Phase I Safety Study of Intratumoral Injection of Clostridium Novyi-NT Spores in Patients With Treatment-refractory Solid Tumor Malignancies
Phase: PHASE1
Conditions: Solid Tumor Malignancies
Sponsor: BioMed Valley Discoveries, Inc

Protocol: BVD-CNV2 
Confidential - Proprietary Information 
x Protocol number: BVD-CNV2. 
x Document title: Phase 1 safety study of intratumoral injection of 
Clostridium novyi-NT spores in patients with treatment-refractory solid 
tumor malignancies. 
x Version number: Protocol Amendment 2. 
x Date of the document: 02 September 2014. 
x NCT number: NCT01924689 

 
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Phase I safety study of intratumoral injection of Clostridium novyi-NT spores in 
patients with treatment-refractory solid tumor malignancies 
 
Protocol Amendment 2 
 
 
 
Sponsor: 
BioMed Valley Discoveries, Inc. 
4520 Main Street, Suite 1650 
Kansas City, MO 64111 
 
Contract Research Organization:  PAREXEL International 
200 West Street 
Waltham, MA 02451 
 
Sponsor Protocol Number: 
BVD-CNV2 
 
Development Phase: 
Phase 1 (safety, efficacy, spore disposition, immune/inflammatory 
correlation) 
 
Last Revised: 
Final Protocol   
10/22/2012 
 
Amendment #1     
05/10/2013 
 
Amendment #2     
09/02/2014 
 
 
 
 
 
 
 
 
 
 
The clinical study will be conducted according to the protocol and in compliance with Good Clinical 
Practices (GCP), the Declaration of Helsinki (Version 2008), and with other applicable regulatory 
requirements. 
 
 
 
 
 
 
 
 
 
 
 
 
Confidentiality Statement 
 
This document contains confidential information of BioMed Valley Discoveries, Inc. Do not copy 
or distribute without written permission from the Sponsor. 

PPD

 
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Declaration of the Investigator 
SIGNATURE PAGE 
 
Protocol Title: Phase I safety study of intratumoral injection of Clostridium novyi-NT spores 
in patients with treatment-refractory solid tumor malignancies 
 
This clinical study protocol was subjected to critical review and has been released by the Sponsor. The 
information it contains is consistent with current risk and benefit evaluation of the study agent, as well 
as with the moral, ethical and scientific principles governing clinical research as set out in the 
Declaration of Helsinki (Version 2008), and the guidelines on Good Clinical Practices (GCP) applicable to 
this clinical study. 
 
 
 
Responsible investigator of the local study center 
 
 
 
 
 
 
 
 
 
 
Name  
Title 
Institution 
Date 

 
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Table of Contents 
List of Abbreviations ..................................................................................................................................... 7 
Contact Information .................................................................................................................................... 10 
Objectives of the Study ............................................................................................................................... 11 
1. Introduction and Background ................................................................................................................. 12 
1.1 Clostridium novyi-NT ......................................................................................................................... 12 
1.2 Preclinical PK of C. novyi-NT spores9 ................................................................................................. 12 
1.3 Toxicity Studies of C. novyi-NT in Non-Tumor-Bearing Animals9 ...................................................... 13 
1.4 Efficacy and Toxicity Studies in Tumor-Bearing Animals ................................................................... 13 
1.5 Exploratory Study of Intratumoral Administration of C. novyi-NT in Companion Canines Bearing 
Spontaneous, Naturally Occurring Solid Tumors ................................................................................... 14 
1.6 Rationale for Intratumoral Treatment of C. novyi-NT in Human Patients ........................................ 14 
1.7 Management of Adverse Effects Related to Treatment with C. novyi-NT ........................................ 15 
2. Investigational Plan ................................................................................................................................. 18 
2.1 Patient Population ............................................................................................................................. 18 
2.2 Eligibility Criteria ............................................................................................................................... 18 
2.2.1 Inclusion Criteria......................................................................................................................... 19 
2.2.2 Exclusion Criteria ........................................................................................................................ 19 
3. Study Design ............................................................................................................................................ 20 
3.1 Dosing ............................................................................................................................................... 21 
3.1.1 
Starting Dose Rationale ....................................................................................................... 21 
3.1.2 
Dose Escalation Scheme ..................................................................................................... 22 
3.1.3 
Investigational Product and Injection ................................................................................. 22 
3.2 Concomitant Medications ................................................................................................................. 22 
3.3 Patient Discontinuation ..................................................................................................................... 23 
3.4 Early Stopping Rule ............................................................................................................................ 23 

 
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4. Study Procedures .................................................................................................................................... 24 
4.1 Study Calendar .................................................................................................................................. 24 
4.2 Safety Evaluation ............................................................................................................................... 28 
4.3 Safety Evaluation Summary .............................................................................................................. 28 
5. Management of Study Agent-related Toxicity ........................................................................................ 29 
6. Adverse Event Reporting ......................................................................................................................... 30 
6.1 Definitions ......................................................................................................................................... 30 
6.2 Reporting ........................................................................................................................................... 31 
6.3 Pregnancy .......................................................................................................................................... 32 
6.4 Follow-up of Adverse Events ............................................................................................................. 32 
6.5 Serious Adverse Event Reporting ...................................................................................................... 32 
6.5.1 Food & Drug Administration (FDA) ............................................................................................. 33 
6.5.2 Institutional Review Board (IRB) ................................................................................................. 34 
7. Efficacy Evaluation .................................................................................................................................. 34 
8. Correlative Studies .................................................................................................................................. 34 
8.1 Measurement of the anti-C. novyi-NT immune and inflammatory responses .................................. 34 
8.2 C. novyi-NT detection in circulation and/or abscess material/post-dose tumor sample ................. 34 
9. Statistical Considerations ........................................................................................................................ 35 
10. Ethical, Legal, and Administrative Requirements ................................................................................. 35 
10.1 Data Recording, Management, and Monitoring .............................................................................. 35 
10.2 Access to Source Data/Documents ................................................................................................. 35 
10.3 Archiving Study Documents ............................................................................................................ 36 
10.4 Good Clinical Practice ...................................................................................................................... 36 
10.5 Protocol Approval and Amendment(s) ............................................................................................ 36 
11. Subject Confidentiality and Rights ........................................................................................................ 37 

 
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11.1 Patient Information and Informed Consent .................................................................................... 37 
11.2 Patient Confidentiality ..................................................................................................................... 37 
11.3 Publication Policy ............................................................................................................................ 37 
References .................................................................................................................................................. 38 
List of Appendices ....................................................................................................................................... 39 
Appendix 1: Study Agent Information ........................................................................................................ 40 
Appendix 2: Study Agent Spill Procedure ................................................................................................... 41 
Appendix 3: SOFA Score Calculations ......................................................................................................... 42 
Appendix 4: Symptoms of Infection ........................................................................................................... 45 
Appendix 5: ECOG Performance Status Scale* ........................................................................................... 46 
Appendix 6: Amendment 2 List of Changes ............................................................................................... 47 
 

 
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List of Abbreviations 
 
Abbreviation 
Definition 
ABG 
Arterial blood gas 
ADL 
Activities of daily living 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
ANC 
Absolute neutrophil count 
AST 
Aspartate aminotransferase 
AUC 
Area under the curve 
BP 
Blood pressure 
BSC 
Biological safety cabinet 
C. novyi-NT 
Clostridium novyi-Non Toxic 
CBC 
Complete blood count 
CBER 
Center for Biologics Evaluation 
CEA 
Carcinoembryonic antigen 
CFR 
Code of Federal Regulations 
CNS 
Central nervous system 
COBALT 
Combination Bacteriolytic Therapy 
CPGT 
Cell Processing and Gene Therapy Facility 
CRP 
C-reactive protein 
CT 
Computed tomography 
CTC 
Common Toxicity Criteria 
CTCAE 
Common Terminology Criteria for Adverse Events 
DLT 
Dose-limiting toxicity 
DNA 
Deoxyribonucleic acid 
Dob 
Dobutamine 
Dop 
Dopamine 
ECG 
Electrocardiogram 
Echo 
Echocardiogram 
ECOG 
Eastern Cooperative Oncology Group (performance status scale) 
eCRF 
Electronic case report form 
EDTA 
Ethylenediaminetetraacetic acid 
Epi 
Epinephrine 
FDA 
Food and Drug Administration 
FiO2 
Fraction of inspired oxygen 
GCP 
Good Clinical Practice 
GCS 
Glascow Coma Scale 
GI 
Gastrointestinal 
GMP 
Good Manufacturing Practice 

 
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Abbreviation 
Definition 
HR 
Heart rate 
ICH 
International Conference on Harmonization 
ICU 
Intensive Care Unit 
IND 
Investigational New Drug 
INR 
International normalized ratio 
IRB 
Institutional Review Board 
IV 
Intravenous 
IT 
Intratumoral 
K2 
Dipotassium 
Lambdaz (λz) 
The terminal elimination rate constant determined by selection of at least three data 
points on the terminal phase of the concentration-time curve. 
MAP 
Mean arterial pressure 
MRI 
Magnetic resonance imaging 
MTD 
Maximum tolerated dose 
NaCl 
Sodium chloride 
NCI 
National Cancer Institute 
NG 
Nasogastric 
Norepi 
Norepinephrine 
NSAID 
Non-steroidal anti-inflammatory drug 
O2 
Oxygen 
PaO2 
Partial pressure of arterial oxygen 
PBS 
Phosphate buffered saline 
PCR 
Polymerase chain reaction 
PEG 
Percutaneous endoscopic gastrostomy 
PEG-J 
Percutaneous enteral gastric/jejunal 
PI 
Principal Investigator 
PK 
Pharmacokinetic(s) 
PR 
Partial response 
PT 
Prothrombin time 
PTT 
Partial thromboplastin time 
RECIST 
Response Evaluation Criteria in Solid Tumors 
ROC 
Receiver operating characteristic 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
SD 
Stable disease 
SOFA 
Sequential Organ Failure Assessment 
SOP 
Standard Operating Procedure 
SpO2 
Oxygen saturation by pulse oximetry 
SST 
Serum separator tube 

 
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Abbreviation 
Definition 
STS 
Soft tissue sarcoma 
T½ 
Terminal elimination half-life calculated as: ln2/Lambdaz 
ULN 
Upper limit of normal 
WBC 
White blood cell 
 
 

 
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Contact Information  
 
 
. 
 
 
Phone: 
 
Fax: 
 
Email: 
 
PPD
PPD
PPD
PPD
PPD
PPD
PPD
PPD

 
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Objectives of the Study 
 
• 
 To determine the safety profile, dose limiting toxicities (DLT), and maximum tolerated dose 
(MTD) of Clostridium novyi–NT (C. novyi-NT) in humans with treatment-refractory solid tumor 
malignancies when administered as a single intratumoral (IT) injection. 
 
•
To document preliminary anti-tumor activity of both the injected tumor and an overall 
response after administering a single IT injection of C. novyi-NT in humans with 
treatment-refractory solid tumor malignancies. The evaluation of anti-tumor activity 
will include: 1) a response for the injected tumor and 2) an overall response. 
 
•
To study the presence of circulating C. novyi-NT spores after administration as a single IT 
injection to humans with treatment-refractory solid tumor malignancies (see Section 4.1 Study 
Calendar, Table 4 and Section 8.2 C. novyi-NT detection in circulation and/or abscess 
material/post-dose tumor sample). 
 
•
To measure the host immune and inflammatory response to C. novyi-NT administered as 
a single IT injection in humans with treatment-refractory solid tumor malignancies. 
 

 
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1. Introduction and Background 
Strategies that successfully target and destroy human cancers exploit differences between normal and 
malignant tissues1. Such differences can be found at the molecular level, as is the case with genetic 
aberrations, or more holistically, as with the physiological aberrations in a tumor. It is known that 
malignant solid tumors are usually composed of a necrotic core and a viable rim. Therapeutic 
interventions to date have focused on the well-vascularized outer shell of the tumor, but few have 
targeted the inner hypoxic core. The inner core of a tumor has unique characteristics that differentiate 
it from normal tissues. The core has a poor vascular supply and is therefore deficient in nutrients and 
oxygen. As a site of active cellular necrosis, the lack of a functional vascular supply limits the clearance 
of noxious cell breakdown and results in a low pH. 
 
Figure 1: 
Tumor microenvironment (Jain et al., 2001)2 
 
 
Such an environment is not suitable for growth of most human cells but is an environment favorable to 
the growth of certain anaerobic bacteria. Over 60 years ago, this concept led investigators to inject 
spores of Clostridium histolyticum into tumor-bearing animals3. Remarkably, the bacteria germinated 
only in the necrotic core of the tumor and liquefied it. In the 1950s and 1960s, spores from Clostridium 
butyricum were injected into patients with a variety of very advanced solid tumor malignancies4-6. Many 
patients had significant germination and destruction of large portions of their tumors, but the very poor 
health and advanced stage of these patients made their management difficult and the absence of 
complete clinical responses subdued further pursuit of this approach. 
1.1 Clostridium novyi-NT 
The agent presented for use in humans in this Phase I study is C. novyi-NT. It was developed after a 
large panel of anaerobic bacteria was screened for the ability to germinate and populate in mouse 
tumor models1. The anaerobe Clostridium novyi (ATCC #19402) had the best anti-tumor efficacy in this 
screen. It was subsequently rendered nonpathogenic by selecting a clone without the major toxin 
(α-toxin) responsible for systemic toxicities associated with this organism1,7,8. The resulting clone, 
named Clostridium novyi-NT, where the NT stands for non-toxic, was employed in a series of 
preclinical studies based on a strategy termed Combination Bacteriolytic Therapy (COBALT) that 
combined C. novyi-NT therapy with traditional chemotherapy or radiation1,7. 
1.2 Preclinical PK of C. novyi-NT spores9 
Pharmacokinetic studies indicate that C. novyi-NT spores, when administered intravenously (IV) to 
mice, are rapidly cleared from the circulation (> 99% spores are cleared within 1 hour) and sequestered 

 
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within the reticuloendothelial system. Long-term distribution studies reveal that these spores are 
eventually eliminated from all tissues by one year. Delivered in spore form (dormant stage), 
C. novyi-NT germinates (transitions from the spore to the vegetative state) when exposed to the 
hypoxic regions of tumors. Thus, the systemic toxicities of C. novyi-NT have been shown to be greater 
in tumor-bearing than in non-tumor-bearing animals. 
 
1.3 Toxicity Studies of C. novyi-NT in Non-Tumor-Bearing Animals9 
Non-tumor-bearing mice and rabbits showed no clinically apparent signs (morbidity, mortality, or clinical 
appearance) of toxicity regardless of treatment dose administered intravenously. However, 
examination of tissues at necropsy revealed both gross and microscopic inflammatory changes that 
appeared to be treatment-dose dependent. These findings, primarily in the liver, spleen, and adrenals, 
were noted at doses of 5 x 108 spores/kg or greater. Non-tumor-bearing animals receiving lower doses 
showed no gross or microscopic abnormalities at necropsy. In animals that received high doses, 
resolution of inflammation was evident on Day 28 and all signs of inflammation were absent in all 
animals by 1 year. To determine if C. novyi-NT spores would germinate in non-tumor hypoxic tissue, 
studies in elderly mice with atherosclerotic plaques and experimental myocardial infarctions were 
treated with C. novyi-NT. There was no evidence of spore localization or germination within these 
vascular lesions. At the conclusion of the study, no clinical or pathologic abnormalities (other than the 
pre-existing cardiovascular lesions) were noted in these mice. These studies demonstrated that C. 
novyi-NT is an agent with no clinical and minimal pathologic toxicity in non-tumor-bearing animals. 
 
1.4 Efficacy and Toxicity Studies in Tumor-Bearing Animals 
Intravenous injection of spores into immune-competent tumor-bearing mice leads to lysis of the tumor 
and an intense inflammatory response. In mice, one of three outcomes is typically observed: One 
subset (25 to 35% of mice) are cured (no tumor recurrence after one year of observation) and develop 
long-term immunity to the original tumor8. Another subset (65 to 75%) demonstrates complete clinical 
responses, but experiences recurrence with regrowth of the original tumor. The remaining subset (0 to 
20%, depending on the experiment) demonstrates tumor destruction but develops significant clinical 
toxicity 2 to 5 days after the initiation of therapy. Relatively simple measures, such as hydration, are 
adequate to reduce this toxicity, often entirely eliminating it9. Studies in larger animals (rabbits) show 
the same cure and recurrence rates with IV C. novyi-NT therapy, but do not show the life-threatening 
clinical toxicity observed in a subset of mice. Treatment-related death was observed in tumor-bearing 
mice, but not in rabbits, treated with C. novyi-NT spores9. In these studies toxicity was related to both 
spore dose and tumor size and appeared to be at least partially related to dehydration, as it could be 
effectively managed with supportive care (hydration) and/or antibiotics. In moribund mice, no specific 
clinical laboratory or pathologic end-organ damage was noted and the only significant finding was 
reversible hepatosplenomegaly. Cured mice had rare remnant inflammatory changes in the liver and 
spleen, but were otherwise no different than untreated animals. These studies show that toxicity in 
tumor-bearing animals can be pronounced (death) in mice with large tumors, but was minimal in larger 
animals (rabbits), and was manageable in mice with hydration or antibiotics. 
 

