Phase 1 Study of Intraperitoneal Infusion of Autologous Monocytes With Sylatron (Peginterferon Alfa-2b) and Actimmune (Interferon Gamma-1b) in Women With Recurrent or Refractory Ovarian Cancer, Fallopian Tube Cancer or Primary Peritoneal Cancer
Phase: PHASE1
Conditions: Fallopian Tube Cancer, Ovarian Cancer, Primary Peritoneal Cancer
Sponsor: National Cancer Institute (NCI)

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
1
Abbreviated Title: Phase 1 IFN + monocytes
NIH Protocol #: 17-C-0011 
Version Date:  12/04/2025
NCT Number: NCT02948426
Title: Phase 1 Study of Intraperitoneal Infusion of Autologous Monocytes with SYLATRON®  
(Peginterferon alfa-2b) and ACTIMMUNE® (Interferon gamma-1b) in Women with 
Recurrent or Refractory Ovarian Cancer, Fallopian Tube Cancer or Primary Peritoneal 
Cancer
NCI Principal Investigator:   
Stanley Lipkowitz, M.D., Ph.D.
Women’s Malignancies Branch (WMB)
Center for Cancer Research (CCR)
National Cancer Institute (NCI)
National Institutes of Health (NIH)
Building 10, Room 4B54
10 Center Drive
Bethesda, MD 20892
Telephone: 240-760-6129
E-mail: lipkowis@navmed.nci.nih.gov
Drug Name:
Sylatron® 
(Peginterferon alfa-2b)
Actimmune® 
(Interferon gamma-
1b)
Autologous monocytes
BB-IND 
Number:
17040
17040
17040
Sponsor:
Center for Cancer 
Research, NCI
Center for Cancer 
Research, NCI
Center for Cancer 
Research, NCI
Manufacturer:
Merck
Horizon Pharma, Inc.
Department of Transfusion 
Medicine (DTM) 
Commercial Agents: None

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
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PRÉCIS 
Background:
•
Monocytes can differentiate into classic M1 macrophages inhibiting tumor 
proliferation and promoting natural killer (NK) cell differentiation.
•
Human alpha interferons (interferon alfa, IFNα), interferon gamma (IFNγ) and 
monocytes have strong anti-neoplastic response in vitro and in vivo
•
IFNα and IFNγ have been shown in early phase clinical trials to be safely 
administered intraperitoneally.
•
Intraperitoneal monocytes alone or activated with IFNγ are safe and feasible as 
demonstrated in phase I clinical studies. 
•
We have shown that the combination of human monocytes, IFN-α2a and IFN-γ1b, or 
pegylated IFN-α, act synergistically against tumor cells in vitro and in mouse models.
Objectives:
•
To identify a maximum tolerated dose of intraperitoneal autologous monocytes and 
Sylatron® (Peginterferon alfa-2b) and Actimmune® (Interferon gamma-1b).
Eligibility:
•
Advanced metastatic or unresectable epithelial ovarian cancer, primary peritoneal 
cancer or fallopian tube cancer that is relapsed and resistant or refractory to prior 
platinum-based standard care systemic regimen.
•
Patients must be off prior chemotherapy, radiation therapy, hormonal therapy or 
biological therapy for at least 4 weeks. 
•
ECOG performance status 0-1 and adequate organ and marrow function. 
Design:
•
This is an open label single arm phase I trial to determine the maximum tolerated 
dose of intraperitoneal monocytes and Sylatron® (Peginterferon alfa-2b) and 
Actimmune® (Interferon gamma-1b).
•
Autologous monocytes obtained through apheresis will be mixed with Sylatron® 
(Peginterferon alfa-2b) and Actimmune® (Interferon gamma-1b) in a 3 + 3 dose 
escalation and administered intraperitoneally once every 28 days. A new product will 
be manufactured for each treatment cycle.
•
Once the maximum tolerated dose is obtained, an expansion cohort will be enrolled to 
better quantify response rate and time to disease progression. 
•
Research samples including peripheral blood and ascites will be obtained prior to the 
initiation of study therapy and prior to the start of each cycle. Tissue biopsies will be 
obtained in the dose expansion phase to characterize the immune infiltration. 
•
Patients will be evaluated every 2 cycles for response using RECIST v1.1 and every 
cycle for safety using CTCAE v4.0.

