occur during or following any vaccine given. 

Any grade 2 or greater autoimmune reaction.

Any grade 3 or greater hematologic or non-hematologic toxicity with the 
exception of lymphopenia.

Any life-threatening event.

Any other unexpected Grade 2 or greater neurological deficit, which is possibly, 
probably, or definitely related to the vaccine therapy that does not respond within 21 
days trial of 0.3mg/kg day dexamethasone or equivalent (max 12mg/day) or Avastin 
or equivalent (10mg/kg every 2 weeks for a maximum of 3 doses)
In addition to the stopping rules specific to the design detailed above, all patients will be monitored 
continuously for treatment-related adverse events by the study PIs Drs. Okada and Mueller. 
Sequential boundaries will be used to monitor the RLT rate. The accrual will be halted if excessive 
numbers of RLTs are seen, that is, if the number of RLTs is equal to or exceeds bn out of n patients 
with full follow-up (see table below). This is a Pocock-type stopping boundary that yields the probability 
of crossing the boundary at most 0.0475 when the rate of RLT is equal to the acceptable rate of 0.20.
For example, in Stratum A, the trial will be stopped if the number of RLTs is equal to or exceeds bn 
out of n patients with completed follow-up.
Number of Patients, n 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Boundary, bn
- - 3 4 4 4 5 5 5 6  6  6  7  7  7  8  8  8  9
This boundary is equivalent to testing the null hypothesis, after each patient, that the event rate is 
equal to 0.2, using a one-sided level 0.021430 test.
θ
φ*
E[Y]
SD[Y]
E[N]
SD[N]
E[Y/N]
SD[Y/N]
0.20
0.0475
3.70
1.62
18.51
2.39
0.21
0.13
0.30
0.2248
5.08
1.55
16.92
4.44
0.34
0.18
0.40
0.5327
5.60
1.49
14.00
5.76
0.48
0.20
0.50
0.8151
5.30
1.54
10.59
5.62
0.60
0.20

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Definitions:
Y = the number of events, random, between 0 and N N = 
the number of patients, random, between 1 and K
φ* = the actual probability of early stopping (hitting the boundary)
E[ ] denotes the expected value (mean) SD[ ] 
denotes the standard deviation
10.3.1 Analysis Population
Intent-to-Treat Population (ITT): The ITT population will include all subjects who are enrolled 
in the study. The ITT population will be the primary population for evaluating efficacy and 
subject characteristics. 
As-Treated Population (AT) The AT population will include all subjects who receive at least 1 
course of study therapy. The AT population will be the primary population for evaluating safety. 
If a patient does not receive any vaccine and poly-ICLC (strata A and B) in combination with 
nivolumab (stratum C), they will be replaced for evaluation of safety.
10.3.2 Analysis of Primary Endpoints

Safety of K27M/TT vaccine and poly-ICLC in combination with nivolumab (stratum C only) will 
be assessed by monitoring for adverse events, scheduled laboratory assessments, vital sign 
measurements, and physical examinations for subjects who receive at least one course of the 
study therapy. The severity of toxicities will be graded according to the NCI CTCAE v5.0. 
Adverse events and will be summarized by maximum intensity and relationship to study drug(s). 

Safety will be assessed every 3 weeks for the first 24 weeks and then every 6 weeks.   
Descriptive statistics will be utilized to display the data on toxicity seen.

OS12 in HLA-A02:01+ children with H3.3K27M positive DIPG (Stratum A) will be the clinical 
efficacy primary endpoint. Any subject enrolled (ITT) will be considered evaluable for clinical 
efficacy. Patients lost to follow-up before 12 months will be considered events and the OS 
probability at 12 months (OS12) will be estimated from the Kaplan-Meier method. Two-sided 
95% CI will be computed based on the Greenwood's formula. 
10.3.3 Analysis of Secondary Endpoints
CTL response based on ELISPOT: A subject will be considered to have responded, if at any of post-
vaccine time point against H3.3K27M antigen, the number of spots is double that at baseline, and there 
are at least 10 spots/20,000 cells, and if the number of the post-vaccine spots is at least three times the 
standard-deviation of the pre-vaccine value.  This definition provides some protection against false 
positive response. We will correlate response with OS data. We will plot the time course of the 
magnitude of response and model it using a mixed-effects model approach.  