 
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1.5 Exploratory Study of Intratumoral Administration of C. novyi-NT in Companion Canines 
Bearing Spontaneous, Naturally Occurring Solid Tumors 
C. novyi-NT has been evaluated in an exploratory and open-label study at multiple veterinary oncology 
centers in companion canines with spontaneous, naturally occurring solid tumors with tumor histology 
enriched for soft tissue sarcomas (STS). The study was designed to evaluate multiple cycles of 
intratumoral (IT) injections of C. novyi-NT spores in canines. The study has been completed. Findings are 
summarized as follows. 
 
Study Conduct:  
In this study, 16 companion dogs received between one and four treatment cycles of intratumoral (IT) 
administrations of C. novyi-NT spores at 1 x 108 spores diluted in 100 μL of saline. Eleven out of 16 dogs 
received all four treatment cycles. Dogs may have received fewer than four treatment cycles due to 
tumor ablation (2), toxicity (2), or progressive disease (1). There were 10 males and 6 females with 
average age of 11 years and average weight of 31 kilograms. The tumor types treated in this study were 
soft tissue sarcoma (13), osteosarcoma (1), melanoma (1), and mast cell tumor (1). The study follow-up 
period was three months.  
 
Safety:  
Most adverse events were mild in severity, with hyperthermia/fever and tumor inflammation being the 
most common AEs expected. All fever events were Grade I or II. Tumor inflammation and abscess 
events, generally considered desired mechanisms of the treatment, were limited to Grades I or II for all 
dogs but one (who experienced Grade III inflammation).  
SAEs were observed in 25% (4/16) of dogs treated; three out of 4 of the events were associated with 
tumor inflammation that required prolonged hospitalization. It is unclear if the remaining event, cervical 
steatitis causing neck pain, was associated with C. novyi-NT or metastasis given the necropsy findings of 
a melanoma lesion in the fat of the cervical spine. 
When comparing C. novyi-NT at 1 x 108 spores/dog IT treatment to 1 x 108 spores/m2 IV treatment in the 
C-100 study, dogs receiving IT treatment experienced far fewer severe AE (Grade III or IV). Twenty-five 
percent (4/16 dogs) receiving IT treatment experienced severe AE compared to 57% (8/14 dogs) 
receiving IV administration of C. novyi-NT in the C-100 study.  
 
Efficacy:  
The incidence of objective response was 38% and included dogs with soft tissue sarcoma and mast cell 
tumor. Though debriding was performed in 3/6 dogs with objective response, this procedure was 
undertaken to eliminate necrotic cellular debris and to potentiate the healing of C. novyi-NT induced 
abscesses; complete healing was observed in 2-4 weeks for all dogs whose tumors were debrided. The 
progression-free rate (at Day 90) was 88%. Four of the eight dogs evaluable at Day 90 had no surgical 
debridement during the study, including one high grade STS - a tumor type and grade not expected to be 
progression-free in 90 days without therapy. 
1.6 Rationale for Intratumoral Treatment of C. novyi-NT in Human Patients 
The favorable risk/benefit profile observed from the preliminary results of the ongoing companion 
canine study with C. novyi-NT IT treatment provides a compelling rationale for translating the 
intratumoral administration of C. novyi-NT to a Phase I investigational study in human patients with 
solid tumors that are either refractory to standard therapy or without an available standard therapy. 
The Phase I study of intravenous administration of C. novyi-NT spores in patients with treatment-
refractory solid tumors [NCT01118819] has been closed so that all efforts could be directed to the 

 
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intratumoral program. The IT treatment protocol will target patients with superficial tumors 
measureable, palpable or clearly identifiable under ultrasound or radiographic guidance and amenable 
to intratumoral injection of C. novyi-NT spores.  
1.7 Management of Adverse Effects Related to Treatment with C. novyi-NT  
 
Local Effects 
As highlighted in the ongoing companion canine studies (Section 1.5 Exploratory Study of Intratumoral 
Administration of C. novyi-NT in Companion Canines Bearing Spontaneous, Naturally Occurring Solid 
Tumors), C. novyi-NT germination can occur within tumor tissues following IT dosing, and may lead to 
tumor inflammation and tumor destruction. Expected inflammatory sequelae may include local 
erythema, warmth, pain, and tenderness near a tumor injection site. These changes may progress and 
result in tissue abscessation in the tumor lesion. 
 
Preliminary experience from the ongoing canine study also demonstrates that tumor inflammation can 
be managed by monitoring and standard medical support measures. Supportive care during the period of 
time when a localized C. novyi-NT infection is being established can result in successful abscess resolution 
as well as subsequent clinical responses. Similarly, application of antibiotics can be delayed in favor of 
other interventions including, hydration, analgesia, and abscess lancing and drainage.  
 
Systemic Effects  
The current protocol administering C. novyi-NT spores via an intratumoral route is expected to result in 
minimal systemic side effects. However, in order to predict and respond to early signs of systemic 
toxicity, this study will utilize the SOFA score (Table 1) to guide antibiotic initiation.  
 
Validated scoring strategies exist that can predict the risk of death from systemic insults, including 
infection. Originally developed for stratifying septic patients, the SOFA scoring system (Sequential Organ 
Failure Assessment) has been used to predict mortality10-12. The SOFA score criteria and scoring system 
are shown below. Scores can range from 0 to 24 and are calculated from the sum of the six organ 
systems evaluated (respiratory, coagulation, liver, cardiovascular, central nervous system [CNS], and 
renal). 

 
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Table 1: 
The SOFA Score (Ferreira et al., 2001.)10  
 
 
Several studies have shown SOFA scores are good predictors of mortality in the intensive care unit (ICU) 
setting. Scores at time of admission and the highest score achieved during hospitalization were strong 
predictors (Figure 2)10. Receiver operating characteristic (ROC) curves using admission (initial) and the 
highest SOFA scores for prediction of mortality repeatedly show area under the curve (AUC) values of 
between 0.79 and 0.90, respectively (Figure 3)10. Sequential organ failure assessment scores determined 
from the optimal threshold (best cut-off point) to discriminate between survival and non- survival in both 
cases were greater than 8. With scores above 8 predicting mortality rates averaging 55% (range 26 to 
95%) and those below this threshold averaged 13% (range 0 to 21%). 
 

 
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Figure 2: 
Mortality rate in relation to the changes in SOFA scores at (A) time of admission or (B) 
the highest SOFA score achieved during hospitalization. (Ferreira et al., 2001.)10 
 
Figure 3: 
Comparison of the area under the ROC curves for prediction of mortality using SOFA 
scores at time of admission or at the highest measured SOFA score achieved during 
hospitalization. (Ferreira et al., 2001.)10 
 
In addition, when applied to bacteremic patients, SOFA scores at time of bacteremia were significantly 
lower in the survivor groups who averaged 7.3 as compared with the non-survivors at 10.0 (p < 0.001)13. 
The best cut-off SOFA score in this group of patients was calculated to be 7.5 from a ROC curve with an 
AUC of 0.77. 
 
In this study, we will utilize the SOFA score and temperature to guide antibiotic initiation in our patients 
treated with C. novyi-NT during the in-patient phase. Following administration of C. novyi-NT, the 
patients will be scored at least every 8 hours or when there is a change in status. Although SOFA scores 
below 7.5 to 8.0 were the derived thresholds to discriminate between survivors and non-survivors, this 
protocol is designed to start antibiotics in a more conservative manner. Therefore, antibiotics will be 
initiated when: 
 

 
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a. The total SOFA score is 5 or greater; or 
b. The SOFA score in any of the following organ systems reaches 2 (respiratory, coagulation, 
cardiovascular, CNS); or 
c. The SOFA score in either the liver or renal systems reaches 3; or 
d.  A patient is found to have 2 temperatures > 38.5°C lasting >12 hours beginning 5 days following 
administration of the study agent; or 
e. Initiation of antibiotics is indicated based on the investigator’s clinical judgment. 
 
The decision to start antibiotics will be based on the patient’s progress, temperature and the SOFA score. 
Once the decision to start antibiotics is made, parenteral piperacillin/tazobactam and oral or parenteral 
metronidazole will be administered until the patient is afebrile, clinically stable and has negative blood 
cultures for C. novyi-NT for at least 48 hours. The patient will then receive oral or parental metronidazole 
for 6 weeks (if the parenteral route is chosen, then a temporary central line will be placed) followed by 
oral doxycycline 100 mg orally twice per day indefinitely. Alternate options for antibiotic coverage for 
patients with allergies can be discussed in consultation with the Medical Monitor. 
 
Patients in whom the criteria for starting IV antibiotics are never met during in-hospital phase will still be 
required to start on therapy with oral doxycycline (100 mg orally twice per day) on Day 7, even in the 
absence of symptoms attributable to the study agent. Oral doxycycline will be continued indefinitely. 
Specifically, Day 7 CT/MRI will be reviewed by the PI with his/her study team prior to patient discharge. If 
CT/MRI scan indicates evidence of abscess formation, the patient will remain hospitalized and will be 
started on IV antibiotics (see Sec. 5). If no evidence of abscess is identified, the patient will be discharged 
as planned on PO antibiotics (doxycycline 100 mg orally twice per day indefinitely). Supportive care 
measures, including antipyretics, analgesics, fluids and pain control, will be managed by the primary 
inpatient team with guidance from the Principal Investigator (PI) and Medical Monitor. In preclinical 
studies vigorous intravenous hydration appeared to improve outcomes following C. novyi-NT injection in 
tumor-bearing animals. Need for surgical or percutaneous drainage will be assessed in a case by case 
basis and appropriate consultation may be requested if clinically indicated. 
 
2. Investigational Plan 
2.1 Patient Population 
 
The study population is patients with solid tumor malignancies that are refractory to standard therapy or 
without available standard therapy. Men and women of all races and ethnic groups are eligible for this 
trial. 
 
2.2 Eligibility Criteria 
 
All eligibility criteria must be met for patients to be eligible for enrollment. Screening studies will remain 
valid up to 3 weeks (21 days) prior to treatment. 
 

 
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2.2.1 Inclusion Criteria 
1. Diagnosis of an advanced solid tumor malignancy. There must be a target tumor which is 
measureable, palpable or clearly identifiable under ultrasound or radiographic guidance and 
amenable to percutaneous injection of C. novyi-NT spores. The targeted lesion must have a 
longest diameter ≥ 1 cm and < 12 cm and be measurable as defined by RECIST 1.1 criteria. The 
target lesion must not be located in either the thoracic, abdominal or pelvic cavities or in the 
brain. There must be no clinical, no functional, and no radiographic evidence of bone 
involvement at the site of the target lesion. 
2. History of prior treatment with at least one line of systemic anticancer therapy, when an 
approved systemic therapy is available, and no curative option is available for continued 
treatment. 
3. At least 4 weeks have elapsed since the completion of major surgery, and the patient has fully 
recovered from this surgery and any post-surgical complications. 
4. Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less (Appendix 5: ECOG 
Performance Status Scale*). 
5. Patient is at least 18 years of age. 
6. Patient is capable of giving informed consent. 
7. Patient of childbearing potential (defined by the clinical sites’ standards) is using adequate birth 
control measures (e.g., barrier method with spermicide; intrauterine device; implantable or 
injectable hormonal contraceptives; surgical sterilization) for the duration of the study and will 
continue to use such precautions for 12 months after receiving treatment. 
8. Patient has no significant valvular heart disease (trace or mild valvular stenosis or regurgitation is 
allowed). 
9. Patient is able to stay within 45 minutes driving time of an emergency room for 28 days after 
dosing. 
10. The patient has a caregiver for 28 days after dosing. 
 
2.2.2 Exclusion Criteria 
1.
Positive pregnancy test. 
2.
Serum creatinine level > 1.5 x the upper limit of normal (ULN), chronic renal failure requiring 
hemodialysis or peritoneal dialysis. 
3.
Patient has any of the following hematologic parameters: 
 
 
− 
Platelet count equal to or less than 100,000/mm3 
 
 
− 
Hemoglobin less than 9.0 g/dL 
 
 
− 
Absolute neutrophil count (ANC) less than 1,000 /mm3 
4. Oxygen saturation (Sp02) of less than 95% on room air. 
5. Mean arterial blood pressure (BP) of less than 70 mmHg. 
6. Glasgow Coma Score (GCS; see Appendix 3: SOFA Score Calculations) of less than 15. 
7. Treatment with an investigational drug within the past 30 days or 5 half-lives of that drug, 
whichever is shorter. 
8. Documented primary brain malignancy or brain metastases. 
9. Clinically significant ascites or clinical evidence or history of portosystemic hypertension or 
cirrhosis. 
10. Laboratory evidence of hepatic dysfunction indicated by any of the following: 
− Bilirubin > 1.5 x the ULN 
− Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) above 2.5X the ULN 

 
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− Alkaline phosphatase above 2.5X the ULN 
− International normalized ratio (INR) greater than 1.3 
11. Patient has a foreign body which in the opinion of the treating investigator could be difficult to 
manage in case of infection (e.g. prosthetic hip). 
12. Clinically significant pleural effusion. 
13. Clinically significant pericardial effusion, circumferential pericardial effusion, or any effusion 
greater than 1.0 cm at any location around the heart. 
14. Need for ongoing treatment with an immunosuppressive agent. 
15. History of solid organ transplantation (with the exception of a corneal transplant > 3 months prior 
to screening). 
16. History of an ischemic insult in the previous 12 months (myocardial infarction, cerebral vascular 
accident, ischemic tissue from injury, transient ischemic attack). 
17. History of a significant medical illness deemed by the PI or local investigators as unsuitable for 
the trial. For example: 
 
 
i. 
Symptomatic congestive heart failure 
 
 
ii.  Psychiatric Illness/social situation that may make study dangerous  
 
 
iii.  Unstable angina pectoris 
18. Asplenia. 
19. Antibiotic allergies that would preclude treatment for a C. novyi-NT infection. 
20. Treatment with antibiotics within 2 weeks (14 days) of dosing. 
21. Active and clinically significant systemic or localized infection. 
 
3. Study Design  
Patients who provide informed consent will undergo screening procedures within 21 days prior to C. 
novyi-NT spore administration. Patients will report to the clinical site within 24 hours of Day 0 to 
reconfirm eligibility and for baseline assessments as described in Table 4. Eligible patients will be 
admitted and enrolled sequentially into a dosing cohort (see Table 3 and dose escalation details below). 
Spore administration will occur on Day 0, and patients will remain in-house for observation through Day 
7 (a total of 8 days). Patients may be allowed for an extended in-hospital stay for observation if a tumor 
abscessation and destruction develops in the treated tumor lesion site. Patients will return to the clinical 
site for follow-up visits at the following time points: Days 11, 14 (Week 2), 18, 21 (Week 3), 25, 28 (Week 
4) and 2, 4, 8, and 12 months post-dose. Assessments of safety, efficacy, and disposition of C. novyi-NT 
will be performed at scheduled time points throughout the study (see Study Calendar and Table 4). 
 
A standard “3+3” dose escalation will be used. The following definitions and rules will be employed: 
 
•
Toxicity Criteria will be those listed in the National Cancer Institute (NCI) Common Terminology 
Criteria for Adverse Events (CTCAE), Version 4.0, which is available at 
http://ctep.cancer.gov/reporting/ctc.html 
•
An adverse event (AE) of Grade 3 toxicity lasting three (3) days or longer or Grade 4 toxicity of any 
duration that is assessed to be at least possibly related to study agent will be considered a DLT. 
Signs and symptoms of C. novyi-NT infection which are associated with a SOFA score > 5 that 
require invasive intervention including percutaneous drainage of an abscess or that result in 
prolonged hospitalization (> 5 days) will also qualify as DLTs.  
•
DLT assessment period is defined as 4 weeks after dosing of the last patient in a cohort. 
•
Toxicity will be assessed from administration of study agent up to 8 weeks. 
•
The following dose escalation rules will apply (see Table 2): 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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Table 2: 
Dose Escalation Decision Rules 
 
Number of Patients with DLT 
at a Given Dose Level 
 
Escalation Decision Rule 
0 out of 3 
The dose escalation will proceed. Three patients will be enrolled at the 
next dose level 
 
 
 
 
1 out of 3 
Three more patients will be enrolled at this dose level 
• If zero of these three patients experience a DLT, then dose escalation 
will proceed to the next dose level. 
• If one or more patients suffer a DLT, then dose escalation will stop. 
This dose will be the maximally administered dose (i.e., the minimum 
intolerated dose). Three additional patients will be entered at the 
next lowest dose level (i.e., the MTD) if only three patients were 
treated previously at that dose. 
 