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
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Study Schema
 
Total Volume (250 mL)
Dose 
Level
Monocytes
total number
SYLATRON ®
Peginterferon alfa2b, mcg 
(final concentration)
ACTIMMUNE ®
Interferon gamma-1b, mcg 
(final concentration)
1
0
25 mcg (0.1 g/mL)
5 mcg (0.02 g/mL)
2
75 x 106  20%
25 mcg (0.1 g/mL)
5 mcg (0.02 g/mL)
3
750 x 106  20%
25 mcg (0.1 g/mL)
5 mcg (0.02 g/mL)
3b*
0
250 mcg (1 g/mL)
50 mcg (0.2 g/mL)
4
750 x 106  20%
250 mcg (1 g/mL)
50 mcg (0.2 g/mL)
*DL3b will enroll if ≥2 subjects enrolled on DL3 or DL4 experience DLT

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
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TABLE OF CONTENTS 
PRÉCIS............................................................................................................................................2
TABLE OF CONTENTS ................................................................................................................4
STATEMENT OF COMPLIANCE ................................................................................................8
1
INTRODUCTION ...................................................................................................................8
1.1
Study Objectives............................................................................................................8
1.1.1
Primary Objective......................................................................................................8
1.1.2
Secondary Objectives ................................................................................................8
1.1.3
Exploratory Objectives ..............................................................................................8
1.2
Background and Rationale ............................................................................................8
1.2.1
Ovarian Cancer ..........................................................................................................8
1.2.2
Intraperitoneal Interferon...........................................................................................9
1.2.3
Intraperitoneal Monocytes.......................................................................................11
1.2.4
Preclinical studies of monocytes combined with both Interferons alpha and gamma
……………………………………………………………………………………..11
1.2.5
Monocytes from women with ovarian cancer .........................................................14
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT........................................................15
2.1
Eligibility Criteria........................................................................................................15
2.1.1
Inclusion Criteria .....................................................................................................15
2.1.2
Exclusion Criteria ....................................................................................................16
2.1.3
Recruitment Strategies.............................................................................................18
2.2
Screening Evaluation...................................................................................................18
2.2.1
Screening activities performed prior to obtaining informed consent ......................18
2.2.2
Screening activities performed after a consent for screening has been signed 
(Registration Part 1)...............................................................................................................18
2.3
Registration Procedures...............................................................................................20
2.3.1
Screen Failures.........................................................................................................20
2.4
Treatment Assignment and Randomization/Stratification Procedures .......................20
2.5
Baseline Evaluation.....................................................................................................21
3
STUDY IMPLEMENTATION .............................................................................................22
3.1
Study Design ...............................................................................................................22
3.1.1
Dose Limiting Toxicity............................................................................................23
3.1.2
Dose Escalation .......................................................................................................23
3.1.3
Maximum Tolerated Dose (MTD)...........................................................................24
3.2
Drug Administration....................................................................................................25