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10.3.4 Other Analyses/Assessments
The other exploratory aims associated with this study will be descriptive and will be limited to frequency 
tables and summary statistics. 
10.4
Evaluation of Safety
Analyses will be performed for all patients having received at least one course of study therapy.  The 
study will use the NCI CTCAE v5.0.
11
Data Reporting/Regulatory Requirements
11.1
Data Reporting
11.1.1 Method
The Principal Investigator and/or his/her designee will prepare and maintain adequate and accurate 
participant case histories with observations and data pertinent to the study.  Study specific Case Report 
Forms (CRFs) will document safety and treatment outcomes for safety monitoring and data analysis.  
All study data will be entered into Advarra® via standardized CRFs in accordance with the CTMS study 
calendar, using single data entry with a secure access account.  The Clinical Research Coordinator 
(CRC) will complete the CRFs as soon as possible upon completion of the study visit; the Investigator 
will review and approve the completed CRFs. 
The information collected on CRFs shall be identical to that appearing in original source documents.  
Source documents will be found in the subject’s medical records maintained at each PNOC site.  For 
participating sites, source documents will be maintained per institutional guidelines.  All source 
documentation should be kept in separate research folders for each subject.
In accordance with federal regulations, the Investigator is responsible for the accuracy and authenticity 
of all clinical and laboratory data entered onto CRFs.  The PI will approve all completed CRFs to attest 
that the information contained on the CRFs is true and accurate. 
All source documentation and CTMS data will be available for review/monitoring by the UCSF DSMC 
and regulatory agencies.
The Principal Investigator will be responsible for ensuring the accurate capture of study data.  At study 
completion, when the CRFs have been declared to be complete and accurate, the database will be 
locked.  Any changes to the data entered into the CRFs after that time can only be made by joint written 
agreement among the Study Chair, the Trial Statistician, and the PNOC Project Leader.
Responsibility for Data Submission
Please refer to Appendix C for data submission timelines.

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11.2
PNOC Oversight and Monitoring Plan
This is a multicenter trial.  The UCSF Helen Diller Family Comprehensive Cancer Center Data Safety 
Monitoring Committee (DSMC) will be the main monitoring entity for this study.  The UCSF DSMC will 
work together with participating member institution PIs and DSMCs to monitor each subject on study. 
The DSMC will routinely review all adverse events and suspected adverse reactions considered 
“serious”.  The UCSF DSMC will audit study-related activities to ensure that the study is conducted in 
accordance with the protocol, local standard operating procedures, FDA regulations, and Good Clinical 
Practice (GCP).  Significant results of the DSMC audit will be communicated to the IRB and the 
appropriate regulatory authorities at the time of continuing review, or in an expedited fashion, as 
applicable.  Please see Appendix D PNOC Data Safety and Monitoring Plan for more information.
11.3
Multicenter Communication
The PNOC operations office provides administration, data management, and organizational support for 
the participating sites in the conduct of the clinical trial.  The PNOC Operations Office will coordinate, at 
minimum, quarterly conference calls with the PNOC member institutions to discuss risk assessment. 
The following items will be discussed, as appropriate:

Enrollment information 

Adverse events (i.e. new adverse events and updates on unresolved adverse events and new 
safety information)

Protocol violations

Other issues affecting the conduct of the study
11.4
Record Keeping and Record Retention
The Principal Investigator for each PNOC institution is required to maintain adequate records of the 
disposition of the drug, including dates, quantity, and use by subjects, as well as written records of the 
disposition of the drug when the study ends per institutional guidelines.  
The site Principal Investigator is required to prepare and maintain adequate and accurate case histories 
that record all observations and other data pertinent to the investigation on each individual administered 
the investigational drug or employed as a control in the investigation. Case histories include the case 
report forms and supporting data including, for example, signed and dated consent forms and medical 
records including, for example, progress notes of the physician, the individual's hospital chart(s), and 
the nurses' notes. The case history for each individual shall document that informed consent was 
obtained prior to participation in the study.
Study documentation includes all CRFs, data correction forms or queries, source documents, Sponsor-
Investigator correspondence, monitoring logs/letters, and regulatory documents (e.g., protocol and 
amendments, IRB correspondence and approval, signed subject consent forms).
Source documents include all recordings of observations or notations of clinical activities and all reports 
and records necessary for the evaluation and reconstruction of the clinical research study.

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In accordance with FDA regulations, the investigator shall retain records for a period of 2 years 
following the date a marketing application is approved for the drug for the indication for which it is being 
investigated; or, if no application is to be filed or if the application is not approved for such indication, 
until 2 years after the investigation is discontinued and FDA is notified.
11.5
Coordinating Center Documentation of Distribution
It is the responsibility of the PNOC operations office to maintain adequate files documenting the 
distribution of study documents as well as their receipt (when possible). The HDFCCC recommends 
that the PNOC operations office maintain a correspondence file and log for each segment of distribution 
(e.g., FDA, drug manufacturer, participating sites, etc.).
Correspondence file: should contain copies (paper or electronic) of all protocol versions, cover letters, 
amendment outlines (summary of changes), etc., along with distribution documentation and (when 
available) documentation of receipt.
Correspondence log: should be a brief list of all documents distributed including the date sent, 
recipient(s), and (if available) a tracking number and date received.
At a minimum, the PNOC operations office must keep documentation of when and to whom the 
protocol, its updates and safety information are distributed.
11.6
Regulatory Documentation
Prior to implementing the protocol at each PNOC institution, the protocol, informed consent form, 
HIPAA authorization and any other information pertaining to participants must be first approved by the 
UCSF Institutional Review Board (IRB) and by the PNOC operations office. Prior to implementing this 
protocol at the participating sites, approval for the UCSF IRB approved protocol must be obtained from 
the participating site’s IRB. 
Appendix B lists the documents which must be provided to PNOC Operations Office before the 
participating site can be initiated and begin enrolling participants.
Upon receipt of the required documents, PNOC operations office will formally contact the site and grant 
permission to proceed with enrollment.
12
Protection of Human Subjects
12.1
Protection from Unnecessary Harm
Each clinical site is responsible for protecting all subjects involved in human experimentation. This is 
accomplished through the IRB mechanism and the process of informed consent. The IRB reviews all 
proposed studies involving human experimentation and ensures that the subject’s rights and welfare 
are protected and that the potential benefits and/or the importance of the knowledge to be gained 
outweigh the risks to the individual. The IRB also reviews the informed consent document associated 
with each study in order to ensure that the consent document accurately and clearly communicates the 
nature of the research to be done and its associated risks and benefits. 