 
> 2 
Dose escalation will be stopped. This dose level will be declared the 
maximally administered dose (i.e. the minimum intolerated dose). Three 
additional patients will be entered at the next lowest dose level (i.e., the 
MTD) if only three patients were treated previously at that dose. 
 
•
Additional patients will be enrolled at the MTD to achieve a total of six patients at that 
dose level if fewer than six patients were treated previously at that dose. 
•
Doses will be increased in successive cohorts until the MTD is reached or until complete 
germination and tumor regression occurs, making higher doses unnecessary. 
•
The MTD (or dose at which complete germination and tumor regression occurs) will be 
the recommended dose for future Phase II C. novyi-NT IT administration studies. 
 
Patients will be closely monitored by a dedicated team of clinicians for infectious complications or other 
treatment-emergent adverse events with the objective of deciding if and when to initiate antibiotics 
and/or additional interventions (Section 5. Management of Study Agent-related Toxicity). Patients will be 
followed with serial imaging studies for therapeutic response. We will observe the first patient in a 
cohort for a minimum of 2 weeks before treating the second patient, while there will be no required 
minimum observation interval before subsequent patients in the same cohort can be dosed. We will 
observe for a minimum 4-week interval between cohorts. The planned follow-up period for every 
patient who receives C. novyi-NT will be 1 year. 
3.1 Dosing 
3.1.1 
Starting Dose Rationale 
The starting dose (Cohort 1) is 1x104 spores administered as a single IT injection. The starting dose is 
about 700x lower than the Cohort 1 total dose administered in the Phase 1 safety study for intravenous 
injection of C. novyi-NT spores (NCT01118819) in which a starting dose of 1x105 spores/kg, equivalent to 
a total dose of ~7x106 spores, was administered to an average 70 kg patient. The starting IT dose of 
1x104 spores is 10,000x lower than the IT study in companion dogs (Section 1.5 Exploratory Study of 
Intratumoral Administration of C. novyi-NT in Companion Canines Bearing Spontaneous, Naturally 
Occurring Solid Tumors). 

 
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3.1.2 
Dose Escalation Scheme 
Three to six patients will receive IT treatment with C. novyi-NT at a dose corresponding to assigned 
cohort (Table 3), starting with Cohort 1. C. novyi-NT spores will be administered as an IT injection into 
the target lesion. Radiographic guidance may be used at the investigator's discretion to aid in targeting 
an area of necrosis in the target lesion. Patients will be given IV hydration after dosing.  
 
Table 3: 
C. novyi-NT Spores Planned Dose Levels for Intratumoral Injection  
Cohort 
 
Number 
of Patients 
 
Dose 
(x 104 spores) 
1 
3 to 6 
1 
2 
3 to 6 
3 
3 
3 to 6 
10 
4 
3 to 6 
30 
5 
3 to 6 
100 
3.1.3 
Investigational Product and Injection 
The investigational product, C. novyi-NT spores, are packaged in vials and stored in a refrigerator with 
temperature maintained between 2 – 8qC. The concentration of spores is 
 
 
suspended in sterile phosphate buffer saline (PBS). The actual concentration may vary slightly among 
the GMP lots.  
 
The investigational drug preparation will occur on the day of administration to the patient. The dilution 
of concentrated spore suspension will be performed at the time of administration in normal sterile 
saline infusion bags of appropriate size to achieve the required dose based on dose level in each 
respective cohort. The injectable volume will be 3 mL and will be withdrawn from the saline bag with 
an appropriate size of syringe (3cc or 5cc) and needle (22-24 gauge). The injection of 3 mL diluted spore 
suspension may be injected with the needle or alternate injection device and the injection can be 
redirected to multiple distinct sites in the tumor to achieve adequate dispersal of spores throughout 
the tumor. The injection may be carried out under radiographic guidance.  
 
3.2 Concomitant Medications 
Any medicinal product, prescribed or over-the-counter, including herbal and other non-traditional 
remedies, is considered a concomitant medication. Prior and concomitant medication use will be 
recorded for the 4 weeks prior to screening until the final study visit. Antibiotic usage is prohibited 
during the 14 days prior to study agent administration (Day 0). 
 
Concomitant medications will be used for the management of adverse effects related to treatment with 
C. novyi-NT spores and for the treatment of unrelated AEs. 
 
Treatment with antibiotics (parenteral piperacillin/tazobactam and metronidazole; oral or parenteral 
metronidazole; oral doxycycline) may be needed. Please refer to Section 5. Management of Study 
Agent-related Toxicity for full details. 
CCI

 
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3.3 Patient Discontinuation 
A discontinuation occurs when an enrolled patient ceases participation in the study, regardless of the 
circumstances, prior to completion of the protocol. The investigator must determine the primary reason 
for discontinuation. An attempt will be made by site staff to have all subjects who discontinue 
prematurely from the study complete, at a minimum, the procedures done at the final visit (i.e., the 12 
Month visit).  
 
A patient will be discontinued from study if any of the following occur: 
 
•
The investigator withdraws the patient from the study in agreement with the Sponsor and 
Medical Monitor. 
 
•
The patient withdraws consent at any time after agent administration. Every effort will be 
made to determine why any subject withdraws from the study prematurely. 
 
•
The patient is lost to follow-up. A genuine effort must be made to determine the reason(s) 
why a patient fails to return for the necessary visits. If the subject is unreachable by 
telephone, a registered letter, at the minimum, should be sent requesting him/her to contact 
the clinic. 
 
•
Disease progression in the injected tumor site based on RECIST 1.1 criteria, as assessed by the 
investigator and not prior to 8 weeks post-dosing. (Caution should be taken in assessing 
progression in the injected tumor prior to 8 weeks since C. novyi-NT germination may cause 
inflammatory changes resulting in “pseudoprogression”.) 
 
•
The patient starts a new anti-cancer therapy or enrolls in another interventional clinical trial.  
 
After discontinuation, further radiographic assessment will not be required and SAEs will no longer be 
reported, unless they are assessed as related or possibly related to C. novyi-NT treatment by the PI. 
Every effort will be made to collect survival information even after discontinuation, including phone calls 
on a quarterly basis for 12 months to the patient, patient’s relatives or primary oncologist. 
 
All patients who withdraw prematurely prior to 4 weeks after dosing for reasons other than an AE 
will be replaced before dose escalation. At any time during the study, the Sponsor and Investigators 
may request that cohorts should be enlarged. Such requests will be discussed with the Sponsor and 
the Medical Monitor, and should be based on all data existing at that time. 
 
3.4 Early Stopping Rule 
 
Based on the literature, the median survival of patients with treatment-refractory advanced metastatic 
solid tumor malignancies is 6 months. These patients will be treated with an intratumoral injection of 
the study agent, and we do not expect study agent-related mortality. The sponsor may terminate the 
trial if toxicity observed indicates an unfavorable risk-to-benefit ratio. 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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4. Study Procedures 
Potentially eligible patients will be referred to the clinical site staff for study screening by contacting an 
investigator or the research nurse for this study. Consent will be administered by an investigator prior 
to all study specific screening procedures. The inclusion/exclusion criteria will be reviewed to 
determine if the patient qualifies for the study. Once the patient is deemed eligible, a date for study 
agent administration will be determined. Patients must begin treatment within 21 days of screening. 
4.1 Study Calendar  
 
Pre-treatment 
(Screening) 
Informed Consent; Medical and Medication History, Physical Exam; Vital signs (BP, HR, respiratory rate, 
oral body temperature); SpO2; ECOG; Routine lab work * (including serum pregnancy); Research lab 
work**; Blood sampling for phosphorus, PT/PTT, uric acid, magnesium, and CRP; CT/MRI Scans; Brain 
MRI; Echo; ECG; weight collection; begin AE monitoring 
Day of 
admission and 
treatment 
 
(Day 0) 
Pre-dose (day -1 - 0): 
Medical history, Physical exam; SpO2; ECOG; Blood Type (follow unit standards); ECG; Routine lab work* 
(including serum pregnancy); Cultures ***; Research lab work**; Blood sampling for phosphorus, PT/PTT, 
uric acid, magnesium, and CRP; Pre-dose tumor biopsy (injected lesion) for immunological assessment and 
tissue banking, Vital signs; SOFA; weight collection; continue AE and concomitant medication monitoring. 
Study agent will be administered as described in Section 2. Investigational Plan and Appendix 1: Study 
Agent Information. 
Post-dose (relative to IT injection): 
• Continuous SpO2 monitoring; 
• Vital signs every 15 minutes (+/- 5 minutes) for 60 minutes, then every 30 minutes 
(+/- 10 minutes) for 60 minutes, then every 60 minutes (+/- 15 minutes) for 120 minutes; 
Subsequent vital sign checks will be performed every 4 hours (+/- 1 hour); 
• Routine lab work at 60 minutes (+/- 15 minutes) and 12 hours post-dose (+/- 2 hours); 
• Research lab work at 60 minutes (+/- 15 minutes) and 12 hours post-dose (+/- 2 hours); 
• Blood sampling for phosphorus, PT/PTT, uric acid, magnesium, and CRP at 60 minutes (+/- 15 
minutes) and 12 hours post-dose (+/- 2 hours); 
x Anaerobic blood cultures for C. novyi-NT at 60 minutes (+/- 15 minutes) and 12 hours post-dose (+/- 
2 hours);  
x Abscess material post-dose for culture, immunological assessment and banking, when performed;  
• SOFA at 8 and 16 hours post-dose (+/- 1 hour)****; 
• Continue AE and concomitant medication monitoring; 
• IV hydration after dosing (IV fluids and duration are at PI’s discretion). 
Days 1-7 
Vital signs every 4 hours (+/- 1 hour) beginning at 24 hours post-dose; Continuous SpO2 monitoring; SOFA 
every 8 hours (+/- 1 hour) beginning at 24 hours post-dose****; Physical once daily; ECOG once daily; 
Routine lab work* once daily beginning at 24 hours post-dose; Blood sampling to measure phosphorus, 
PT/PTT, uric acid, magnesium, and CRP once daily; Research lab work** once daily; Anaerobic blood cultures
for C. novyi-NT once daily; CT/MRI Scans (Day 7 only); Weight collection (Day 7 only); Continue AE and 
concomitant medication monitoring; Abscess material for culture, immunological assessment and banking 
(when performed). 
 
Patients will be discharged after all procedures/assessments are completed on Day 7. 
Outpatient Visits [Abscess material post-dose for culture, immunological assessment and banking (when performed)] 
Day 11, Day 18, 
Day 25 
Physical; vital signs; ECOG, Continue AE and concomitant medication monitoring 
 Day 14, Day 21 
Physical; Vital signs; ECOG; Routine lab work*; Research lab work**; Blood sampling to measure 
phosphorus, PT/PTT, uric acid, magnesium, and CRP; Weight collection; Anaerobic blood cultures for C. 
novyi-NT. Continue AE and concomitant medication monitoring;  

 
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Day 28, Months 
2, 4, 8, and 12 
Physical; Vital signs; ECOG; Routine lab work*; Research lab work **; Blood sampling to measure 
phosphorus, PT/PTT, uric acid, magnesium, and CRP; Weight collection; Anaerobic cultures for C. novyi-NT; 
CT/MRI Scans; Continue AE and concomitant medication monitoring. 
Tumor biopsy from injected lesion and/or non-injected lesion at month 1 (optional) and month 2 (required) 
post-dose for immunological assessment, and tissue banking. Biopsy collection and time points may vary 
depending on tissue availability, local management of tumor inflammation or abscessation, and whether 
the biopsy can be easily and safely obtained. Biopsy for cultures may be performed at PI’s discretion. 
BP = blood pressure; HR = heart rate; SpO2 = oxygen saturation (by pulse oximetry); ECOG = Eastern Cooperative Oncology 
Group Performance Status Scale; CT = computed tomography; MRI = magnetic resonance imaging; Echo = echocardiogram; 
ECG = electrocardiogram; AE = adverse event; SOFA = Sequential Organ Failure Assessment; PT = prothrombin time; PTT = 
partial thromboplastin time; CRP = C-reactive protein 
*Routine lab work includes: complete blood count (CBC) with differential and serum chemistry panel 
**Research lab work includes whole blood and serum for studies described in Section 8. Correlative Studies. 
***Blood cultures (anaerobic for C. novyi-NT and aerobic). 
****Clinical laboratory values for SOFA assessments will be based on the most recent values obtained for clinical laboratory 
tests. 

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Table 4: 
Schedule of Assessments 
Admit Procedure 
Screen  
(Day -21 
to -1) 
(Day -1 
to 0) 
Dosing  
(Day 0) 
Day 0- Post-dose Time Point (Relative to IT Injection) 
Days 1 to 7*  
(24 h to 192 
h) 
Follow-up 
Day 11, 
18, 25 
(±1 day) 
Follow-up  
Day 14, 21  
(± 1 day) 
Follow-up  
Wk 4 to 12 
Mon**  
(± 2 days) 
15 
min 
30 
min 
45 
min 
60 
min 
90 
min 
2 h 
3 h 
4 h 
8 h 
12 h 
16 h 
20 h 
Eligibility Evaluation 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Brain MRI 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiogram 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECG 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Safety Evaluation 
Physical Exam 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X
Vital Signse 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xa 
X 
X 
X
SpO2 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SOFA Score Asses 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Xb 
 
 
 
ECOG 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X
CBC with differential 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
Xc 
 
X 
X
Serum Chemistry panelf 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
Xd 
 
X 
X
Magnesium 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
Phosphorus 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
Uric Acid 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
PT/PTT 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
CRP 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
Weight collection 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X (D7) 
 
X 
X
AE Monitoring 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concomitant Medications 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aerobic blood cultures1 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anaerobic blood cultures (for 
detection of C. novyi-NT) 
 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
Blood type 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Efficacy Evaluation 
CT or MRI scans2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X (D7) 
 
 
X
Serum Banking 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X
Whole blood Researchg 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X (D1 & D7) 
 
X  
X 
Tumor biopsy h 
 
X i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x i 
Abscess materialj . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment 
C. novyi-NT  
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV hydration 
 
 
Xk 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
Page 27 of 67 
 
 
ECOG = Eastern Cooperative Oncology Group (Performance Status Scale); SpO2 = oxygen saturation (by pulse oximetry); SOFA = Sequential Organ Failure Assessment; CBC 
= complete blood count; PT = prothrombin time; PTT = partial thromboplastin time; CRP = C-reactive protein; ECG = electrocardiogram; AE = adverse event; CT = 
computed tomography; MRI = magnetic resonance image 
* 
Procedure will be performed either once daily or at the specified time points. 
**  Visits will be at 28 days and 2, 4, 8, and 12 months (±2 days) after dosing. 
1. 
Additional aerobic and anaerobic blood cultures may also be performed when clinically indicated. 
2. 
Whichever modality best suited for tumor assessment. Same imaging modality should be used throughout the course of the study. CT/MRI scans for targeted injection 
lesion and any metastatic lesions. 
a. 
Vital signs were obtained every 4 hours beginning 24 hours post-dose (i.e., at 24, 28, 32, 36, 40, 44, 48…192 h). 
b. 
SOFA with SpO2 will be conducted every 8 hours beginning 24 hours post-dose (i.e., at 24, 32, 40, 48…192 h). 
c. 
Blood will be collected for CBC with differential once daily beginning 24 hours post-dose. 
d. 
Blood will be collected for serum chemistry panel once daily beginning 24 hours post-dose.  
e. 
Vital signs will include blood pressure, heart rate, respiratory rate, and oral temperature. 
f. 
In addition to magnesium, phosphorus, uric acid (measured at specified time points), serum chemistry panel will include: glucose, calcium, albumin, total protein, 
sodium, potassium, lactate dehydrogenase, chloride, blood urea nitrogen, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and 
bilirubin. 
g. 
Whole blood for immunological assessment is collected at Day-1 to 0, D7, D14, D21, week 4, and month 2 (there is no D1 collection); whole blood for banking is 
collected at Day -1 to 0, D1, D7, D14, D21, week 4 to 12 month follow-up visits, and will be used for C. novyi-NT detection and immunological assessment. 
h. 
Tumor biopsy collections will be done only to those patients who have given consent for tumor biopsy collections and will be used for immunological assessment and tissue 
banking.  
i. 
Pre-dose tumor biopsy is collected from the injected lesion; Post-dose tumor biopsy (injected and/or non-injected lesions) at month 1 (optional) and month 2 (required) 
may depend on tissue availability, local management of tumor inflammation or abscessation, and whether the biopsy can be easily and safely obtained. Biopsy for 
cultures may also be performed at PI’s discretion. 
j.  
Abscess material samples collected and banked only when performed as part of the management of local tumor inflammation and abscessation.  
k. 
IV hydration after dosing. IV fluids and duration are at PI’s discretion. 
 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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4.2 Safety Evaluation 
 
Monitoring for AEs will occur from the time of informed consent until the patient completes his/her 
participation in the study. The post-dosing observation period will begin with an 8-day inpatient stay 
(Days 0 to 7). This inpatient stay can be extended and requires that at least 2 days elapse from the 
resolution of any signs of infection or serious AEs (SAEs; defined in Section 6. Adverse Event Reporting 
below) before discharge. 
 