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3.3
Dose Modifications .....................................................................................................25
3.3.1
General Management of Toxicities .........................................................................25
3.3.2
General Recommendations for Dose Modification and Management of 
Hematologic Adverse Events occurring after the DLT period..............................................25
3.3.3
General Recommendations for Dose Modification and Management of Non-
Hematologic Adverse Events.................................................................................................27
3.3.4
Safety Protocol Stopping Rules...............................................................................28
3.4
Study Calendar ............................................................................................................29
3.5
Criteria for Removal from Protocol Therapy and Off Study Criteria .........................31
3.5.1
Criteria for removal from protocol therapy .............................................................31
3.5.2
Off-Study Criteria....................................................................................................31
4
CONCOMITANT MEDICATIONS/MEASURES...............................................................32
4.1
Prohibited Medications................................................................................................32
5
BIOSPECIMEN COLLECTION...........................................................................................32
5.1
Correlative Studies for Research/Pharmacokinetic Studies ........................................32
5.1.1
Peripheral blood and ascites ....................................................................................32
5.1.2
Plasma......................................................................................................................34
5.1.3
Tissue biopsies (expansion phase)...........................................................................35
5.1.4
Sampling Schedule ..................................................................................................35
5.2
Sample Storage, Tracking and Disposition .................................................................36
5.2.1
Figg Lab Blood Processing Core (BPC)..................................................................36
5.2.2
NCI-Frederick Leidos Biomedical, Inc. Laboratory................................................37
5.2.3
Women’s Malignancies Branch (formerly Annunziata Laboratory).......................38
5.2.4
Holland Laboratory, NIAID ....................................................................................38
6
DATA COLLECTION AND EVALUATION......................................................................38
6.1
Data Collection............................................................................................................38
6.2
Data Sharing Plans ......................................................................................................39
6.2.1
Human Data Sharing Plan .......................................................................................39
6.3
Response Criteria ........................................................................................................39
6.3.1
Definitions ...............................................................................................................39
6.3.2
Disease Parameters ..................................................................................................40
6.3.3
Methods for Evaluation of Measurable Disease......................................................41
6.3.4
Response Criteria.....................................................................................................43
6.3.5
Duration of Response ..............................................................................................45
6.3.6
Progression-Free Survival .......................................................................................45

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6.4
Toxicity Criteria ..........................................................................................................45
7
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN.....45
7.1
Definitions...................................................................................................................45
7.2
OHSRP Office of Compliance and Training /  IRB Reporting...................................45
7.2.1
Expedited Reporting ................................................................................................45
7.2.2
IRB Requirements for PI Reporting at Continuing Review ....................................46
7.3
NCI Clinical Director Reporting .................................................................................46
7.4
NIH Required Data and Safety Monitoring Plan ........................................................46
7.4.1
Principal Investigator/Research Team.....................................................................46
7.4.2
Data Safety Monitoring Board (DSMB)..................................................................46
8
SPONSOR PROTOCOL/SAFETY REPORTING................................................................46
8.1
Definitions...................................................................................................................46
8.1.1
Adverse Event..........................................................................................................46
8.1.2
Serious Adverse Event (SAE) .................................................................................46
8.1.3
Life-threatening .......................................................................................................47
8.1.4
Severity....................................................................................................................47
8.1.5
Relationship to Study Product .................................................................................47
8.1.6
Adverse Events of Special Interest (AESI) .............................................................47
8.2
Assessment of Safety Events.......................................................................................48
8.3
Reporting of Serious Adverse Events .........................................................................48
8.4
Waiver of expedited reporting to CCR........................................................................48
8.5
Safety Reporting Criteria to the Pharmaceutical Collaborators ..................................48
8.5.1
Horizon Pharma, Inc................................................................................................48
8.5.2
Merck Sharp & Dohme Corp...................................................................................49
8.6
Reporting Pregnancy ...................................................................................................49
8.6.1
Maternal exposure ...................................................................................................50
8.6.2
Paternal exposure.....................................................................................................50
8.7
Regulatory Reporting for Studies Conducted Under CCR-Sponsored IND ...............50
8.8
Sponsor Protocol Deviation Reporting........................................................................50
9
CLINICAL MONITORING PLAN.......................................................................................51
10
STATISTICAL CONSIDERATIONS ..................................................................................51
11
COLLABORATIVE AGREEMENTS..................................................................................52
12
HUMAN SUBJECTS PROTECTIONS................................................................................52
12.1
Rationale For Subject Selection ..................................................................................52