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12.2
Protection of Privacy
Patients will be informed of the extent to which their confidential health information generated from this 
study may be used for research purposes. Following this discussion, they will be asked to sign the 
HIPAA form and informed consent documents. The original signed document will become part of the 
patient’s medical records, and each patient will receive a copy of the signed document. The use and 
disclosure of protected health information will be limited to the individuals described in the informed 
consent document.

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13
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polarized dendritic cells and polyinosinic-polycytidylic acid stabilized by lysine and 
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Sampson JH, Heimberger AB, Archer GE, et al: Immunologic escape after 
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Salazar AM, Levy HB, Ondra S, et al: Long-term treatment of malignant gliomas with 
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Brandes AA, Franceschi E, Tosoni A, et al: MGMT promoter methylation status can 
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Radbruch A, Fladt J, Kickingereder P, et al: Pseudoprogression in patients with 
glioblastoma: clinical relevance despite low incidence. Neuro Oncol 17:151-9, 2015
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Warren KE, Poussaint TY, Vezina G, et al: Challenges with defining response to 
antitumor agents in pediatric neuro-oncology: a report from the response assessment in pediatric 
neuro-oncology (RAPNO) working group. Pediatr Blood Cancer 60:1397-401, 2013
31.
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14
Appendices
Appendix A
Performance Status Criteria
Karnofsky
Lansky
Score
Description
Score
Description
100
Normal, no complaints, no 
evidence of disease
100
Fully active, normal.
90
Able to carry on normal activity, 
minor signs or symptoms of 
disease.
90
Minor restrictions in physically 
strenuous activity.
80
Normal activity with effort; some signs 
or symptoms of disease.
80
Active, but tires more quickly
70
Cares for self, unable to carry on 
normal activity or do active work.
70
Both greater restriction of and less 
time spent in play activity.
60
Required occasional assistance, 
but is able to care for most of 
his/her needs.
60
Up and around, but minimal active 
play; keeps busy with quieter activities.
50
Requires considerable assistance 
and frequent medical care.
50
Gets dressed, but lies around much of 
the day; no active play, able to 
participate in all quiet play and 
activities.
40
Disabled, requires special care and 
assistance.
40
Mostly in bed; participates in quiet 
activities.
30
Severely disabled, hospitalization 
indicated.  Death not imminent.
30
In bed; needs assistance even for 
quiet play.
20
Very sick, hospitalization indicated.  
Death not imminent.
20
Often sleeping; play entirely limited to 
very passive activities.
10
Moribund, fatal processes 
progressing rapidly.
10
No play; does not get out of bed.

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Appendix B
PNOC Institutions Required Regulatory Documents 
Before you can start enrollment at your site you must submit the following documents to PNOC:
Participating Site IRB approval(s) for the protocol, appendices, informed consent form and 
HIPAA authorization 
Participating Site IRB approved consent form 
Participating Site IRB membership list 
Participating Site IRB’s Federal Wide Assurance number and OHRP Registration number 
Copy of the 1572 (Note: 1572 form is not required for FDA-exempt trials)
Curriculum vitae and medical license for each investigator and consenting professional 
Documentation of Human Subject Research Certification training for investigators and key staff 
members at the Participating Site 
Participating site laboratory certifications and normals 
Signed copy of the completed delegation of authority log (found in PNOC Documents > Forms)
Signed copy of the protocol signature page
Signed copy of the final contract
Upon receipt of the required documents, PNOC will formally contact the site and grant permission to 
proceed with enrollment.  All documents can be uploaded directly to SharePoint by navigating to your 
site's page and clicking "Add Documents"
Each PNOC site is responsible for ensuring all regulatory documents in SharePoint are up to date. 
Sites will upload new or revised documents as applicable to reflect any changes, including changes in 
staff and approved/expired documents.