During the inpatient observation period, the patient will be assessed for safety per the schedule of 
events. Sequential organ failure assessment scoring will be performed every 8 hours or with any change 
in clinical status. Any clinical signs or symptoms of infection will be reported within 1 hour of onset by 
the inpatient clinical team to the local investigator or delegates. Management of study agent related 
toxicity will be governed by the criteria set-forth in the following Section 5. Management of Study Agent-
related Toxicity. 
 
Following the inpatient observation period and during the first 28 days post-treatment, patients will be 
followed in two ways; all patients will be required to be evaluated during scheduled visits on Days 11, 
14, 18, 21, 25 and 28. Patients will receive daily phone interviews on the days when they are not 
scheduled for a clinic visit to evaluate and catalogue any changes in status. These phone interviews will 
consist of a review of symptoms of infection (see Appendix 4: Symptoms of Infection), temperature 
checks and compliance with antibiotic regimen. At any time, the PI or local investigator will be available 
for immediate consultation by phone (information provided on Patient ID card), and if necessary in 
person at the outpatient clinic or as an inpatient based on the clinical scenario. The patient must have a 
caregiver available through Day 28, and must stay within 45 minutes driving time of an emergency room 
for 28 days after dosing. The PI or local investigator will be available 24/7 throughout the entire study. 
 
After the first Day 28 visit, the patient will continue to be evaluated at scheduled visits, and the PI or 
local investigator will remain available as needed. 
 
During all scheduled visits, a physical examination, vital signs and ECOG status will be assessed. Clinical 
laboratory tests, and blood cultures will be obtained during the visits outlined in the schedule of events. 
Imaging will be performed, as scheduled to investigate the possibility of abscess formation or to explore 
the possibility of unexpected toxicity. Additional consultants from other subspecialties will be called 
upon as the clinical situation dictates. 
 
4.3 Safety Evaluation Summary 
 
Days 0 to 7 
Inpatient observation 
Days 8 to 28 
Twice weekly scheduled visits 
Daily phone interviews 
Months 2 to 12 
Scheduled visits 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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5. Management of Study Agent-related Toxicity 
 
Management decisions regarding all day-to-day or emergent matters will be performed by the inpatient 
clinical team. The PI and Medical Monitor may be consulted regarding management decisions. 
 
After spore injection and during the initial 8 days, supportive care measures, including antipyretics, 
analgesics, fluids, and pain control, may be managed by the primary inpatient team with guidance from 
the PI or treating investigator. 
 
Initiation of antibiotics will be based on assessments by the investigator and the inpatient clinical team. 
The guiding criteria for initiating antibiotics will be as follows: 
 
1. A total SOFA score of 5 or greater; OR 
2.  An individual organ system SOFA score of 2 or greater within the respiratory, cardiac, 
coagulation, or central nervous systems; OR 
3.  An individual organ system SOFA score of 3 or greater within the liver or renal systems; OR 
4.  Antibiotics will be initiated if a patient is found to have 2 temperatures >38.5°C lasting >12 
hours beginning 5 days following administration of the study agent; OR 
5.   Initiation of antibiotics is indicated based on the investigator’s clinical judgment and regardless 
of the SOFA score. 
 
Sequential Organ Failure Assessment score calculation is described in detail in Appendix 3: SOFA Score 
Calculations. 
 
Patients in whom the criteria for starting IV antibiotics are never met during in-hospital phase will still be 
required to start on therapy with oral doxycycline (100 mg orally twice per day) on Day 7, even in the 
absence of symptoms attributable to the study agent. Oral doxycycline will be continued indefinitely. 
Specifically, Day 7 CT/MRI will be reviewed by the PI with his/her study team prior to patient discharge. 
If CT/MRI scan indicates evidence of abscess formation, the patient will remain hospitalized and will be 
started on IV antibiotics (see Sec. 5). If no evidence of abscess is identified, the patient will be 
discharged as planned on PO antibiotics (doxycycline 100 mg orally twice per day indefinitely). 
 
Antibiotics will be administered according to the following schedule: 
 
1.
Parenteral piperacillin/tazobactam and metronidazole until the patient is afebrile and clinically 
stable for 48 hours, switch to 
2.
Six weeks of oral or parenteral metronidazole. If the parenteral route is chosen, then a 
temporary central line will be placed after terms in #1 are met, followed by 
3.
Indefinite oral doxycycline (100 mg twice daily) 
 
Substitution for any antibiotics can be made for patients with allergy or if intolerance or hypersensitivity 
develops. Choice of replacement antibiotic will be based on the sensitivity profile of C. novyi-NT, which 
will be provided by the Sponsor to the clinical site(s), and input from Infectious Diseases as appropriate. 
 
Need for surgical drainage will be assessed on a case-by-case basis, and surgical consultation will be 
requested as the case dictates. When surgical drainage of the tumor is conducted a material sample will 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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be collected for culture and banking. 
6. Adverse Event Reporting 
6.1 Definitions 
 
An Adverse Event (AE) is any new untoward medical occurrence or worsening of a pre-existing medical 
condition in a clinical investigation subject administered an investigational medicinal product, even if it 
does not have a causal relationship with that product. Any unfavorable or unintended sign, symptom, 
or disease temporally associated with the use of the study agent, whether or not it is considered study 
agent-related will be considered an AE. This includes any newly occurring event or previous condition 
that has increased in severity or frequency since the administration of the study agent. An unexpected 
AE is any AE that is not explicitly described in the Investigational New Drug (IND) application, protocol, 
or informed consent document. 
 
All Grade 3 and 4 clinical laboratory results that represent an increase in severity from baseline will be 
reported as AEs. A Grade 1 or 2 clinical laboratory abnormality should be reported as an AE only if it is 
considered clinically significant by the investigator. 
 
A Serious Adverse Event (SAE) is any AE, occurring at any dose and regardless of causality that: 
 
•  Results in death. 
 
•  Is life-threatening. Life-threatening means that the patient is at immediate risk of death from 
the reaction as it occurs; it does not include a reaction which hypothetically might cause death 
had it occurred in a more severe form. 
 
•  Requires inpatient hospitalization or prolongation of pre-existing hospitalization except when 
an extended inpatient hospitalization is required to manage local tumor inflammation or 
abscessation in the injected tumor lesion site. This does not include scheduled admissions for 
study-related issues (e.g., inpatient IT injection of study agent) 
 
•  Results in persistent or significant disability/incapacity. Disability is defined as a substantial 
disruption of a person’s ability to conduct normal life functions. 
 
•  Is a congenital anomaly/birth defect 
 
•  Is an important medical event. An important medical event is an event that may not result in 
death, be life-threatening, or require hospitalization, but may be considered an SAE when, 
based upon appropriate medical judgment, may jeopardize the patient and may require an 
intervention (medical or surgical) to prevent one of the outcomes listed above as a definition 
of SAE (e.g., bronchospasm). 
 
Clarification of the terms ‘severe’ and ‘serious’ should be made. These terms are not synonymous. 
‘Severe’ is a measure of intensity and may describe a non-serious AE. Intensity is graded as mild, 
moderate, or severe. ‘Serious’ is a term that characterizes events that pose a threat to a patient’s life or 
important bodily function. 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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6.2 Reporting 
 
All AEs, including observed or volunteered problems, complaints, or symptoms from the time of 
informed consent until 8 weeks post dose are to be recorded, regardless of causality. After 8 weeks 
post-dose, only AEs with possible, probable, or definite relationship to the study agent will be 
reported with follow up as noted above for AEs within the first 8 weeks post treatment.  
 
Adverse events will be evaluated against the baseline history and physical examination and intensity 
graded using the NCI CTCAE, Version 4.0, which can be accessed at 
http://ctep.cancer.gov/reporting/ctc.html. Clinical syndromes associated with laboratory 
abnormalities are to be recorded as appropriate (e.g., diabetes mellitus). When possible, signs and 
symptoms indicating a common underlying pathology should be noted as one comprehensive event. 
 
When recorded the AE is to be evaluated for: 
 
1.
Duration: Time of onset and length of time of toxicity. 
 
2.
Intensity (NCI CTCAE 4.0): 
 
Grade 1: 
Mild or asymptomatic or mild symptoms or clinical or diagnostic observations only 
or intervention not indicated. 
Grade 2: 
Moderate or minimal, local or noninvasive intervention indicated or limiting age-
appropriate instrumental ADL*. 
Grade 3: 
Severe or medically significant but not immediately life-threatening or 
Grade 4: 
Life-threatening consequences or urgent intervention indicated. 
Grade 5: 
Death related to AE. 
 
ADL = activities of daily living; AE = adverse event 
*Instrumental ADL refer to preparing meals, shopping for groceries or clothes, using 
the telephone, managing money, etc. 
**Self-care ADL refer to bathing, dressing and undressing, feeding self, using the toilet, taking 
medications, 
and not bedridden. 
 
3.
Causal relationship between the study agent and the AE will be based on: 
 
•   temporal relationship of the event to the study agent; 
 
•   whether an alternative etiology has been identified; 
 
•   biological plausibility. 
 
The relationship to treatment will be determined by the investigator and reported on the SAE form, as 
appropriate. The following terms will be used: 
•
Not Related: likely or clearly due to causes other than the study drug 
•
Related: possibly, probably, or definitely related to the study drug 
The action taken (none, study drug withheld permanently, medication given, or other), outcome 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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(resolved, ongoing, death, or unknown), and whether the event was serious will also be recorded. 
 
6.3 Pregnancy 
 
The Sponsor has a responsibility to monitor the outcome of all pregnancies reported during the clinical 
study. 
 
Pregnancy alone is not regarded as an AE unless there is a suspicion that the study agent may have 
interfered with the effectiveness of a contraceptive medication. Elective abortions without 
complications should not be regarded as AEs, unless they were therapeutic abortions (see below). 
Hospitalization for normal delivery of a healthy newborn should not be considered an SAE. 
 
Each pregnancy must be reported by the Investigator to the Sponsor within 30 days after becoming 
aware of the pregnancy. The Investigator must follow-up and document the course and the outcome of 
all pregnancies even if the patient withdraws from the clinical study or if the clinical study is finished. 
All outcomes of pregnancy must be reported by the Investigator to the Sponsor on the pregnancy 
outcome report form within 30 days after he/she has gained knowledge of the normal delivery or 
elective abortion. 
 
Any SAE that occurs during pregnancy must be recorded on the SAE report form (e.g., maternal serious 
complications, therapeutic abortion, spontaneous abortion, ectopic pregnancy, stillbirth, neonatal 
death, congenital anomaly, birth defect) and reported in accordance with the procedure for reporting 
SAEs. 
 
6.4 Follow-up of Adverse Events 
 
All AEs reported for a patient, irrespective of the suspected causality, will be monitored until the event 
has resolved or stabilized, until any abnormal laboratory values have returned to baseline or stabilized at 
a level acceptable to the PI or investigator and Medical Monitor, until there is a satisfactory explanation 
for the changes observed, or until the patient is lost to follow-up. 
 
6.5 Serious Adverse Event Reporting 
 
The local investigator will review each SAE and evaluate the intensity and the causal relationship of the 
event to study agent. All SAEs will be recorded from signing of informed consent until 8 weeks after 
study agent administration. After 8 weeks post-dose, only SAEs with possible, probable, or definite 
relationship to the study agent will be reported. 
 
Serious AEs must be reported as soon as possible after the PI or investigator has become aware of its 
occurrence by submitting a completed SAE form to PAREXEL 
 by fax at 
 
or via email at 
 
 
In the event that the site is unable to complete the SAE form to report the event within 24 hours of their 
becoming aware of the event, the investigators must report the SAE over the telephone via the SAE 
PPD
PPD
PPD

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
Page 33 of 67 
answering service at 
 and then provide the completed SAE form via fax or email.  
 
As a minimum requirement, the initial notification should provide the following information: 
 
• Study number 
 
• Subject number 
 
• Gender 
 
• Date of birth 
 
• Name of investigator and full clinical site address 
• SAE term 
 
• Details of SAE 
 
• Criterion for classification as ‘serious’ 
 
• Study drug name, or code if unblinded, and treatment start date 
 
• Date of SAE onset 
 
• Causality assessment (If insufficient information is available to make this classification, then, 
by default, the SAE will be considered 'related'.) 
 
PAREXEL 
 will notify BioMed Valley Discoveries, Inc. via email of an SAE within 1 
business day of discovery or notification. 
 
Initial reports of SAEs must be followed later with detailed descriptions of the events. All relevant 
information will be recorded and faxed to the PAREXEL 
 within 24 hours of receipt of the 
information. The Sponsor may also request additional information on the SAE, which the investigator or 
an authorized delegate must fax to the Sponsor. 
 
Serious AEs will be reported to the following regulatory bodies as described. In addition, an expedited 
report will be provided that describes any patient who requires tumor drainage or develops sepsis. 
 
6.5.1 Food & Drug Administration (FDA) 
In compliance with 21CFR 312.32 the Sponsor will notify the FDA, Center for Biologics Evaluation and 
Research (CBER) division, of any adverse experience associated with the use of the study agent that is 
both serious and unexpected. Each notification shall be made as soon as possible and no later than 15 
calendar days after the Sponsor’s initial receipt of the information. In addition, the Sponsor shall also 
notify the FDA of any unexpected fatal or life-threatening experience associated with the use of the drug 
as soon as possible but no later than 7 calendar days after the Sponsor’s initial receipt of the 
information. Follow-up information to the initial event report shall be submitted as soon as subsequent 
relevant information is available. 
CCI
PPD
PPD

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
Page 34 of 67 
 
6.5.2 Institutional Review Board (IRB) 
All SAEs will be reported to the IRB per institutional guidelines. If an AE requires modification of the 
study protocol and informed consent, these modifications will be provided to the IRB with the report of 
the AE. Follow-up information to the initial event report shall be submitted as soon as subsequent 
relevant information is available. 
 
7. Efficacy Evaluation 
Response and progression will be evaluated using the international criteria proposed by the Response 
Evaluation Criteria in Solid Tumors (RECIST) Committee (version 1.1: http://www.eortc.be/recist/). 
 
Objective responses will be measured by serial CT or MRI scans of the injected tumor and sites of 
metastatic involvement. Overall response, based on CT/MRI scan results, will be based on observation 
of measurable and non-measurable disease as compared to baseline and nadir in target and non-
target tumors per RECIST 1.1. CT or MRI scans may be submitted to a third party vendor for review.  
 
8. Correlative Studies  
Correlative samples will be collected and stored for up to 5 years. Whole blood samples will be 
collected for immunological assessments and C. novyi-NT detection. When performed, post-injection 
site abscess material samples will be collected and stored (for up to 5 years). Archived tissue may be 
used for correlative studies provided that informed consent from the subject is obtained, or when not 
possible, a waiver of consent is granted by the IRB. Comprehensive information on sample acquisition, 
handling and storage are to be found in the study manual. Sample tube labels should include the 
patient identification number/protocol code, sample number and visit number and will be detailed in 
the study laboratory manual. Refer to study manual for samples storage conditions at the study center 
until shipment under appropriate conditions to the third party laboratory vendor and/or sample 
storage location. Samples will be used to evaluate the following parameters: 
 
8.1 Measurement of the anti-C. novyi-NT immune and inflammatory responses 
 
The immune and systemic inflammatory responses during C. novyi-NT treatment will be evaluated by 
serial measurement of anti-C. novyi-NT antibodies, CRP, selected cytokines, and analysis of selected 
immune cell populations in blood. C-reactive protein and certain cytokines (IL-6, IL-8, TNF-alpha, etc.) 
are markers of systemic inflammation. Patient whole blood and serum samples will be obtained as 
indicated on the study calendar and, when performed, pre-dose and post-dose tumor samples and 
abscess material will be collected.  
 