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12.2
Participation of Children .............................................................................................52
12.3
Participation of Subjects Unable to Give Consent ......................................................52
12.4
Evaluation of Benefits and Risks/Discomforts ...........................................................53
12.5
Risks/Benefits Analysis...............................................................................................53
12.5.1
Potential Risks .........................................................................................................53
12.5.2
Benefits....................................................................................................................54
12.6
Consent Process and Documentation ..........................................................................54
12.6.1
Request for Waiver of Consent for Screening Activities ........................................54
12.6.2
Telephone reconsent:...............................................................................................55
13
REGULATORY AND OPERATIONAL CONSIDERATIONS..........................................55
13.1
Study Discontinuation and Closure.............................................................................55
13.2
Quality Assurance and Qualtiy Control ......................................................................55
13.3
Conflict of Interest Policy ...........................................................................................56
13.4
Confidentiality And Privacy........................................................................................56
14
PHARMACEUTICAL INFORMATION..............................................................................57
14.1
Peginterferon alfa-2b (SYLATRON)..........................................................................57
14.1.1
DTM preparation (dose levels 2, 3, 4).....................................................................57
14.2
Interferon gamma-1b...................................................................................................57
14.2.1
DTM preparation (dose levels 2, 3, 4).....................................................................58
14.3
Preparation of Peginterferon alfa-2b and Interferon gamma-1b in the Clinical Center 
Pharmacy (for Dose Levels 1 and 3b) .......................................................................................58
15
REFERENCES ......................................................................................................................61
16
APPENDICES .......................................................................................................................64
16.1
Appendix A: Performance Status Criteria...................................................................64
16.2
Appendix B: DTM Standard Operating Procedures....................................................65
16.3
Appendix C: List of Drugs interacting with CYP1A2or CYP2D6 .............................77
16.4
Appendix D: Standard operating procedure for intraperitoneal infusion....................78
16.5
Appendix E: Sample Chemotherapy/Biotherapy  Treatment Note.............................79

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Council on Harmonisation Good 
Clinical Practice (ICH GCP) and the following: 
• United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 
CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.
1
INTRODUCTION
1.1
STUDY OBJECTIVES
1.1.1
Primary Objective
1.1.1.1
To identify a maximum tolerated dose of intraperitoneal autologous monocytes and 
Sylatron® (Interferon alfa-2b) and Actimmune® (Interferon gamma-1b).
1.1.2
Secondary Objectives
1.1.2.1
To quantify the response rate and time to disease progression
1.1.3
Exploratory Objectives
1.1.3.1
To characterize the immune infiltration into ascites and tumor (expansion cohort)
1.1.3.2
To analyze circulating leukocyte populations
1.2
BACKGROUND AND RATIONALE
1.2.1
Ovarian Cancer
Ovarian cancer is the leading cause of death due to gynecological malignancies, and the fifth 
leading cause of death due to cancer in women. Patients are diagnosed late in the course of 
disease (Stage 3 or 4) due to lack of early symptoms and reliable non-invasive testing. Because 
of the late diagnosis and aggressiveness of the disease, ovarian cancer results in approximately 
14,000 deaths per year. Standard of care for the treatment of ovarian cancer is tumor 
cytoreductive surgery followed by administration of platinum and taxane based chemotherapy 
[1]. The disease course is characterized by a high rate of relapse despite an initial good response 
to the therapy [2]. Patients are classified as chemotherapy sensitive, resistant or refractory. 
Sensitive patients – who relapse more than 6 months after initial treatment – are re-treated with 
platinum-based combinations. Without curative second line treatment for patients with resistant 
or refractory epithelial ovarian cancer (EOC), median survival is 16 months, with most of the 
population dying within the first two years [3]. 