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Appendix C
Required Data and Time Table for Submission
Form
Submission Timeline
Eligibility Checklist
Complete prior to registration
On Study Forms
Within 14 business days of registration
Baseline Assessment Forms
Within 14 business days of registration
Treatment Forms
Within 10 business days of the last day of the cycle
Adverse Event Report Forms
All AEs are due within 10 business days of the date of 
assessment.
Serious Adverse Event Reporting
Please refer to section on Expedited Reporting. 
Response Assessment Forms
Within 10 business days of the completion of the cycle 
required for response evaluation
Off Treatment/Off Study Forms
Within 14 business days of completing treatment or being 
taken off study for any reason
Follow up/Survival Forms
Within 14 business days of the protocol defined follow up visit 
date

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Appendix D
 PNOC Data and Safety Monitoring 
PNOC Data Safety and Monitoring Plan for a Phase 1 Study
It is the responsibility of each PNOC member institution to follow the National Cancer Institute (NCI) 
approved Data Safety and Monitoring Plan (DSMP) for their site. For PNOC trials in which the UCSF PI 
holds the IND, the UCSF DSMC will be responsible for monitoring all participating sites, including 
UCSF. Remote institutions will be electronically monitored unless there are significant findings or issues 
identified that warrant an in-person visit. In addition to the guidelines laid out in this document, each 
PNOC member institution must comply with the policies and standards put forward by their own 
institutional DSMC/DSMB. 
The UCSF DSMC/DSMB activities for this study will include: 

Monitoring every month/six months through the DLT period (depending on subject accrual) 

Review of suspected adverse reactions considered “serious” (SAEs)  

Minimum of a biennial regulatory audit
Monitoring and reporting guidelines
All institutional Phase 0 or Phase 1 therapeutic studies are designated with a high risk assessment.  
The data is monitored monthly by the UCSF DSMC/DSMB as subjects are enrolled and includes all 
visits monitored up through the Dose Limiting Toxicity (DLT) period.  
The UCSF Helen Diller Family Comprehensive Cancer Center (HDFCCC) DSMC is responsible for 
monitoring data quality and patient safety for all HDFCCC institutional clinical studies. In the case of all 
PNOC protocols, the UCSF DSMC will work together with the non-UCSF PNOC member institution in 
order to ensure DSMP compliance. The UCSF DSMC/DSMB will be responsible for generating regular 
monitoring reports. These reports will be used by the UCSF DSMC to assess data quality, patient 
safety, and protocol compliance as well as to make decisions about dose escalations, where 
applicable. 
PNOC and the UCSF DSMC reserve the right to conduct on-site monitoring at any non-UCSF member 
institution if DSMP requirements are not being met. If the need to perform a monitoring visit at a non-
UCSF member institution arises, source documents will be provided by the member institution prior to 
the visit in order for the UCSF DSMC to monitor protocol compliance, patient safety, and to verify data 
entry. 
The PNOC Operations Office provides administration, data management, and organizational support 
for the PNOC member institutions in the conduct of any PNOC clinical trial.  The PNOC Operations 
Office will summarize and communicate adverse events, safety data, and other study matters to the 
PNOC member institutions on a quarterly basis.
The Study Chair is responsible for the overall conduct of any PNOC trial and for monitoring its safety 
and progress at all participating sites (as outlined in the PNOC Study Chair and Co-Chair 
Responsibilities SOP).  The Study Chair will conduct continuous review of data and subject safety and 

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discuss each subject’s treatment with the PNOC Operations Office. The discussions are documented in 
the PNOC Operations Office meeting minutes.
Multicenter communication
The PNOC Operations Office will coordinate, at minimum, quarterly conference calls with the PNOC 
member institutions to discuss risk assessment. The following items will be discussed, as appropriate:

Enrollment information

Cohort updates (e.g. DLTs and dose escalations)

Adverse Events (e.g. new AEs, unresolved AEs, and new safety information)

Protocol violations

Other study conduct issues
Dose level considerations
Dose level assignments for any subject scheduled to begin treatment must be confirmed by the 
PNOC Operations Office via e-mail.
If an unexpected Dose Limiting Toxicity (DLT) arises in a subject treated at any participating PNOC 
member institution, all member institutions must be notified of the DLT by the PNOC Operations Office 
within 1 business day. Member institutions will otherwise be provided with final DLT reports as they 
become available.
Adverse event review and monitoring
PNOC uses the web-based OnCore® Clinical Trials Management System for all patient registrations 
and the Advarra EDC for data entry.  The OnCore® System will also track patient level protocol 
compliance and safety information. The Advarra EDC system is CFR part 11 compliant. For Phase I 
studies, all clinically significant Adverse Events (AEs) will be entered into the Advarra EDC, regardless 
of relationship. All Adverse Events entered into Advarra® will be reviewed on a weekly basis by the 
PNOC Operations Office. The PNOC Operations Office will discuss the toxicity, grade, and relationship 
to study intervention for all AEs in question. 
All Adverse Events must be entered into Advarra® within 10 business days of becoming aware of the 
event. Member institutions will submit this information to PNOC via the Adverse Event Form within 
Advarra®. 
In addition, all adverse reactions considered “serious” (also called Serious Adverse Events, or SAEs), 
regardless of relationship, must be entered in OnCore® and Advarra, and reported to the PNOC 
Operations Office within 1 business day.  SAEs will be reviewed and monitored by the UCSF DSMC 
on an ongoing basis, and will be discussed at the UCSF DSMC meeting, which take place every six (6) 
weeks. 
If a death occurs during the treatment phase of the study, or within 30 days after the last administration 
of the study drug(s), and is determined to be related either to the investigational drug or to any research 
related procedure, the Study Chair and the PNOC Operations Office must be notified by the member 
institution within 1 business day. The Study Chair or the PNOC Operations Office must then notify the 