8.2 C. novyi-NT detection in circulation and/or abscess material/post-dose tumor sample 
 
Scheduled whole blood sampling will take place as indicated in the study calendar (Section 4.1 Study 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
Page 35 of 67 
Calendar) and Table 4. Anaerobic blood cultures and/or abscess material/post-dose tumor sample 
(when performed) will be assessed to determine the presence (from circulation) of C. novyi-NT. 
 
9. Statistical Considerations 
Before database lock, a statistical analysis plan (SAP) will be issued as a separate document, providing 
detailed methods for the analyses outlined below. Any deviations from the planned analyses will be 
described and justified in the final integrated clinical study report. 
 
Markers of systemic inflammation, such as CRP and cytokines, will be graphed as continuous variables 
over time, and descriptive statistics will be provided for these variables. Exploratory graphs will be 
constructed to show the relationship between these responses and their time course. 
 
Individual patient safety data will be listed. Continuous safety data will be summarized by dose level 
using descriptive statistics, and categorical safety data will be summarized by dose level using frequency 
tables. Shift tables and categorical frequency tables will be presented for safety data as appropriate. 
 
10. Ethical, Legal, and Administrative Requirements 
10.1 Data Recording, Management, and Monitoring 
 
The investigator(s) will prepare and maintain adequate and accurate records of all observations and 
other data pertinent to the clinical study for each study participant. Frequent communication between 
the clinical site(s) and the Sponsor and/or their representative is essential to ensure that the safety of 
the study is monitored adequately. The investigator(s) will make all appropriate safety assessments on 
an ongoing basis. The Medical Monitor may review safety information as it becomes available 
throughout the study.  
 
All aspects of the study will be carefully monitored with respect to GCP and standard operating 
procedures (SOPs) for compliance with applicable government regulations by PAREXEL International. The 
study monitor will have access to all records necessary to ensure integrity of the data and will review the 
progress of the study with the PI/local investigator. 
 
10.2 Access to Source Data/Documents 
 
Data collection for this protocol will be accomplished using electronic data capture. 
 
The local investigator will ensure the accuracy, completeness, and timeliness of the data reported to the 
Sponsor. Data collection processes and procedures will be reviewed and validated to ensure 
completeness, accuracy, reliability, and consistency. A complete audit trail will be maintained of all data 
changes. The investigator or designee will cooperate with the Sponsor’s representative(s) for the 
periodic review of study documents to ensure the accuracy and completeness of the data capture 
system at each scheduled monitoring visit. 
 

 
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The investigator or designee will prepare and maintain adequate and accurate study documents 
(medical records, ECGs, AE and concomitant medication reporting, raw data collection forms, etc.) 
designed to record all observations and other pertinent data for each patient receiving study agent. 
 
The investigator will allow contract designees, authorized regulatory authority inspectors, and the IRB to 
have direct access to all documents pertaining to the study. 
 
Electronic consistency checks and manual review will be used to identify any errors or inconsistencies in 
the data. This information will be provided to the respective study sites by means of electronic or 
manual queries. 
 
10.3 Archiving Study Documents 
 
According to International Conference on Harmonization (ICH) guidelines, essential documents should 
be retained for a minimum of 2 years after the last approval of a marketing application in an ICH region 
and until there are no pending or contemplated marketing applications in an ICH region or at least 
2 years have elapsed since the formal discontinuation of clinical development of the study agent. 
However, these documents should be retained for a longer period if required by the applicable legal 
and/or regulatory requirements. The Sponsor should inform the investigator(s)/institution(s) in writing 
of the need for record retention and should notify the investigator(s)/institution(s) in writing when the 
trial-related records are no longer needed. 
 
10.4 Good Clinical Practice 
 
The clinical study also will be carried out in keeping with national and local legal requirements (in 
accordance with United States Code of Federal Regulations [21 CFR 312.50 and 21 CFR 56]) and abiding 
by the guidelines of the ICH guidelines on GCP and the moral, ethical and scientific principles governing 
clinical research as set out in the Declaration of Helsinki (Version 2008). 
 
10.5 Protocol Approval and Amendment(s) 
 
Before the start of the clinical study, the clinical study protocol and other relevant documents will be 
approved by the IRB, in accordance with local legal requirements. All ethical and legal requirements 
must be met before the first patient is enrolled in the clinical study. 
 
This protocol is to be followed exactly. To alter the protocol, amendments must be written, which must 
be released by the responsible staff and receive IRB approval prior to implementation (as appropriate). 
 
Administrative changes may be made without the need for a formal amendment, but will also be 
mentioned in the integrated clinical study report. All amendments will be distributed to all study 
protocol recipients with appropriate instructions. 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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11. Subject Confidentiality and Rights 
11.1 Patient Information and Informed Consent  
 
Before each patient is enrolled in the clinical study, written informed consent will be obtained according 
to the regulatory and legal requirements of the participating country. As part of this procedure, the 
investigator must explain orally and in writing the nature, duration, and purpose of the study, and the 
action of the study agent in such a manner that the patient is aware of the potential risks, 
inconveniences, or AEs that may occur. The patient should be informed that he/she is free to withdraw 
from the study at any time. He/She will receive all information that is required by federal regulations 
and ICH guidelines. 
 
The informed consent document must be signed and dated; one copy will be handed to the patient, and 
the investigator will retain a copy as part of the clinical study records. The investigator will not 
undertake any investigation specifically required for the clinical study until written consent has been 
obtained. The terms of the consent and when it was obtained must also be documented. 
 
If a protocol amendment is required, then the informed consent document may need to be revised to 
reflect the changes to the protocol. If the informed consent document is revised, it must be reviewed 
and approved by the responsible IRB, and signed by all patients subsequently enrolled in the clinical 
study as well as those currently enrolled in the clinical study. 
 
Separate consent will be requested to obtain/retain blood, serum and abscess material/biopsy samples 
(when available). Samples will be stored for 5 years for future analysis, which may include genomic 
evaluation of the tumor tissue, as warranted by our rapidly-advancing understanding in this field. 
Separate consent will also be requested to obtain, when possible, photographs of the tumor pre- and at 
various time points post-dose.  
 
11.2 Patient Confidentiality 
 
In order to maintain patient privacy, all electronic case report forms (eCRFs), source documents, study 
agent accountability records, study reports and communications will identify the patient by initials and 
the assigned patient number. The patient’s confidentiality will be maintained and will not be made 
publicly available to the extent permitted by applicable laws and regulations. 
11.3 Publication Policy 
 
By signing the clinical study protocol, the PI/local investigator agrees with the use of results of the 
clinical study for the purposes of national and international registration, publication, and information for 
medical and pharmaceutical professionals. If necessary, the competent authorities will be notified of the 
PI’s/local investigator's name, address, qualifications, and extent of involvement. 
 
An investigator shall not publish any data (poster, abstract, paper, etc.) without having consulted with 
the Sponsor in advance. 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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References 
1. 
Dang, L.H., Bettegowda, C., Huso, D.L., Kinzler, K.W. & Vogelstein, B. Combination 
bacteriolytic therapy for the treatment of experimental tumors. Proc Natl Acad Sci U S A 27, 
27 (2001). 
2. 
Jain, R.K. & Forbes, N.S. Can engineered bacteria help control cancer? Proc Natl Acad Sci U S A 
98, 14748-50 (2001). 
3. 
Parker, R.C., Plummer, H.C., Siebenmann, C.O. & Chapman, M.G. Effect of histolyticus 
infection and toxin on transplantable mouse tumors. Proc. Soc. Exp. Biol. Med. 66, 461 
(1947). 
4. 
Mose, J.R. Clostridium Strain M55 and its effect on Malignant Tumors. in Bactéries anaérobies 
1st edn (ed. Fredette, V.) 229-247 (Montreal: Institut de Microbiologie et l'Hygiène de 
Université de Montréal, 1967). 
5. 
Mose, J.R. Onkolyse durch Clostridien. in 3rd International Congress of Chemotherapy (ed. 
Thieme, G.) 1972 (Stuttgart, Germany, 1963). 
6. 
Carey, R.W., Holland, J.F., Whang, H.Y., Neter, E. & Bryant, B. clostridial oncolysis in man. Eur. J. 
Cancer 3, 37-46 (1967). 
7. 
Dang, L.H. et al. Targeting Vascular and Avascular Compartments of Tumors with C. novyi-NT 
and Anti-Microtubule Agents. Cancer Biol Ther 3, 326-37 (2004). 
8. 
Agrawal, N. et al. Bacteriolytic therapy can generate a potent immune response 
against experimental tumors. Proc Natl Acad Sci U S A 101, 15172-7 (2004). 
9. 
Diaz, L.A., Jr. et al. Pharmacologic and toxicologic evaluation of C. novyi-NT spores. Toxicol Sci 
88, 562-75 (2005). 
10. 
Ferreira, F.L., Bota, D.P., Bross, A., Melot, C. & Vincent, J.L. Serial evaluation of the SOFA score 
to predict outcome in critically ill patients. JAMA 286, 1754-8 (2001). 
11. 
Vincent, J.L. et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure 
in intensive care units: results of a multicenter, prospective study. Working group on "sepsis- 
related problems" of the European Society of Intensive Care Medicine. Crit Care Med 26, 
1793-800 (1998). 
12. 
Vincent, J.L. et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe 
organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of 
the European Society of Intensive Care Medicine. Intensive Care Med 22, 707-10 (1996). 
13. 
Routsi, C. et al. Application of the sequential organ failure assessment (SOFA) score 
to bacteremic ICU patients. Infection 35, 240-4 (2007). 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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List of Appendices 
Appendix 1: Study Agent Information 
Appendix 2: Study Agent Spill Procedure 
Appendix 3: SOFA Score Calculations 
Appendix 4: Symptoms of Infection 
Appendix 5: ECOG Performance Status Scale* 
Appendix 6: Amendment 2 List of Changes 
 
 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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Appendix 1: Study Agent Information 
Study Agent Development/Purification 
C. novyi-NT is a gram-positive obligate anaerobe rendered nonpathogenic through selection of a clone in 
which the bacteriophage carrying the major systemic toxin (α-toxin) gene is absent. The α-toxin is the 
major toxin responsible for pathogenicity of this organism, and was eliminated by dilution cloning 
coupled with heat treatment to inactivate extracellular phage. A resultant clone, termed C. novyi-NT, 
was shown not to carry the α-toxin and subsequently used for all pre-clinical work and for Good 
Manufacturing Practice (GMP) grade agent development for use in humans. 
 
Packaging/Labeling 
Omnia Biologics, Inc. is responsible for the manufacturing and for the formulation of C. novyi-NT spores. 
The C. novyi-NT spores are packaged in glass vials at a concentration of approximately 
 
 suspended in sterile PBS and will be labeled with the following information: identity of test 
article, number of particles contained and volume, directions for use, storage requirements, caution 
statement, lot number. 
 
Storage and Security Conditions 
Vials of C. novyi-NT spores will be stored at 2-8°C controlled temperature environment under 
constant temperature monitoring with access limited to authorized study personnel. 
 
Study Agent Preparation 
The preparation of the injectable drug suspension will take place on the day of IT administration. The 
vial(s) containing C. novyi-NT spores will be diluted using the appropriate volume of sterile 0.9% 
sodium chloride (NaCl). C. novyi-NT spore preparation and dilution will take place in a designated 
biological safety cabinet (BSC) and may be carried out at room temperature. The vial should be 
vortexed to ensure an even suspension of spores before the appropriate volume of aliquot is drawn 
for dilution. The appropriate volume of spores will be drawn from the vial and added into an 
appropriate size of sterile saline infusion bag for dilution. The resulting saline bag will be inverted 
multiple times to ensure that the spores are mixed completely with the saline and there are no visible 
particulates.  3 mL of the diluted spore suspension will be withdrawn from the saline bag with an 
appropriate size of syringe (3 mL or 5 mL) for injection. The proper volume of the concentrated spores 
and the proper size of the saline bag for dilution will be determined by the dose level for respective 
cohorts, and the exact information will be included in the Investigational Drug Manual. 
 
Study Agent Administration 
The study agent will be administered starting with Cohort 1 at a dose of 1 x 104 spores followed by dose 
escalation as described in Section 3. Study Design. The patient will be given IV hydration after dosing. IV 
fluids and duration are at PI’s discretion. 
 
Study Agent Disposal 
In the event of a spill of the study agent, a clean-up protocol exists (Appendix 2: Study Agent Spill 
Procedure). This protocol and the supplies necessary will be on hand at the time of study agent 
administration. Otherwise, dosing administration supplies will be collected and sealed in a biohazard 
bag and destroyed. The vial(s) and dilution bag will be destroyed per the institution’s standard for 
biohazard waste.  
CCI

 
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Appendix 2: Study Agent Spill Procedure 
 
Procedure is based on the evaluation of the disinfection of C. novyi-NT study. If there is a spill of 
C. novyi-NT spores, perform the following: 
 
1. 
If applicable, promptly remove any contaminated garments 
2. 
If gloves were contaminated, remove gloves and put on new gloves 
3. 
Cover spill with paper towels 
4. 
Flood the spill with 10% bleach 
5. 
After 40 minutes, clean up the spill with paper towels 
6. 
Dispose of the materials in a biohazard bag 
7. 
Wipe the area/equipment with sterile 70% Isopropyl Alcohol (IPA)-saturated towels 
8. 
Dispose of the towels in a biohazard bag 
9. 
Document the spill per clinical site SOPs 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Appendix 3: SOFA Score Calculations 
Sequential Organ Failure Assessment score will be calculated by adding the individual scores from 
each organ system based on the table below. 
 
Modified SOFA Score 
0 
1 
2 
3 
4 
Respiration 
PaO2/FiO2 (torr) 
>400 
≤400 
≤300 
≤200 
With respiratory 
support 
≤100 
With respiratory 
support 
SpO2/FiO2 (torr) 
≥512 
<512 
<357 
<214 
With respiratory 
support 
<89 
With respiratory 
support 
Coagulationa 
Platelets (x103/mm3) 
>150 
≤150 
≤100 
≤50 
≤20 
Liver a
 
Bilirubin (mg/dL) 
(μmol/L) 
<1.2 
<20 
1.2-1.9 
20-32 
2.0-5.9 
33-101 
6.0-11.9 
102-204 
>12.0 
>204 
Cardiovascular 
Hypotension 
No 
hypotension 
MAP 
<70 mmHg 
Dopamine ≤5 
or dobutamine 
(any dose)b 
Dopamine >5 
or epi ≤0.1 
or norepi ≤0.1 or 
phenylephrine 
≤300c or 
vasopressin 
<0.04 units/min 
Dopamine >15 
or epi >0.1 
or norepi >0.1 or 
phenylephrine 
>300
c or 
vasopressin 
≥0.04 units/min 
Central Nervous 
System (Glasgow 
coma score scale) 
 
15 
 
13-14 
10-12 
6-9 
<6 
 
Modified SOFA Score 
0 
1 
2 
3 
4 
Respiration 
PaO2/FiO2 (torr) 
>400 
≤400 
≤300 
≤200 
With respiratory 
support 
≤100 
With respiratory 
support 
Renala
 
Creatinine (mg/dL) 
(μmol/L) 
or urine output 
<1.2 
<110 
1.2-1.9 
110-170 
2.0-3.4 
171-299 
3.5-4.9 
300-440 
or <500 mL/day 
>5.0 
>440 
or <200 mL/day 
Adapted from Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, et al. Use of the SOFA score to 
assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. 
Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 
1998;26(11):1793-800. 
PaO2 = partial pressure of arterial oxygen; FiO2 = fraction of inspired oxygen = SpO2: oxygen saturation by pulse oximetry; 
epi = epinephrine; norepi = norepinephrine; MAP = mean arterial pressure. 
a 
Clinical laboratory values for SOFA assessments will be based on the most recent values obtained for clinical 
laboratory tests 
b 
Data on file. 
c 
Adrenergic agents administered for at least 1 hour (doses given are in μg/kg/min). 
*To convert torr to kPa, multiply the value by 0.1333. 
 
  
+   
+   
+   
+   
_+   
=   
 
Respiratory 
Renal 
Coagulation 
Liver 
Cardiovascular 
CNS (GCS) 
SOFA Score 
 

 
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Coagulation, Liver, Cardiovascular and Renal scores will be determined from the most recent 
laboratory values, vital signs, or clinical measurements. Central nervous system evaluations will be 
assessed using the GCS; the GCS is presented below. The PaO2/FI02 ratio for the Respiratory score 
will be determined using transcutaneous pulse oximetry values to estimate PaO2 – unless actual 
measured PaO2 is available. A conversion chart is shown below. 
 