Abbreviated Title:  Phase 1 IFN + monocytes
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Ovarian cancer is largely retained in the peritoneal cavity, with metastases outside of the 
peritoneum occurring late in disease if at all. In 2006 there was a major advance in the treatment 
of a portion of the population of women diagnosed with EOC [4] . Patients with stage III 
optimally resected cancer were given cisplatin IP and paclitaxel IV and IP, compared to standard 
IV administration of both drugs. There was a 15-month increase in overall survival. This study 
showed that IP delivery of agents was a viable therapeutic option, and that IP therapy could 
increase efficacy of treatment.
Adoptive cell therapy was pioneered and developed in the Intramural Research Program. 
Autologous adoptive cell therapy of tumor infiltrating lymphocytes (TILs) is under development 
for the treatment of melanoma [5]. TIL therapy is based upon the observations that lymphocytes 
recognize and kill cancer cells. Based on these observations it was posed that the anti-
inflammatory environment of the tumor inhibited a de novo immune response. Clinical trials 
have tested numerous strategies for re-activating lymphocytes, and other leukocyte subsets. 
The generation of pharmaceutical grade IFNs in the 1980s generated a large number of human 
trials aimed at using the anti-viral and anti-neoplastic properties of IFNs [6]. The FDA licensed 
IFNα-2a and IFNα-2b for treatment of melanoma, hairy cell leukemia, follicular lymphoma, 
chronic myelogenous leukemia and AIDS related Kaposi’s sarcoma. The trials did show greater 
efficacy than standard of care, and are used as second and third line treatments. Furthermore, it 
has been shown that activated monocytes are capable of killing malignant cells [7]. While 
different combinations of IFNs and monocytes were tested in human clinical trials for their 
tumoricidal properties, the three have never been combined (Table 1).
Experimental agents
References
IFN-2a,2b
[8, 9],[10-12]
IFN
[13-16]
Monocytes
[17, 18]
IFN + monocytes
[19]
Table 1. Clinical development of interferons and monocytes as anti-cancer therapy
1.2.2
Intraperitoneal Interferon 
During the late 1980s and 1990s phase one trials were completed testing IP infusion of immune 
modifying agents, including, but not limited to IFNα or IFNγ for treatment of cancers involving 
organs in the peritoneal cavity.  The large-scale production of cytokines and the production of 
therapeutic grade lymphocytes through counter-elutriation paved the way for infusion of the 
cytokines, lymphocytes, and cytokine stimulated lymphocytes for the treatment of malignancies 
of the peritoneal cavity. Studies focused on, but were not limited to, the treatment of ovarian 
cancer. 

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1.2.2.1
Phase I clinical studies
Intraperitoneal (IP) IFNα was used in the first intraperitoneal immunotherapy studies conducted 
in patients with ovarian cancer. The promising results of these studies, however, were eclipsed 
by the emergence of taxane based therapies at the time, and have not been taken further than 
early phase clinical trials. The first Phase 1 study of IP immunotherapy for ovarian cancer 
evaluated infusion of high dose IFNα-2a as salvage therapy for patients with high grade 
epithelial ovarian cancer.  Of 14 patients receiving IFNα-2a over sixteen weeks, 6 patients (36%) 
had complete response, one patient (1%) had partial response, and 6 patients (55%) had disease 
progression [8, 9]. There was found to be an increase in NK cell activity and antibody dependent 
cell cytotoxic activity in response to IFNα-2a in 11 of the patients that were treated [11].That 
trial was followed by a study of 20 patients treated for 8 weeks. Eleven patients (55%) 
responded, and five of those patients (25%) had complete response. The median duration of 
complete response was 11 months. The most common adverse effects not requiring dose 
reduction were fever (80%), abdominal pain (32%), and leukopenia (52%) [12].  In a study with 
39 patients with ovarian cancer given intraperitoneal IFNα-2b in combination with 
chemotherapy, 14/35 patients achieved a pathological CR with only one patient discontinuing 
treatment due to severe fatigue [10].  In a pharmacokinetics study, IP and blood levels of IFNα-
2b were measured after administration. All patients had metastatic disease within the peritoneal 
cavity and were given a range of IFNα-2b from 5x106 units to 15x106 units. The bioavailability 
of IP IFNα-2b was found to be 30 fold higher intraperitoneally compared to in the peripheral 
blood, with a slower elimination half-life (10-32hr IP compared to 5-13 hours in the peripheral 
blood) [20].
The first study of high dose IP IFNγ for the treatment of ovarian cancer enrolled 27 patients with 
relapsed, chemo-resistant disease. Unfortunately, none of the patients on this small trial showed 
objective response, with 14 patients having progressive disease during the protocol [15]. A 
follow up of the first IP IFNγ study was published in 1996. A total of 109 patients enrolled. All 
patients had stage three or greater epithelial ovarian cancer and were given IFNγ either by 
subcutaneous injection or IP injection through an implanted catheter. Twenty-three patients 
(23.5%) had a complete response, while 8 (8%) patients had a partial response [16].  In a study 
with 7 patients treated with IP IFNγ, there was an increase in NK cell activity and tumor-
associated lymphocytes and macrophages but no objective responses [14]. A similar study with 8 
patients treated with IP IFNγ found similar rises in tumor associated lymphocytes and 
macrophages: 1 patient with a complete response, 2 with partial responses and 2 with stable 
disease [13].  Pharmacokinetic studies showed that IFNγ was retained within the peritoneum for 
longer than 24 hours with up to a 150-200 fold increase in peak levels above that in plasma. All 
patients who received IP IFNγ 4–8 x106 IU/m2 developed transient fever ≥38°F. Release into the 
blood was found only in the higher doses (>2x106 IU/m2), with a peak level reached in the serum 
at 6 hours. The peak levels in the peritoneal cavity increased as IFNγ dose increased, with 
30.7 IU/mL with 0.05x106 IU/m2 up to 1,720 IU/mL with 8x106 IU/m2) and levels persisted in 
both the blood and peritoneum for up to 24hr [15]. One of the most important observations from 
the studies was the tolerable side effect profile, and prolonged intraperitoneal concentrations of 
IFNs. No published studies report the co-administration of IFNs IP. Together these studies show 
that IP administration of IFNα or IFNγ is a potentially testable therapeutic treatment. 