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UCSF DSMC Chair, or qualified alternate, within 1 business day of this notification.  The contact may 
be by phone or e-mail.
Increase in adverse event rates
If an increase in the frequency of Grade 3, 4, or 5 Adverse Events (above the rate reported in the 
Investigator Brochure or package insert), the Study Chair or the PNOC Operations Office is responsible 
for notifying the UCSF DSMC at the time the increased rate is identified.  
If at any time the Study Chair or the PNOC Operations Office halts enrollment or ends the study due to 
safety issues, the UCSF DSMC Chair and Manager must be notified within 1 business day via e-mail.  
The UCSF DSMC must receive a formal letter within 10 business days, and the UCSF IRB must be 
notified.
UCSF data and safety monitoring committee contacts:
UCSF DSMC Chair
Katie Kelley, MD 
San Francisco, CA 94115
UCSF DSMC Manager
John McAdams, MS
San Francisco, CA 94143
UCSF DSMC Monitors
UCSF-Box #0128
San Francisco, CA 94143

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Appendix E
 Specimen Collection Immuno-Monitoring 
Sampling and Shipping information

Blood for in vitro assays: up to 50-60 ml of blood (7 x 10 cc green top tubes: each tube 
should be filled as much as possible) for mononuclear cell preservation (before injection of 
vaccines).  The volume will depend on the weight of the child based on the justification 
below. These samples will be sent to UCSF. Please refer to the PNOC member site 
SharePoint for details regarding shipping instruction and collection. 

Blood for circulating tumor DNA – we will collect 6-7 ml at baseline and with each MRI 
assessment (- 7 days). Please refer to the PNOC members SharePoint site for details 
regarding shipping instruction and collection. 
The minimum age enrolling in this trial is 3 years. The mean blood volume for a child is about 80 ml/kg. 
Up to 5% of total blood volume over a 24 hour period and up to 10% of the whole blood volume over an 
8 week period might be removed for laboratory evaluations if the subject has a normal hematocrit 41. 
Based on our experience children with DIPG undergoing focal radiation have a normal hematocrit and 
since these children are not receiving any other therapies we anticipate that these children all have a 
normal hematocrit. 
Based on the WHO criteria the weights based on the 50% percentile are as follows:
3 year old approximately 14 kg
4 year old approximately 16 kg
5 year old approximately 8 kg
The total blood volume for a 3 year old child is about 80x 14 kg = 1,120 ml. 5% of 56 ml; 10%112 ml. 
The total blood volume for a 4 year old child is about 80x 16 kg = 1,280 ml. 5% of 64 ml, 10%128ml. 
The total blood volume for a 5 year old child is about 80x 18 kg = 1,440ml. 5% of 72 ml; 10% 144 ml. 
Based on these recommendations we will take 50 cc in green top tubes in children < 16 kg and 60cc in 
children >/= 16 kg for the immune-monitoring. We will assure that recommended dose of 5% of total 
volume in a 24 hour period will not be exceeded. ctDNA and other laboratory evaluations will be 
scheduled on different days as required by the guidelines. 
Sample Shipment Instructions
Please refer to the PNOC member website SharePoint for details regarding shipping of collected 
specimens. 

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 Appendix F Biospecimen Banking
Samples are collected only from patients who have agreed to have their tissues and blood banked and 
used for future research. Any leftover specimen samples such as tumor specimens and cell derivatives 
will be reserved for banking and stored at UCSF. Banked specimens may be used for further validation 
or, if the subject agrees, for future medical research. The laboratories have storage procedures 
designed to ensure that the storage process maintains the molecular and cellular integrity of the 
specimen.
 
When specimens arrive at UCSF, they will be entered in OnCore and assigned an appropriate storage 
location. Both of the specimen's unique identifiers will be entered into the system. If a specimen or 
aliquot of derivatives is shared with another project investigator, it will be recorded and tracked, which 
will maintain a record for reporting and audit purposes. The specimen and any other derivatives may be 
stored for up to 20 years to answer research scientific questions related to cancer and/or study drugs.
 
To obtain samples, investigators submit a request form to the Tissue Bank Manager. The request form 
requires an explanation of the tissue requested (type, number of samples, justification), description of 
the study, Institutional Review Board (IRB) approval, and Project Leader authorization. The Manager 
reviews each request for feasibility before presentation to the Scientific Core Committee.