Some laboratory or clinical parameters may be transient, correctable, spurious, or the result of 
non- study agent effects (e.g. narcotics, sleeping aids, or anti-emetics on cognitive function). If 
platelet counts, bilirubin, or creatinine levels are considered as such, then they must be rechecked 
within 12 hours of the value in question for SOFA scoring purposes. Respiratory, BP, or cognitive 
parameters should be corrected within 2 hours of the measurement in question. If a non-study 
agent is clearly responsible for alteration in a specific laboratory or clinical parameter, then this 
should be documented in the patient's chart and not used for SOFA calculations. 
 
Glasgow Coma Scale (GCS): 
The scale comprises three tests: eye, verbal, and motor responses. The three values separately as 
well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while 
the highest is 15. 
 
Best eye response (E): 
There are 4 grades starting with the most severe: 
 
1.   No eye opening 
2.   Eye opening in response to pain (Patient responds to pressure on the patient’s fingernail bed; 
if this does not elicit a response, supraorbital and sternal pressure or rub may be used) 
3.   Eye opening to speech (Not to be confused with an awaking of a sleeping person; such 
patients receive a score of 4, not 3) 
4.   Eyes opening spontaneously 
 
Best verbal response (V): 
There are 5 grades starting with the most severe: 
 
1.   No verbal response 
2.   Incomprehensible sounds (Moaning but no words) 
3.   Inappropriate words (Random or exclamatory articulated speech, but no conversational 
exchange) 
4.   Confused (The patient responds to questions coherently but there is some disorientation 
and confusion) 
5.   Oriented (Patient responds coherently and appropriately to questions such as the 
patient’s name and age, where they are and why, the year, month, etc.) 
 
Best motor response (M): 
There are 6 grades starting with the most severe: 
 
1.   No motor response 
2.   Extension to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, 
extension of wrist, decerebrate response) 

 
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3.   Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of 
forearm, flexion of wrist, decorticate response) 
4.   Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist 
when supra-orbital pressure applied; pulls part of body away when nailbed pinched) 
5.   Localizes to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-
line and gets above clavicle when supra-orbital pressure applied.) 
6.   Obeys commands (The patient does simple things as asked.) 
 
The SpO2/FIO2 or PaO2/FIO2 ratio: 
The PaO2/FiO2 ratio can be determined from an arterial blood gas (ABG) or estimated from a SpO2 
measurement obtained from a saturation monitor. It is important to note that SpO2/FiO2 ratios have 
not been validated for SpO2 values greater than 97%. Thus, for patients receiving supplemental 
oxygen (more than room air [O2 in room air = 21%]) the site staff will need to either reduce the 
inspired oxygen briefly to allow a reading to be determined below 97% or perform an ABG to obtain a 
PaO2. (For patients who have a SpO2 value of > 97% on room air, the site can use the PaO2 conversion 
value since the inspired oxygen cannot be further manipulated, and any SpO2 value > 98% while 
receiving room air will yield a converted SpO2/FiO2 of > 512). SpO2 measurements below 90% 
warrant a blood gas evaluation. 
 
SpO2 (%) 
PaO2 
(mmHg) 
99.7 
463 
99 
171 
98 
112 
97 
91 
96 
81 
95 
74 
94 
69 
93 
65 
92 
62 
91 
59 
90 
57 
 
The fraction of inspired oxygen FI02 used to calculate the SpO2/FiO2 or PaO2/FI02 ratio will be based on 
the values from the following chart. 
 
O2 (L/Min) 
by nasal cannula 
 
FIO2 
None 
0.21 
1 
0.24 
2 
0.27 
3 
0.30 
4 
0.33 
5 
0.36 
6 
0.39 

 
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Appendix 4: Symptoms of Infection 
 
The following questions will be asked as part of daily phone interviews on Days 8 to 28:  
1.
Do you have any fevers? If so, what is your temperature? 
2.
Do you have any sweats or shaking chills? 
3.
Do you have any changes in the tumor site (visual, palpable, etc.)? 
4.
Do you have a fast heartbeat or any palpitations? 
5.
Do you have any shortness of breath or rapid breathing? 
6.
Do you have a productive cough? 
7.
Do you have any nausea or vomiting?  
8.
Do you have any abdominal pain? 
9.
Do you have any diarrhea? 
10. Do you have any bleeding problems?  
11. Do you have any pain with urination? 
12. Do you have any changes in urine output? 
13. Do you have any lightheadedness or dizziness? 
14. Do you have any problems with confusion (noted by you or others)?  
15. Do you have a new rash around the tumor site or other areas? 
 
 

 
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Appendix 5: ECOG Performance Status Scale* 
 
 
Grade ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or 
sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about 
more than 50% of waking hours 
3 
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair 
5 
Dead 
 
* As published in Am. J. Clin. Oncol.: Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., 
Carbone, P.P.: Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 
1982. 
 
Courtesy of the Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair.  

 
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Appendix 6: Amendment 2 List of Changes 
 
Amendment rationale  
The primary rationale for this amendment is to update eligibility criteria, to include additional sample 
collections for immunological assessment and C. novyi-NT detection, and to tighten up logistics issues 
which had been apparent during the beginning months of the study. Minor grammatical and formatting 
changes were also made to the protocol for clarity (not listed below). 
 Administrative changes  
x
Amendment 2 List of Changes was added as Appendix 6;  
x
Table of Content was updated to reflect the change; and 
x
BioMed Valley Discoveries, Inc. contact information was updated. 
 
Modifications to Protocol: 
All modifications to the protocol are noted below using the following formatting conventions: 
x
Bold and strike through text: Deleted Text 
x
Bold and italicized text: Added Text 
 
“Objectives of the Study” 
The third objective has been modified  
 
Changed text:  
 
To study the disposition presence of circulating C. novyi-NT spores after administration as a single IT 
injection to humans with treatment-refractory solid tumor malignancies (see Section 4.1 Study 
Calendar, Table 4 and Section 8.2 C. novyi-NT detection in circulation and/or abscess material/post-
dose tumor sample). 
 
Rationale:  
‘Presence’ is a better terminology since the assays for detection of C. novyi-NT spores are not likely to be 
adequate to document the route of elimination. 
 
Section “1.1 Clostridium novyi-NT”  
First paragraph has been modified. 
 
Changed text: 
The agent presented for use in humans in this Pphase I study is C. novyi-NT. It was developed after a 
large panel of anaerobic bacteria was screened for the ability to germinate and populate in mouse 
tumor models1. The anaerobe Clostridium novyi (ATCC #19402) had the best anti-tumor efficacy in this 
screen. It was subsequently rendered nonpathogenic by selecting a clone without the major toxin (α-
toxin) responsible for systemic toxicities associated with this organism1,7,8. The resulting clone, named 
Clostridium novyi-NT, where the NT stands for non-toxic, was employed in a series of preclinical 
studies based on a strategy termed Combination Bacteriolytic Therapy (COBALT) that combined C. 
novyi-NT therapy with traditional chemotherapy or radiation1,7. 
 

 
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Rationale: To define NT for clarity.  
 
Section “1.2 Preclinical PK of C. novyi-NT spores9 
 
Changed text: 
 
Pharmacokinetic studies indicate that C. novyi-NT spores, when administered intravenously (IV) to 
mice, are rapidly cleared from the circulation (> 99% spores are cleared within 1 hour) and sequestered 
within the reticuloendothelial system. Long-term distribution studies reveal that these spores are 
eventually eliminated from all tissues by one year. Delivered in spore form (dormant stage), C. novyi-
NT germinates (transitions from the spore to the vegetative state) when exposed to the hypoxic 
regions of tumors. Thus, the systemic toxicities of C. novyi-NT have been shown to be greater in 
tumor-bearing than in non-tumor-bearing animals. 
 
Rationale: To provide clarity on the species in which the information was obtained.  
 
Section “1.5 Exploratory Study of Intratumoral Administration of C. novyi-NT in Companion 
Canines Bearing Spontaneous, Naturally Occurring Solid Tumors” 
 
Changed text: 
 
C. novyi-NT is being has been evaluated in an ongoing exploratory and open-label study at multiple 
veterinary oncology centers in companion canines with spontaneous, naturally occurring solid tumors 
with tumor histology enriched for soft tissue sarcomas (STS). The study was designed to evaluate 
multiple cycles of intratumoral (IT) or intravenous (IV) injections of C. novyi-NT spores in canines. The 
study has been completed. Findings are summarized as follows. 
 
Study Conduct:  
In this study, 16 companion dogs received between one and four treatment cycles of intratumoral (IT) 
administrations of C. novyi-NT spores at 1 x 108 spores diluted in 100 μL of saline. Eleven out of 16 
dogs received all four treatment cycles. Dogs may have received fewer than four treatment cycles due 
to tumor ablation (2), toxicity (2), or progressive disease (1). There were 10 males and 6 females with 
average age of 11 years and average weight of 31 kilograms. The tumor types treated in this study 
were soft tissue sarcoma (13), osteosarcoma (1), melanoma (1), and mast cell tumor (1). The study 
follow-up period was three months.  
 
Safety:  
Most adverse events were mild in severity, with hyperthermia/fever and tumor inflammation being 
the most common AEs expected. All fever events were Grade I or II. Tumor inflammation and abscess 
events, generally considered desired mechanisms of the treatment, were limited to Grades I or II for all 
dogs but one (who experienced Grade III inflammation).  
SAEs were observed in 25% (4/16) of dogs treated; three out of 4 of the events were associated with 
tumor inflammation that required prolonged hospitalization. It is unclear if the remaining event, 
cervical steatitis causing neck pain, was associated with C. novyi-NT or metastasis given the necropsy 

 
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findings of a melanoma lesion in the fat of the cervical spine. 
When comparing C. novyi-NT at 1 x 108 spores/dog IT treatment to 1 x 108 spores/m2 IV treatment in 
the C-100 study, dogs receiving IT treatment experienced far fewer severe AE (Grade III or IV). Twenty-
five percent (4/16 dogs) receiving IT treatment experienced severe AE compared to 57% (8/14 dogs) 
receiving IV administration of C. novyi-NT in the C-100 study.  
 
Efficacy:  
The incidence of objective response was 38% and included dogs with soft tissue sarcoma and mast cell 
tumor. Though debriding was performed in 3/6 dogs with objective response, this procedure was 
undertaken to eliminate necrotic cellular debris and to potentiate the healing of C. novyi-NT induced 
abscesses; complete healing was observed in 2-4 weeks for all dogs whose tumors were debrided. The 
progression-free rate (at Day 90) was 88%. Four of the eight dogs evaluable at Day 90 had no surgical 
debridement during the study, including one high grade STS - a tumor type and grade not expected to 
be progression-free in 90 days without therapy. 
 
The first cohort of canine subjects were treated with IT administration of C. novyi-NT at a dose of 
1x108 spores injected into a single, target tumor per treatment cycle.  The study allows for a maximum 
of 4 cycles of therapy. A cycle of therapy is defined as a single IT injection of C. novyi-NT into one 
target tumor. Treated subjects are followed for 90 days following the first exposure to C. novyi-NT. 
Subjects may be followed long-term for progression and survival. 
 
Sixteen canines received IT therapy (Table 1 and Table 2). The study revealed that objective disease 
response can occur following germination of C. novyi-NT spores in tumors dosed via IT injection into a 
single tumor. Germination is evidenced by erythema, warmth and tenderness in and around the 
injection site. In a subset of cases, these tumor reactions progress and lead to the formation of tissue 
abscesses and concurrent tumor destruction. Furthermore, robust germination appears to occur in the 
absence of severe systemic adverse effects. 
 
1.5.1 Study Objectives and Key Eligibility Criteria in Companion Animals 
  
The objectives of the study include 1) safety evaluation of IT administration of C. novyi-NT spores at 
a dose of 1 x 108 spores per injection per cycle for up to 4 cycles of weekly dosing; and 2) anti-tumor 
efficacy evaluation per RECIST 1.1 guidelines. 
 
Notable inclusion criteria limit eligibility based on tumor size (1 to 7 cm in the longest diameter) and 
tumor location (amenable to intratumoral injection).  Cases are excluded if they have received 
antibiotics within 7 days of enrollment or if they have received systemic or local anti-cancer therapy 
within 21 days of enrollment.   
 
Enrolled cases can be treated with up to 4 cycles of IT administration of C. novyi-NT spores at a 
weekly interval, or at an interval determined jointly by the study Investigators, Medical Monitor and 
Sponsor based on observed adverse reactions and/or efficacy following completion of each cycle.  
 
1.5.2 Preliminary Study Results in Companion Animals 
 
Findings reported here reflect data collected as of Oct 15th 2012. The study is currently open for 

 
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screening additional cases for enrollment.  
 
Study Demographics and Progress 
Of 16 cases screened, 12 were assigned to receive up to 4 cycles of intratumoral C. novyi-NT 
therapy. The demographics are summarized in Table 1. 
 
Table 1:  Demographic Summary of Companion Canines Treated with IT Administration of C. novyi-NT  
 
ID 
Breed 
Age 
Sex 
Tumor Histology 
Grade 
# of cycles of IT 
Doses Received 
04 R01
Golden Retriever 
7
M 
Soft tissue sarcoma 
Low 
4
04 R02
Golden Retriever 
11
M 
Soft tissue sarcoma 
Low 
4
04 R03
Boxer 
9
M 
Soft tissue sarcoma 
Low 
3
04-R04 
Saint Bernard mix 
11 
F 
Chondroblastic 
osteosarcoma 
High 
1 
04 R05
Shetland 
13
M 
Soft tissue sarcoma 
Intermediat
4
10 R01
Golden Retriever 
13
M 
Melanoma 
High 
2
11 R01
Maltese 
10
M 
Soft tissue sarcoma 
Intermediat
1
11 R02
Labrador Retriever 
11
F 
Soft tissue sarcoma 
Intermediat
3
11 R04
Husky mix 
10
M 
Soft tissue sarcoma 
Low 
2
16 R02
Labrador Retriever 
9
M 
Soft tissue sarcoma 
Low 
4
16 R03
Shepherd mix 
10
F 
Soft tissue sarcoma 
Low 
2
26 R01
Labrador mix 
7
M 
Soft tissue sarcoma 
Intermediat
4
 
Preliminary Safety Evaluation in Companion Animals 
An intratumoral dose of 1 x 108 C. novyi-NT spores was well tolerated in cases receiving 1, 2, 3 or 4 
cycles of therapy.  The adverse events (AEs) were almost exclusively limited to Grade 1 and Grade 2, 
and most were consistent with the anticipated tumor inflammatory reactions resulting from the 
mechanism of action of the C. novyi-NT therapeutic. The AEs were managed effectively following 
clinical management with hydration, NSAIDs, and tumor debridement. 
 
Grade 3 AEs were noted in two cases. In one case (#16-R03), Grade 3 diarrhea, tumor swelling and 
lameness occurred within 4 days following the second cycle of therapy. All symptoms were stable and 
resolved over the subsequent 7 days following effective management with hydration, NSAIDs, and 
tumor debridement. The second case (#10-R01) experienced Grade 3 tetraparesis starting 2 days 
following the second cycle of therapy. The symptoms resolved with antibiotics and corticosteroids, 
and the subject regained full strength over the subsequent 10 days.  
 
A Grade 4 AE was noted in one case (#11-R01).  Thrombocytopenia (Grade 4) was identified at the Day 
90 visit. Symptoms resolved 21 days after the Day 90 visit without any medical treatment. Notably, 
this subject also exhibited Grade 1 and Grade 3 symptoms of thrombocytopenia at screening and 
baseline, respectively.    
 
Preliminary Efficacy Evaluation in Companion Animals 
As of October 15th 2012, 4 of 12 subjects have been evaluated with a partial response (PR), 5 of 12 
subjects have been evaluated with stable disease (SD), and 3 of 12 subjects have been evaluated with 

 
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progressive disease.  A preliminary objective response rate of 33% (4 of 12 subjects) to-date has been 
observed; these cases are summarized in Table 2. Complete response is difficult to ascertain in the 
short term given changes to tissue via remodeling that may be occurring at the treatment site post 
abscessation.  CT imaging and other modalities may better distinguish healthy versus tumor tissue at 
the tumor site. 
 
In those cases with partial response, the tumor site exuded necrotic or liquefied tissue fragments after 
limited debridement and drainage. Two of the responders (04-R03 and 11-R01) were assessed to be 
grossly tumor free at their most recent evaluation at day 60 and day 120, respectively. Subject #04-
R03 has no visible remnants of tumor tissue on examination. Subject #11-R01 appears to be tumor 
free with only remnants of scar tissue on evaluation. Their clinical courses are summarized in Table 3.  
 