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1.2.3
Intraperitoneal Monocytes
The anti-tumor effect of activated monocytes is well characterized. Monocytes are precursors of 
resident tissue macrophages, and their functions in normal homeostasis include antigen 
presentation, phagocytosis of apoptotic cells, and tissue development. [21] Monocytes adapt to 
their microenvironment and differentiate based on cytokine, chemokine and metabolite 
expression [22]. In the presence of a tumor, monocytes differentiate into classical M1 
macrophages that inhibit tumor proliferation and secrete proinflammatory cytokines and 
chemokines. They are also able to promote natural killer (NK) cell differentiation, providing a 
rapid cytotoxic response to tumor cells [18, 23, 24]. This response is further potentiated by the 
release of IFNs by NK cells, promoting the tumoricidal effects of these cells [25]. Macrophages 
differentiated towards an M1 phenotype can potentially be exploited in the clinic to selectively 
target tumor cells without damaging normal tissue [26]. Monocytes can also differentiate into 
M2 (alternative macrophages) that promote tumor proliferation [27-29] and are associated with a 
poor prognosis in advanced epithelial ovarian cancer [30]. Therefore, the success of monocytes 
as an anti-tumor treatment approach may depend on the ability to maintain the M1 phenotype 
and avoid M2 differentiation in the tumor microenvironment.
Several studies have shown that monocytes can be isolated from the peripheral blood in large 
numbers (1 billion) and at relatively high purity (80-95%) [31, 32]. Two phase 1 safety trials 
studied intraperitoneal infusion of autologous monocytes activated with IFNγ or muramyl 
tripeptide phosphatidylethanolamine (MTP-PE) [19],[17]. These studies showed that IP 
administration of IFN stimulated monocytes was safe and feasible for the treatment of peritoneal 
carcinoma of colorectal origin. Indium-111 (111In) labeled monocytes were visualized using 
whole-body Gamma Camera Imaging, and were found to be confined to the peritoneal cavity and 
not present in the lungs, heart or liver after up to 5 days of monitoring [19].  A subsequent study 
assessed autologous transplantation of monocytes stimulated with liposomal-muramyl tripeptide 
phosphatidyl ethanolamine (L-MTP-PE), a potent adjuvant, for the treatment of carcinomas of 
the peritoneum. Patients’ abdomens were imaged at 30 minutes and 7 days post-infusion. Once 
again, the 111In was confined to the peritoneal cavity with no measurable activity in liver or 
lungs. Patients experienced low grade toxicities of fevers, chills and abdominal pain. [31]. 
Response rates were not reported. 
1.2.4
Preclinical studies of monocytes combined with both Interferons alpha and gamma
Given the recent successes of immunotherapy in other malignancies, intraperitoneal 
immunotherapy is a promising area for exploration in cancers predominantly confined to the 
peritoneal cavity, such as ovarian cancer. Our experimental approach is based on previous 
observations that IFNs themselves are potent anti-neoplastic proteins [6]. We have shown in 
vitro and in animal models that monocyte stimulation with IFN-α and IFN-γ achieves M1 
differentiation, important for anti-tumor activity. These human monocytes, in combination with 
human alpha interferons (IFNα-2a or pegylated IFNα-2b) and interferon gamma (IFNγ-1b) are 
potent killers of cancer cell lines in vitro [33, 34]. Our studies included 6 ovarian cancer cell 
lines, and demonstrated that the presence of monocytes additionally decreased viability of some 
cell lines at low doses of interferons (Figure 1) [35]. Our most recent, unpublished work 
suggests that the mechanism of killing is partially mediated by surface TNF-related apoptosis-
inducing ligand (TRAIL) on monocytes that induces cell death via extrinsic apoptosis.