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Appendix G
 Medications Associated With Prolonged QTc
 
Medications that prolong QTc
Amiodarone 
Flecainide
Anagrelide
Fluconazole
Arsenic trioxide
Haloperidol
Azithromycin
Ibutilide
Chloroquine
Methadone
Chlorpromazine 
Moxifloxacin
Ciprofloxacin 
Ondansetron
Citalopram
Pentamidine
Clarithromycin 
Pimozide
Disopyramide 
Procainamide
Dofetilide
Propofol
Domperidone 
Quinidine
Droperidol
Sevoflurane
Dronedarone 
Sotalol
Erythromycin 
Thioridazine
Escitalopram
Vandetanib
Medications that MAY prolong QTc
Aripiprazole
Lapatinib
Bortezomib
Lenvatinib
Bosutinib
Leuprolide
Ceritinib
Mirtazapine
Clomipramine
Nicardipine
Crizotinib
Nilotinib
Dabrafenib
Olanzapine
Dasatinib
Osimertinib
Degarelix
Pazopanib

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Desipramine
Promethazine
Dolasetron
Risperidone
Eribulin mesylate
Sorafenib
Famotidine
Sunitinib
Foscarnet
Tacrolimus
Gemifloxacin
Vemurafenib
Granisetron
Venlafaxine
Isradipine
Vorinostat

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Appendix H Quality of Life Measures
PNOC HEALTH RELATED QUALITY OF LIFE & NEUROCOGNITIVE MEASURES
Please note: Measures that are not available in the local language or the patient’s native 
language should not be administered.  
Pediatric Quality of Life Inventory (PedsQL):  
To assess treatment and disease impact on quality of life, we will use the PedsQL 4.0 Generic Core 
Scales and the PedsQL 3.0 Cancer Module. These rating forms have multidimensional child self-report 
and parent proxy report scales to assess health-related quality of life (QOL) in children, adolescents, 
and young adults ages 2 – 25 years.    It consists of a 23-item core measure of global QOL that has 
four subscales:  physical functioning, emotional functioning, social functioning, and school functioning.  
There are different forms for parents of patient’s ages 2 – 17 years (toddler: 2 – 4; young child: 5 – 7; 
children: 8 – 12; teen:  13 – 17) and parallel self-report forms for patient’s ages 5 – 25 years (young 
child: 5 – 7; child: 8 – 12; teen: 13 – 17; young adult:  18 – 25).  It takes approximately 5 – 10 minutes 
to complete.  
Patient-Reported Outcomes Measurement Information System (PROMIS):
To assess treatment and disease impact on overall health, we will use the PROMIS Pediatric/ Parent-
Proxy-49. This measure consists of seven 8-item short forms to assess mental health, physical health, 
and social health. The specific short forms are: 

Emotional Distress – Anxiety

Emotional Distress – Depression

Fatigue

Pain – Interference

Pain – Intensity

Physical Function – Mobility

Peer Relationships
We will also collect information about Cognitive Function through the pediatric cognitive supplement 
short form 7a. To include patients greater than 17 years of age, we will utilize the PROMIS 57 for adults 
as well as the adult cognitive abilities short form 8a.
PROMIS is available in Spanish and selected forms are also available is other languages such as 
Chinese, Korean, German, etc. Self-reported measures are used for children ages 8 – 17. Parent 
proxy-reported measures are used for children ages 5 – 17. The test takes approximately 5 – 10 
minutes to complete.
Behavior Rating Inventory of Executive Function (BRIEF): 
To assess treatment and disease impact on executive functioning and self-regulation, we will use the 
BRIEF. The BRIEF-P Preschool will be used for preschool children and consists of 63 items, the 
BRIEF-2 Parent Form will be used for children and consists of 86 items, the BRIEF-2 Self Report Form 
will be used for adolescents, and the BRIEF-A Adult Self Report Form will be used for young adults and 

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consists of 75 items.  All assessments are also available in Spanish and take approximately 10 – 15 
minutes to complete.  
*Please see PNOC QOL Guide found in PNOC SharePoint website for more information
CogState:
To assess treatment and disease impact on domains of neurocognition, we will use CogState testing 
(see Table 1). The CogState test battery will take about 30 minutes and will be completed during a 
routine follow up visit or remotely, whatever is more convenient for the family and patient. 
CogState data are automatically scored and stored on a secure server. All CogState tasks were 
developed as computerized adaptations of traditional neuropsychological measures. We will employ 
tasks assessing the following domains: executive function, visual attention, processing speed and 
working memory (visual and verbal). 
Table 1: Summary of Individual CogState Tasks
Neurocognitive 
Function
Name of Task
Score
Time to 
Administer
Interpretation
Working Memory 
Groton Maze-
Learning Task 
# of errors made 
across 5 trials 
Approximately 7 
minutes
Lower scores reflect 
better performance 
Visual Attention 
Identification 
Task 
Mean log 10 
reaction time for 
correct response 
Approximately 3 
minutes
Lower scores reflect 
better performance 
Processing 
Speed 
Detection Task 
Mean log 10 
reaction time for 
correct response 
Approximately 3 
minutes
Lower scores reflect 
better performance 
Working Memory
One-Back Test 
Arcsine proportion 
of total items 
correct 
Approximately 3 
minutes
Higher scores reflect 
better performance 
Verbal Learning 
and Memory 
International 
Shopping list 
International 
Shopping list 
(recall & 
recognition) 
# of correct 
responses made in 
remembering the 
list on three 
consecutive trials 
or at recall at a 
single session.
Approximately 
10 minutes
Higher scores reflect 
better performance 
ADHD Rating Scale:
To assess treatment and disease impact on attention, we will use the ADHD Rating Scale–5: Home 
Version. The ADHD rating scales are based on the diagnostic criteria for ADHD as described in the 
Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Both versions of 