Table 2: Preliminary Evaluation of Cases Treated with C. novyi-NT IT Therapy with Partial Response 
(PR) and Stable Disease (SD)  
 
 
Case # 
Tumor Measurement (mm, longest diameter) 
Preliminary Evaluation 
Baseline 
Clinical Course 
04-R01 
15 
0 (Day 60) 
PR 
04-R02 
46 
52 (Day 21); 73 (Day 25); 0 (tumor fell 
off) (Day 26) 
PR 
04-R03 
56 
0 (Day 18); 0 (Day 60) 
PR 
11-R01 
29 
9.4 (Day 21); 8.3 (Day 111); suspected 
scar tissue remnants (Day 120) 
PR 
11-R02 
43 
48 (Day 30) 
SD 
11-R04 
29 
26 (Day 14) 
SD 
16-R02 
91 
100 (Day 32) 
SD 
16-R03 
34 
29 (Day 19) 
SD 
26-R01 
24 
25 (Day 25) 
SD 
 

 
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Table 3: Response of Two Cases Treated with C. novyi-NT Intratumoral Therapy 
  
Case Features 
Case 1 (04-R03, 
) 
Case 2 (11-R01, 
) 
Tumor Type 
Peripheral nerve sheath tumor, grade I 
Peripheral nerve sheath tumor, grade II 
Tumor Size 
55.8mm (longest diameter) 
29.0mm (longest diameter) 
Prior Treatment 
None 
Surgical excision 10 months prior to enrollment, local tumor recurrence 
IT Dose & # Cycles 
1x108 spores/injection; 3 cycles 
1x108 spores/injection; 1 cycle 
Clinical Course 
Day 15: Moderate infection signs; Grade 1 AEs: lameness/swelling/   
    bleeding/fever/anorexia; Grade 2 AEs: lethargy and pain. All 
resolved    
    by Day 19 
Day 16: Tumor lanced and debrided 
Days 16-54: Wound managed with bandage changes, prior tumor site 
nearly healed 
Day 2: Mild infection signs (swelling and erythema) 
Day 3: Tumor lanced and drained 
Day 14: Wound healed 
Day 70: Suspected scar tissue remaining at the tumor site 
Biological Activity  
Symptoms of tumor destruction starting on Day 14 after the 3rd cycle 
Symptoms of tumor destruction starting on Day 2 after 1st cycle 
Tumor Gross 
Response  
 
 
 
 
CT Scan (Pre- and 
Post- Treatment)  
 
 
 
 
Preliminary Outcome 
Grossly tumor free at 60 days post 1st cycle  
Grossly tumor free at 120 days post 1st cycle 
Day -3
Day -1
Day 19
Day 54
Day 70
Day 0
Day -4
Day 10
PPD
PPD
PPD
PPD
PPD
PP
PP
PPDPP

 
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Rationale: To provide final findings of the completed canine study. 
 
Section “1.6 Rationale for Intratumoral Treatment of C. novyi-NT in Human Patients”  
First paragraph has been modified. 
 
Changed text: 
 
The favorable risk/benefit profile observed from the preliminary results of the ongoing companion 
canine study with C. novyi-NT IT treatment provides a compelling rationale for translating the 
intratumoral administration of C. novyi-NT to a Phase I investigational study in human patients with solid 
tumors that are either refractory to standard therapy or without an available standard therapy. In 
conjunction with the current ongoing The Phase I study of intravenous administration of C. novyi-NT 
spores in patients with treatment-refractory solid tumors [NCT01118819] has been closed so that all 
efforts could be directed to the intratumoral program. Tthe IT treatment protocol will target patients 
with superficial tumors measureable, palpable or clearly identifiable under ultrasound or radiographic 
guidance and amenable to intratumoral injection of C. novyi-NT spores. 
 
Rationale: To update the study status of the IV C. novyi-NT trial and to reflect the eligibility criteria 
changes.   
 
1.7 “Management of Adverse Effects Related to Treatment with C. novyi-NT “ 
Second paragraph has been modified. 
 
Changed text: 
 
Preliminary experience from the ongoing canine study also demonstrates that tumor inflammation can 
be managed by monitoring and management standard medical support measures. Supportive care 
during the period of time when a localized C. novyi-NT infection is being established can result in 
successful abscess management, resolution as well as subsequent clinical responses. Similarly, 
application of antibiotics can be delayed in favor of other interventions including, hydration, analgesia, 
and abscess lancing and drainage.   
 
Rationale: to provide clarity in the AE management.  
 
2.1 “Patient Population” 
 
Changed text: 
 
The study population is patients with solid tumor malignancies that are refractory to standard therapy or 
without available standard therapy. Men and women and members of all races and ethnic groups are 
eligible for this trial. 
 
Rationale: To simplify the language for patient population.  
 
Section “2.2.1 Inclusion Criteria” 
Inclusion criterion #1 has been modified. 

 
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Changed text: 
Diagnosis of an advanced solid tumor malignancy.  There must be a target tumor which is measureable, 
palpable or clearly identifiable under ultrasound or radiographic guidance and amenable to 
percutaneous injection of C. novyi-NT spores.  The targeted lesion must have a longest diameter ≥ 1 cm 
and < 12 cm and be measurable as defined by RECIST 1.1 criteria. The target lesion must not be located 
in either the thoracic, abdominal or pelvic cavities or in the brain.  There must be no clinical, no 
functional, and no radiographic evidence of bone involvement at the site of the target lesion.    
 
Rationale: To achieve greater consistency in the location of lesions injected. 
 
Section “2.2.2 Exclusion Criteria”  
Exclusion criterion #7 has been modified. 
 
Changed text:  
Treatment with an investigational drug within the past 30 days or 5 half-lives of that drug, whichever is 
shorter. 
 
Rationale: To provide more clarity in Exclusion Criteria 7. 
 
Exclusion criterion #19 has been modified. 
 
Changed text:  
Antibiotic allergies which that would preclude treatment for a C. novyi-NT infection., in the event that 
antibiotics are required. 
 
Rationale: Per the study protocol, all patients will receive antibiotics starting D7.  
 
Section “3. Study Design” 
Second paragraph has been modified. 
 
Changed text:  
A standard “3+3” dose escalation will be used.  The following definitions and rules will be employed: 
 
•
Toxicity Criteria will be those listed in the National Cancer Institute (NCI) Common Terminology 
Criteria for Adverse Events (CTCAE), Version 4.0, which is available at 
http://ctep.cancer.gov/reporting/ctc.html 
•
An adverse event (AE) of Grade 3 toxicity lasting three (3) days or longer or Grade 4 toxicity of any 
duration that is assessed to be at least possibly related to study agent will be considered a DLT. 
Signs and symptoms of C. novyi-NT infection which are associated with a SOFA score > 5 that 
require invasive intervention including percutaneous drainage of an abscess or that result in 
prolonged hospitalization (> 5 days) will also qualify as DLTs.  
•
DLT assessment period is defined as 4 weeks after dosing of the last patient in a cohort. 
•
Toxicity will be assessed from administration of study agent up to 8 weeks. 
•
The following dose escalation rules will apply (See Table 5 2): 
•
Additional patients will be enrolled at the MTD to achieve a total of six patients at that dose level 
if fewer than six patients were treated previously at that dose. 
•
Not more than six patients will be treated at any dose level. 

 
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•
Doses will be increased in successive cohorts until the MTD is reached or until complete 
germination and tumor regression occurs, making higher doses unnecessary. 
•
The MTD (or dose at which complete germination and tumor regression occurs) will be the 
recommended dose for future Phase II C. novyi-NT IT administration studies. 
 
Rationale: To clarify that 4 weeks is the required DLT observation period and to align with the 4-week 
required interval between cohorts (Sec. 3.0). To allow cohort enlargement when indicated by study 
data.  
 
3.1.1 
“Starting Dose Rationale” 
 
Changed text:  
The starting dose (Cohort 1) is 1x104 spores administered as a single IT injection. The starting dose is 
about 700x lower than the Cohort 1 total dose administered in the current Phase 1 safety study for 
intravenous injection of C. novyi-NT spores (NCT01118819) in which a starting dose of 1x105 spores/kg, 
equivalent to a total dose of ~7x106 spores, is was administered for to an average 70 kg patient. The 
starting IT dose of 1x104 spores is 10,000x lower than the current dose being used in the ongoing IT 
study in companion dogs (Section 1.5). 
 
Rationale: To reflect the discontinuation of the IV C. novyi-NT study.  
 
3.1.2 
Dose Escalation Scheme 
Changed text:  
Three to six patients will receive IT treatment with C. novyi-NT at a dose corresponding to assigned 
cohort (Table 3), starting with Cohort 1.  C. novyi-NT spores will be administered as an IT injection into 
the target lesion. Radiographic guidance may be used at the investigator's discretion to aid in targeting 
an area of necrosis in the target lesion. Patients will be given IV hydration for 2 hours after dosing.  
 
Rationale:  
To update IV hydration after dosing to be consistent with “Table 4: Schedule of Assessments” for clarity.   
 
3.1.3 
Investigational Product and Injection 
First and second paragraphs have been modified. 
 
Changed text: 
The investigational product, C. novyi-NT spores, are packaged in vials and stored in a refrigerator with 
temperature maintained between 2 – 8 qC. The concentration of spores is 
 
spores/mL suspended in sterile phosphate buffer saline (PBS). The actual concentration may vary 
slightly among the GMP lots.  
 
The investigational drug preparation will occur on the day of administration to the patient. The dilution 
of concentrated spore suspension will be performed at the time of administration in normal sterile 
saline infusion bags of appropriate size to achieve the required dose based on dose level in each 
respective cohort. The injectable volume will be 3 mL and will be withdrawn from the saline bag with 
an appropriate size of syringe (3cc or 5cc) and needle (22-24 gauge). The injection of 3 mL diluted spore 
suspension may be injected with the needle or alternate injection device and the injection can be 
CCI

 
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redirected to multiple distinct sites in the tumor to achieve adequate dispersal of spores throughout 
the tumor. The injection may be carried out under radiographic guidance.  
 
Rationale:  
To update packaging information.  To broaden the language to allow the use of alternate injection 
device for C. novyi-NT injection. 
 
Section “3.3 Patient Discontinuation” 
First and second paragraphs have been modified. 
 
Changed text: 
A discontinuation occurs when an enrolled patient ceases participation in the study, regardless of the 
circumstances, prior to completion of the protocol. The investigator must determine the primary reason 
for discontinuation.  An attempt will be made by site staff to have all subjects who discontinue 
earlyprematurely from the study complete, at a minimum, the procedures done at the final visit (i.e., 
the 12 Month visit).   
A patient will be discontinued from study if any of the following occur: 
 
•
The investigator withdraws the patient from the study in agreement with the Sponsor and 
Medical Monitor. 
 
•
The patient withdraws consent at any time after agent administration. Every effort will be 
made to determine why any subject withdraws from the study prematurely. 
 
•
The patient is lost to follow-up.  A genuine effort must be made to determine the reason(s) 
why a patient fails to return for the necessary visits.  If the subject is unreachable by 
telephone, a registered letter, at the minimum, should be sent requesting him/her to contact 
the clinic. 
 
•
Disease progression in the injected tumor site based on RECIST 1.1 criteria, as assessed by the 
investigator and not prior to 8 weeks post-dosing. (Caution should be taken in assessing 
progression in the injected tumor prior to 8 weeks since C. novyi-NT germination may cause 
inflammatory changes resulting in “pseudoprogression”.) 
 
•
The patient starts a new anti-cancer therapy or enrolls in another interventional clinical trial.  
 
Rationale: To provide more clarity. 
 
Last 2 paragraphs have been modified. 
 
Changed text: 
After discontinuation, further radiographic assessment will not be required and SAEs will no longer be 
reported, unless they are assessed as related or possibly related to C. novyi-NT treatment by the PI. 
Every effort will be made to collect survival information even after discontinuation, including phone calls 
on a bimonthly quarterly basis for 12 months to the patient, patient’s relatives or primary oncologist. 
 

 
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All patients who withdraw prematurely prior to 84 weeks after dosing for reasons other than an AE 
will be replaced before dose escalation.  At any time during the study, the Sponsor and 
Investigators may request that cohorts should be enlarged.  Such requests will be discussed with 
the Sponsor and the Medical Monitor, and should be based on all data existing at that time. 
 
Rationale: To align with the 4-week DLT observation period and the 4-week required interval between 
patients (Sec. 3.0). To allow for flexibility in enlarging a cohort based on emerging safety and/or efficacy 
data.  
 
Section “4.1 Study Calendar” 
Pre-treatment (Screening) section has been modified. 
Changed text: 
Pre-treatment 
(Screening) 
Informed Consent; Medical and Medication History, Physical Exam; Vital signs (BP, HR, respiratory rate, 
oral body temperature); SpO2; ECOG; Routine lab work * (including serum pregnancy); Research lab 
work**; Blood sampling for phosphorus, PT/PTT, uric acid, magnesium, and CRP; CT/MRI Scans; Brain 
MRI; Echo; ECG; weight collection; begin AE monitoring 
 
Rationale: To add weight collection to the Screening visit. 
 
Day of admission and treatment (Day 0) section has been modified. 
Changed text: 
Day of 
admission and 
treatment 
 
(Day 0) 
Pre-dose (day -1 - 0): 
Medical history, Pphysical exam; SpO2; ECOG; Blood Type (follow unit standards); ECG; Routine lab work* 
(including serum pregnancy); Cultures ***; Research lab work**; Blood sampling for phosphorus, PT/PTT, 
uric acid, magnesium, and CRP; Pre-dose tumor biopsy (injected lesion) for immunological assessment and 
tissue banking, Vital signs; SOFA; weight collection; continue AE and concomitant medication monitoring 
Study agent will be administered as described in the Investigational Plan section and Appendix 1: Study 
Agent Information. 
 
Post-dose (relative to IT injection): 
• Continuous SpO2 monitoring; 
• Vital signs every 15 minutes (+/- 5 minutes) for 60 minutes, then every 30 minutes 
(+/- 10 minutes) for 60 minutes, then every 60 minutes (+/- 15 minutes) for 120 minutes. 
Subsequent vital sign checks will be performed every 4 hours (+/- 1 hour); 
• Routine lab work at 60 minutes (+/- 15 minutes) and 12 hours post-dose (+/- 2 hours); 
• Research lab work at 60 minutes (+/- 15 minutes) and 12 hours post-dose (+/- 2 hours); 
• Blood sampling for phosphorus, PT/PTT, uric acid, magnesium, and CRP at 60 minutes (+/- 15 
minutes) and 12 hours post-dose (+/- 2 hours); 
• Anaerobic blood cultures for C. novyi-NT at 60 minutes (+/- 15 minutes) and 12 hours post-dose (+/- 
2 hours); 
x Abscess material post-dose for culture, immunological assessment and banking, when performed. 
• SOFA at 8 and 16 hours post-dose (+/- 1 hour)****; 
• Continue AE and concomitant medication monitoring. 
• IV hydration after dosing (IV fluids and duration are at PI’s discretion). 
 
 
Rationale:  
Pre-dose (day -1 – 0) Section: Blood was added before Type for clarity.  To add collection of tumor 
biopsy on injected lesion for immunological assessment and banking. To add weight collection to the 
Pre-dose (day -1 - 0).   

 
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Post-dose (relative to IT injection) Section: To add the 60 minutes (+/- 15 minutes) collections for 
routine lab; research lab; blood sampling for phosphorus, PT/PTT, uric acid, magnesium, and CRP; to add 
IV hydration after dosing and anaerobic blood cultures to the list to be consistent with “Table 4: 
Schedule of Assessments” for clarity.   
To add the collection of abscess material post-dose for culture and banking (when performed) to 
evaluate immune and inflammatory responses as well as detection of C. novyi-NT for correlative studies. 
 

 
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Days 1-7 section has been modified. 
 
Changed text: 
Days 1-7 
Vital signs every 4 hours (+/- 1 hour) beginning at 24 hours post-dose; Continuous SpO2 monitoring; SOFA 
every 8 hours (+/- 1 hour) beginning at 24 hours post-dose****; Physical once daily; ECOG once daily; 
Routine lab work* once daily beginning at 24 hours post-dose; Blood sampling to measure phosphorus, 
PT/PTT, uric acid, magnesium, and CRP once daily; Research lab work** once daily; Anaerobic blood 
cultures for C. novyi-NT once daily, urine cultures (when available) once daily; CT/MRI Scans (Day 7 
only); Weight collection (Day 7 only); Continue AE and concomitant medication monitoring; Abscess 
material for culture, immunological assessment and banking (when performed). 
Patients will be discharged after all procedures/assessments are completed on Day 7. 
 
Rationale: To remove the collection of urine cultures since C. novyi-NT is not expected to culture from 
urine.  To add collection of patient weight at Day 7 and collection of abscess material post-dose for 
culture, immunological assessment and banking (when performed) to evaluate immune and 
inflammatory responses as well as detection of C. novyi-NT for correlative studies. 
 