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the ADHD Rating Scale–5 consist of two symptom subscales, Inattention (9 items) and Hyperactivity–
Impulsivity (9 items), as well as a Total Scale (18 items). In addition, the ADHD Rating Scale–
5 assesses six domains of impairment that are common among children with ADHD: relationships with 
significant others, peer relationships, academic functioning, behavioral functioning, homework 
performance, self-esteem. The ADHD Rating Scale–5 has separate forms for children (ages 5–10 
years) and adolescents (ages 11–17 years). The test takes 5 – 10 minutes to administer and is 
available in Spanish.
Adaptive Behavior Assessment System, Third Edition (ABAS-3)
To assess treatment and disease impact on adaptive life skills, we will use the ABAS-3 questionnaire. 
ABAS-3 is used to measure adaptive skills important for everyday living. It has norms from birth to 89 
years of age. The ABAS-3 has several versions: the Parent/Primary Caregiver Form, which consists of 
232 items, the Parent Form (232 items), and the Adult Form (239 items). The ABAS-3 assesses several 
skill areas: communication, community use, functional academics, health and safety, home or school 
living, leisure, motor, self-care, self-direction, social, and work. The test takes 25 – 30 minutes to 
administer and is available in Spanish. 
 
Table 2: ADMINISTRATION SCHEDULE
Baseline
Every 3 monthsa
End of 
treatmentd
Follow up period
Every 12 months until the 
start of a new treatment
PEDs-QL 
Generic Core Scales
Cancer Module
X
X
X
X
PROMIS 
Parent-Proxy-49
Pediatric Profile-49
PROMIS 57 Profile
Pediatric cognitive 
supplement short form 7a
Adult cognitive abilities 
short form 8a.
X
X
X
X
CogState
X
X
X
Baseline
Every 6 months for two 
years then every 12 months 
after two years, while on 
treatmentb
End of 
treatmentd, e
Follow up period
Every 12 months 
until the start of a 
new treatmentc 
ABAS-3  
Parent/Primary Caregiver 
Form 
Parent Form 
Adult Form 
X
X
X
X

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a Every 3 months from the date of previous administration +/- 14 days
b Every 6 months from the date of previous administration +/- 14 days
c If the ABAS BRIEF or ADHD measures were not administered at EOT because they were already 
completed within 6 months of the EOT visit, they should be collected in follow up when the 6 month 
elapses from date of last administration. They should then be collected every 12 months. 
d  +/- 14 days
e If measures have been administered within the past 6 months of EOT visit, they do not need to be 
repeated
f If participant is at EOT and CogState was administered less than 6 months prior, please contact 
PNOC Operations Office for specific guidance.
BRIEF®
BRIEF®P Preschool 
BRIEF® 2  Parent Form
BRIEF® 2  Self Report 
Form
BRIEF®-A Self Report 
Form
X
X
X
X
ADHD Rating Scale-5; 
Home Version Adolescent
Home Version Child
X
X
X
X
CogState
X
X
Xf
X