Outpatient Visits section has been modified. 
 
Changed text: 
Outpatient Visits (Abscess material post-dose for culture, immunological assessment and banking when performed) 
 
Rationale: To add the collection of abscess material post-dose for culture, immunological assessment 
and banking (when performed) to evaluate immune and inflammatory responses as well as detection of 
C. novyi-NT for correlative studies. 
 
Day 14, Day 21 section has been modified. 
Changed text: 
Day 14, Day 21 
Physical; Vital signs; ECOG; Routine lab work*; Research lab work**; Blood sampling to measure 
phosphorus, PT/PTT, uric acid, magnesium, and CRP; Weight collection; Anaerobic blood cultures for C. 
novyi-NT -NT. Urine cultures when available; Continue AE and concomitant medication monitoring 
 
Rationale: To remove the collection of urine cultures since C. novyi-NT is not expected to culture from 
urine.  To add collection of patient weight at Day 14 and Day 21 outpatient visits.  To correct C. novyi-NT 
naming error for clarity. 
 
Day 28, Months 2, 4, 8, and 12 section has been modified. 
Changed text: 

 
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Day 28, Months 
2, 4, 8, and 12 
Physical; Vital signs; ECOG; Routine lab work*; Research lab work **; Blood sampling to measure 
phosphorus, PT/PTT, uric acid, magnesium, and CRP; Weight collection; Anaerobic cultures for C. novyi-NT -
NT; CT/MRI Scans; Continue AE and concomitant medication monitoring. Tumor biopsy from injected 
lesion and/or non-injected lesion at month 1 (optional) and month 2 (required) post-dose for 
immunological assessment, and tissue banking. Biopsy collection and time points may vary depending 
on tissue availability, local management of tumor inflammation or abscessation, and whether the biopsy 
can be easily and safely obtained. Biopsy for cultures may also be performed at PI’s discretion. 
 
Rationale: To add collection of patient weight (Day 28 and Months 2, 4, 8, and 12 visits) and collection of 
tumor biopsies (month 1 and month 2).  To correct C. novyi-NT naming error for clarity. 
 
 
Section “4.1 Study Calendar” footnotes 
Footnote ** has been modified. 
Changed text: **Research lab work includes whole blood and serum for studies described in the section, 
Correlative Studies. 
 
Rationale: To expand sample collection types for correlative studies to include whole blood in addition 
to serum.   
Footnote *** has been modified. 
Changed text: *** Blood cultures (anaerobic for C. novyi-NT and aerobic); urine when available. 
 
Rationale: To reflect changes in “4.1 Study Calendar” section. 
Section “Table 4: Schedule of Assessments” 
 
 
 

 
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Table 74: Schedule of 
Assessments 
Admit Procedure 
Screen  
(Day -21 
to -1) 
(Day -1 
to 0) 
Dosing  
(Day 0) 
Day 0- Post-dose Time Point (Relative to IT Injection) 
Days 1 to 7*  
(24 h to 192 
h) 
Follow-up 
Day 11, 
18, 25 
(±1 day) 
Follow-up  
Day 14, 21  
(± 1 day) 
Follow-up  
Wk 4 to 12 
Mon**  
(± 2 days) 
15 
min 
30 
min 
45 
min 
60 
min 
90 
min 
2 h 
3 h 
4 h 
8 h 
12 h 
16 h 
20 h 
Eligibility Evaluation 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Brain MRI 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiogram 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECG 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Safety Evaluation 
Physical Exam 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
Vital Signse 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Xa 
X 
X 
X 
SpO2 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SOFA Score Asses 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
X 
 
Xb 
 
 
 
ECOG 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
CBC with differential 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
Xc 
 
X 
X 
Serum Chemistry panelf 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
Xd 
 
X 
X 
Magnesium 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
Phosphorus 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
Uric Acid 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
PT/PTT 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
CRP 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
Weight collection 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X (D7) 
 
X 
X 
AE Monitoring 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Concomitant Medications 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Aerobic blood cultures1 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anaerobic blood cultures (for 
detection of C. novyi-NT) 
 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
Urine cultures (if available) 
 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
Blood type 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Efficacy Evaluation 
CT or MRI scans2 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X (D47) 
 
 
X 
Serum Banking 
X 
X 
 
 
 
 
X 
 
 
 
 
 
X 
 
 
X 
 
X 
X 
Whole blood Researchg 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
X (D1 & D7) 
 
X  
X  
Tumor biopsy h 
 
X i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
x i 
Abscess material j  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment 
C. novyi-NT  
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV hydration 
 
 
Xk 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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ECOG = Eastern Cooperative Oncology Group (Performance Status Scale); SpO2 = oxygen saturation (by pulse oximetry); SOFA = Sequential Organ Failure Assessment; CBC = 
complete blood count; PT = prothrombin time; PTT = partial thromboplastin time; CRP = C-reactive protein; ECG = electrocardiogram; AE = adverse event; CT = computed 
tomography; MRI = magnetic resonance image 
* 
Procedure will be performed either once daily or at the specified time points. 
**    Visits will be at 28 days and 2, 4, 8, and 12 months (±2 days) after dosing. 
a. 
Vital signs were obtained every 4 hours beginning 24 hours post-dose (i.e., at 24, 28, 32, 36, 40, 44, 48…192 h). 
b. 
SOFA with SpO2 will be conducted every 8 hours beginning 24 hours post-dose (i.e., at 24, 32, 40, 48…192 h). 
c. 
Blood will be collected for CBC with differential once daily beginning 24 hours post-dose. 
d. 
Blood will be collected for serum chemistry panel once daily beginning 24 hours post-dose.  
e. 
Vital signs will include blood pressure, heart rate, respiratory rate, and oral temperature. 
f. 
In addition to magnesium, phosphorus, uric acid (measured at specified time points), serum chemistry panel will include: glucose, calcium, albumin, total protein, sodium, 
potassium, lactate dehydrogenase, chloride, blood urea nitrogen, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and bilirubin. 
g. 
Whole blood for immunological assessment is collected at Day-1 to 0, D7, D14, D21, week 4, and month 2 (there is no D1 collection); whole blood for banking is collected at 
Day -1 to 0, D1, D7, D14, D21, week 4 to 12 month follow-up visits, and will be used for C. novyi-NT detection and immunological assessment. 
h.     Tumor biopsy collections will be done only to those patients who have given consent for tumor biopsy collections and will be used for immunological assessment and tissue 
banking.  
i.      Pre-dose tumor biopsy is collected from the injected lesion; Post-dose tumor biopsy (injected and/or non-injected lesions) at month 1 (optional) and month 2 (required)    
may depend on tissue availability, local management of tumor inflammation or abscessation, and whether the biopsy can be easily and safely obtained. Biopsy for    
cultures may also be performed at PI’s discretion. 
j      Abscess material samples collected and banked only when performed as part of the management of local tumor inflammation and abscessation.  
k.   IV hydration after dosing. IV fluids and duration are at PI’s discretion.  
  
 
Rationale: To clarify changes in “4.1 Study Calendar” section and to add whole blood collection for immunological assessment and C. novyi-NT detection. 

 
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Section “4.2 Safety Evaluation” 
First paragraph has been modified. 
 
Changed text:  
Monitoring for AEs will occur from the time of informed consent until the patient completes his/her 
participation in the study. The post-dosing observation period will begin with an 85-day inpatient stay 
(Days 0 to 74).  This inpatient stay can be extended and requires that at least 2 days elapse from the 
resolution of any signs of infection or serious AEs (SAEs; defined in Adverse Event Reporting below) 
before discharge. 
 
Rationale: To correct inpatient stay days to be consistent with ”4.1 Study Calendar” section for clarity. 
Section “4.3 Safety Evaluation Summary” 
Summary has been modified. 
 
Changed text:  
Days 0 to 47 
Inpatient observation 
Days 58 to 28 
Twice weekly scheduled visits 
Daily phone interviews 
Months 2 to 12 
Scheduled visits 
 
Rationale: To correct inpatient stay days and weekly scheduled visits to be consistent with ”4.1 Study 
Calendar” section for clarity. 
Section “5. Management of Study Agent-related Toxicity” 
Last paragraph has been modified. 
 
Changed text: 
Need for surgical drainage will be assessed on a case-by-case basis, and surgical consultation will be 
requested as the case dictates.  When surgical drainage of the tumor is conducted a material sample 
will be collected for culture and banking. 
 
Rationale: To reflect changes in “4.1 Study Calendar” section for clarity. 
Section 6.5 Serious Adverse Event Reporting 
Second paragraph has been modified. 
 
Changed text:  
Serious AEs must be reported as soon as possible after the PI or investigator has become aware of its 
occurrence by submitting a completed SAE form to the Medical Monitor PAREXEL 
 by 
fax at 
 or via email at 
.by telephone as soon as 
possible after the PI or investigator has become aware of its occurrence. 
 
Medical Monitor  
 
 
PAREXEL International 
CCI
CCI
CCI
PPD
PPD

 
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Fax: 
 
Email: 
 
 
In the event that the site is unable to complete the SAE form to report the event within 24 hours of 
their becoming aware of the event, the investigators must report the SAE over the telephone via the 
SAE answering service at 
, and then provide the completed SAE form via fax or email.  
The PI/investigator must complete an SAE form and submit it to PAREXEL – North American Medical 
Services within 24 hours of becoming aware of the event. 
 
Completed SAE forms should be faxed to 
.  Alternatively, investigators may report SAEs 
over the telephone via the SAE hotline 
; they will be required to provide the completed 
SAE forms within the next 24 hours. 
 
Rationale: To reflect update contact and procedure changes in SAE reporting. 
Section 7. “Efficacy Evaluation” 
 
Changed text: 
Response and progression will be evaluated using the international criteria proposed by the Response 
Evaluation Criteria in Solid Tumors (RECIST) Committee (version 1.1:  http://www.eortc.be/recist/). 
 
Objective responses will be measured by serial CT or MRI scans of the injected tumor and sites of 
metastatic involvement.  Overall tumor response, based on CT/MRI scan results, will be based on 
observation of measurable and non-measurable disease as compared to baseline and nadir in target 
and non-target tumors per RECIST 1.1. CT or MRI scans may be submitted to a third party vendor for 
review.  
 
Rationale: To provide consistency with the study objective 2.   
 
Section “8. Correlative Studies” 
First paragraph has been modified. 
 
Changed text:  
From the collection of serial blood Correlative samples, serum will be isolated collected and stored 
(for up to 5 years).  Whole blood samples will be collected for immunological assessments and C. 
novyi-NT detection.  When performed, post-injection site abscess material samples will be 
collected and stored (for up to 5 years).   Archived tissue may be used for correlative studies 
provided that informed consent from the subject is obtained, or when not possible, a waiver of 
consent is granted by the IRB. Comprehensive information on sample acquisition, handling and 
storage are to be found in the study manual.  Sample tube labels should include the patient 
identification number/protocol code, sample number and visit number and will be detailed in the 
study laboratory manual.  Refer to study manual for samples storage conditions at the study 
center until shipment under appropriate conditions to the third party laboratory vendor and/or 
sample storage location. Samples will be used to evaluate the following parameters: 
 
PPD
PPD
PPD
PPD
PPD
CCI
CCI
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Rationale: To reflect changes in “4.1 Study Calendar” section and provide general sample collection 
information for clarity. 
Section “8.1 Measurement of the anti-C. novyi-NT immune and inflammatory responses” 
First paragraph has been modified. 
Changed text:  
The immune and systemic inflammatory responses during C. novyi-NT treatment will be evaluated by 
serial measurement of anti-C. novyi-NT antibodies, CRP, and selected cytokines, and analysis of 
selected immune cell populations in blood. C-reactive protein and certain cytokines (IL-6, IL-8, TNF-
alpha, etc.) are markers of systemic inflammation.  These will be measured using commercially 
available kits. Patient whole blood and serum samples will be obtained as indicated on the study 
calendar and, when performed, pre-dose and post-dose tumor samples and abscess material will be 
collected.   , and will be screened at the end of the study in batch.  Whole blood (6 mL) will be 
collected in a serum separator tube (SST) at the designated time points and processed using standard 
procedures for serum separation.  Serum will be divided into 1 mL aliquots and stored at -80oC. 
  
Rationale: To reflect changes in “4.1 Study Calendar” section and to remove detailed sample collection 
information.  The general sample collection information was moved to the beginning of section 8. 
Section “8.2 C. novyi-NT detection in circulation” 
Section title and first paragraph has been modified. 
Changed text:  
8.2 C. novyi-NT detection in circulation and/or abscess material/post-dose tumor sample 
 
Scheduled patient whole blood sampling will take place as indicated in the study calendar (section 
4.1) and Table 4.  Anaerobic blood cultures and/or abscess material/post-dose tumor sample (when 
performed) will be assessed to determine the presence or absence (clearancefrom circulation) of 
C. novyi-NT. 
 
Rationale: To reflect changes in “4.1 Study Calendar” and study objectives sections. 
 
Section 10.4 Good Clinical Practice 
Changed text:  
 
The clinical study also will be carried out in keeping with national and local legal requirements (in 
accordance with United States Code of Federal Regulations [21 CFR 312.50 and 21 CFR 56]) and abiding 
by the principles guidelines of the ICH guidelines on GCP and the moral, ethical and scientific 
principles governing clinical research as set out in the Declaration of Helsinki (Version 2008). 
 
Rationale: To provide more clarity in GCP.  
 
Section “11.1 Patient Information and Informed Consent” 
New paragraph at the end of the section was added. 
 
Added text:  
Separate consent will be requested to obtain/retain blood, serum and abscess material/biopsy 

 
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samples (when available). Samples will be stored for 5 years for future analysis, which may include 
genomic evaluation of the tumor tissue, as warranted by our rapidly-advancing understanding in this 
field. Separate consent will also be requested to obtain, when possible, photographs of the tumor pre- 
and at various time points post-dose.   
 
Rationale: To update patient consent to reflect the expanded sample collection for future analysis. 
 

 
PHASE I C. NOVYI-NT IT ADMINISTRATION, BVD-CNV2 PROTOCOL AMENDMENT 2, 02SEP2014 
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Appendix 1: Study Agent Information 
Changed text: 
Packaging/Labeling 
The Johns Hopkins Cell Processing and Gene Therapy Facility (CPGT) Omnia Biologics, Inc. is 
responsible for the manufacturing and for the formulation of C. novyi-NT spores.  The C. novyi-NT spores 
are packaged in threaded cryovials glass vials at a concentration of approximately 
 
 
spores/mL suspended in sterile PBS and will be labeled with the following information: identity of test 
article, number of particles contained and volume, directions for use, storage requirements, caution 
statement, lot number. 
 
Storage and Security Conditions 
CryovialsVials of C. novyi-NT spores will be stored at 2-8oC controlled temperature environment 
under constant temperature monitoring with access limited to authorized study personnel. 
 
Study Agent Preparation 
The preparation of the injectable drug suspension will take place on the day of IT administration. The 
vialcryovial(s) containing C. novyi-NT spores will be unsealed and diluted using the appropriate 
volume of sterile 0.9% sodium chloride (NaCl). C. novyi-NT spore preparation and dilution will take 
place in a designated biological safety cabinet (BSC) and may be carried out at room temperature. The 
vial should be vortexed to ensure an even suspension of spores before the appropriate volume of 
aliquot is drawn for dilution. The appropriate volume of spores will be drawn from the vial and added 
into an appropriate size of sterile saline infusion bag for dilution.  The resulting saline bag will be 
inverted multiple times to ensure that the spores are mixed completely with the saline and there are 
no visible particulates.   3 mL of the diluted spore suspension will be withdrawn from the saline bag 
with an appropriate size of syringe (3 mL or 5 mL) for injection. The proper volume of the 
concentrated spores and the proper size of the saline bag for dilution will be determined by the dose 
level for respective cohorts, and the exact information will be included in the Investigational Drug 
Manual. 
 
Study Agent Administration 
The study agent will be administered starting with Cohort 1 at a dose of 1 x 104 spores followed by dose 
escalation as described in the Study Design (Section 3).  The patient will be given IV hydration for 2 
hours after dosing.  IV fluids and duration are at PI’s discretion. 
 
Study Agent Disposal 
In the event of a spill of the study agent, a clean-up protocol exists (Appendix 2: Study Agent Spill 
Procedure).  This protocol and the supplies necessary will be on hand at the time of study agent 
administration.  Otherwise, dosing administration supplies will be collected and sealed in a 
biohazard bag and destroyed. 
The vialcryovial(s) and dilution bag will be destroyed per the institution’s standard for biohazard 
waste.  
 
Rationale: To update manufacturing location and packaging information.  To update IV hydration after 
dosing to be consistent with “Table 4: Schedule of Assessments” for clarity.   
CCI