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REFERENCES (for QOL):
1.
Eiser C, Morse R: Quality-of-life measures in chronic diseases of childhood, Core Research, 
2001 
2.
Macartney G, Harrison MB, VanDenKerkhof E, et al: Quality of Life and Symptoms in Pediatric 
Brain Tumor Survivors A Systematic Review. Journal of Pediatric Oncology Nursing 31:65-77, 2014
3.
Zeltzer LK, Recklitis C, Buchbinder D, et al: Psychological status in childhood cancer survivors: 
a report from the Childhood Cancer Survivor Study. Journal of Clinical Oncology 27:2396-2404, 2009
4.
Vannatta K, Gartstein MA, Short A, et al: A controlled study of peer relationships of children 
surviving brain tumors: teacher, peer, and self ratings. Journal of Pediatric Psychology 23:279-287, 
1998
5.
Lawenda BD, Gagne HM, Gierga DP, et al: Permanent alopecia after cranial irradiation: dose–
response relationship. International Journal of Radiation Oncology* Biology* Physics 60:879-887, 2004
6.
Sanders C, Egger M, Donovan J, et al: Reporting on quality of life in randomised controlled 
trials: bibliographic study. Bmj 317:1191-1194, 1998
7.
Clarke S-A, Eiser C: The measurement of health-related quality of life (QOL) in paediatric 
clinical trials: a systematic review. Health Qual Life Outcomes 2:66, 2004
8.
Bradlyn AS, Harris CV, Spieth LE: Quality of life assessment in pediatric oncology: a 
retrospective review of phase III reports. Social Science & Medicine 41:1463-1465, 1995
9.
Trama A, Dieci M: Quality of life in clinical trials for children. European journal of clinical 
pharmacology 67:41-47, 2011
10.
Nathan PC, Furlong W, Barr RD: Challenges to the measurement of health‐related quality of life 
in children receiving cancer therapy. Pediatric blood & cancer 43:215-223, 2004
11.
Eiser C, Morse R: Can parents rate their child's health-related quality of life? Results of a 
systematic review. Quality of Life Research 10:347-357, 2001
12.
Chassany O, Sagnier P, Marquis P, et al: Patient-reported outcomes: the example of health-
related quality of life—a European guidance document for the improved integration of health-related 
quality of life assessment in the drug regulatory process. Drug Information Journal 36:209-238, 2002
13.
Varni JW, Seid M, Kurtin PS: PedsQL™ 4.0: Reliability and validity of the Pediatric Quality of 
Life Inventory™ Version 4.0 Generic Core Scales in healthy and patient populations. Medical care 
39:800-812, 2001
14.
Cella DF, Tulsky DS, Gray G, et al: The Functional Assessment of Cancer Therapy scale: 
development and validation of the general measure. Journal of clinical oncology 11:570-579, 1993
15.
Aaronson NK, Ahmedzai S, Bergman B, et al: The European Organization for Research and 
Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in 
oncology. Journal of the national cancer institute 85:365-376, 1993
16.
Goodwin DA, Boggs SR, Graham-Pole J: Development and validation of the pediatric oncology 
quality of life scale. Psychological Assessment 6:321, 1994
17.
Armstrong FD, Toledano SR, Miloslavich K, et al: The Miami pediatric quality of life 
questionnaire: parent scale. International Journal of Cancer 83:11-17, 1999
18.
Weitzner MA, Meyers CA, Gelke CK, et al: The functional assessment of cancer therapy (FACT) 
scale. Cancer 75:1151-1161, 1995
19.
Lai J-S, Cella D, Tomita T, et al: Developing a health-related quality of life instrument for 
childhood brain tumor survivors. Child's Nervous System 23:47-57, 2007
20.
Lai J-S, Nowinski C, Victorson D, et al: Quality-of-Life Measures in Children With Neurological 
Conditions Pediatric Neuro-QOL. Neurorehabilitation and neural repair 26:36-47, 2012

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Appendix I
 Management Algorithms
These general guidelines constitute guidance to the Investigator and may be supplemented by 
discussions with the Medical Monitor representing the Sponsor. The guidance applies to all immuno-
oncology agents and regimens.
A general principle is that differential diagnoses should be diligently evaluated according to standard 
medical practice. Non-inflammatory etiologies should be considered and appropriately treated.
Corticosteroids are a primary therapy for immuno-oncology drug-related adverse events. The oral 
equivalent of the recommended IV doses may be considered for ambulatory patients with low-grade 
toxicity. The lower bioavailability of oral corticosteroids should be taken into account when switching to 
the equivalent dose of oral corticosteroids.
Consultation with a medical or surgical specialist, especially prior to an invasive diagnostic or 
therapeutic procedure, is recommended.
The frequency and severity of the related adverse events covered by these algorithms will depend on 
the immuno-oncology agent or regimen being used.

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GI Adverse Event Management Algorithm
Rule out non-inflammatory causes. If non-inflammatory cause is identified, treat accordingly and 
continue I-O therapy. Opiates/narcotics may mask symptoms of perforation. Infliximab should not be 
used in cases of perforation or sepsis. 
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids.
Renal Adverse Event Management Algorithm
Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O 
therapy.

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Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids.
Pulmonary Adverse Event Management Algorithm

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Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O 
therapy. Evaluate with imaging and pulmonary consultation. 
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids
Hepatic Adverse Event Management Algorithm
Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O 
therapy. Consider imaging for obstruction.

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Page 104 of 107
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids.
Endocrinopathy Adverse Event Management Algorithm
Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O 
therapy. Consider visual field testing, endocrinology consultation, and imaging.

Version 2.1, Version Date: 3/1/2021        
 
Protocol PNOC 007/CC# 150819
Page 105 of 107
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids.
Skin Adverse Event Management Algorithm
Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O 
therapy.

Version 2.1, Version Date: 3/1/2021        
 
Protocol PNOC 007/CC# 150819
Page 106 of 107
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids.
*Refer to NCI CTCAE v5 for term-specific grading criteria.
^If SJS/TEN is suspected, withhold I-O therapy and refer patient for specialized care for assessment and treatment. If SJS or TEN is 
diagnosed, permanently discontinue I-O therapy.
Neurological Adverse Event Management Algorithm
Rule out non-inflammatory causes. If non-inflammatory cause, treat accordingly and continue I-O 
therapy.

Version 2.1, Version Date: 3/1/2021        
 
Protocol PNOC 007/CC# 150819
Page 107 of 107
Patients on IV steroids may be switched to an equivalent dose of oral corticosteroids (e.g. prednisone) at start of tapering or earlier, 
once sustained clinical improvement is observed. Lower bioavailability of oral corticosteroids should be taken into account when 
switching to the equivalent dose of oral corticosteroids