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Figure 1. IFN activated monocytes are potent killers of ovarian cancer cell lines. Ovarian 
cancer cells were treated with IFNα-2a and/or IFNγ with or without monocytes. Cell line CaOV3 
showed the greatest effect of monocyte addition with either IFN. OVCAR-3 was the most 
sensitive to the combination of IFNs without monocytes. OVCAR-5 killing was most dependent 
on the presence of both IFNs and monocytes. Other cell lines showed variable response to the 
tested combinations. * p<0.05, **p<0.01, ***p<0.001, ****p<0.0001
We expanded this observation to demonstrate that intra-tumoral injection of monocytes with 
IFNs decreased human ovarian cancer xenograft size (Figure 2) [36]. Importantly, the 
monocytes introduced into the tumor differentiated into inflammatory M1 macrophages when in 
the presence of both IFNs (Figure 3). 

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Figure 2 Intratumoral administration of IFNs activated Monocytes inhibited tumor growth 
and prolonged survival (A) Mice were injected SC with 10 × 106 OVCAR-3 cells and treated 
with monocytes (3 × 107) or IFN-α2a and IFN-γ (20 ng each), or combination by i.t. injection on 
day 0, 15 or 30 post-tumor implantation. Mice receiving combination therapy showed significant 
inhibition of tumor growth compared to IFNs alone, monocytes alone and PBS. (B) Kaplan-
Meier survival curves of mice with OVCAR-3 tumors are shown (n=5 per group). CR, complete 
regression. Tumor volumes measured by Vernier caliper; survival calculated based on sacrifice 

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when tumors size reached > 2 cm in diameter. Experiments were repeated twice; bars, SD.
Figure 3. IFNs activate differentiation of monocytes to classical (M1) macrophages in 
OVCAR-3 tumors The tumor samples were collected on day 17 (2 days after 15 day post 
inoculation treatment, respectively) from the mice in Fig. 1A and the immunofluorescence 
microscopy were done using antibodies specific for IL-12, CXCL10, NOS2, IL-10, and Arginase-
1. Bars, 50 μm, Magnification X400.
We have shown in vitro and in the nude mouse that while IFNα-2a or IFNγ-1b work with 
monocytes to kill tumor cells, and the combination of all three can achieve the greatest amount 
of tumoricidal activity. Intratumoral injection of these cells in mice resulted in a reduction in 
tumor burden and increased overall survival [36]. Additional unpublished data show that IP 
administration of human monocytes primed with alpha and gamma interferons reduces both 
tumor burden and ascites volume in a xenograft model of human ovarian cancer (OVCAR3). 
Furthermore, we demonstrated that monocytes and IFNs improve tumor shrinkage with 
carboplatin and paclitaxel and significantly increase tumor cell death [35]. Both unpublished and 
published data strongly suggest that the monocytes must be in contact with the tumor cells for 
killing.  Thus, the rationale for IP immunotherapy is not only to deliver higher concentrations of 
the drug directly to the tumor, but also to skew monocytes to the M1 phenotype and to activate 
NK cells in the tumor microenvironment, potentiating tumor cell death.
1.2.5
Monocytes from women with ovarian cancer
We have shown that monocytes isolated through elutriation at the NIH blood bank and 
monocytes isolated from anti-coagulated peripheral blood from healthy women from the NIH 
blood bank are capable of killing tumor cells (Figure 4).  We have also shown that patients with 
epithelial ovarian cancer have normal populations of monocytes compared to age matched 
controls, and the patient monocytes are as effective as healthy age matched control monocytes in 
killing ovarian cancer cell lines.

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Figure 4. Monocytes 
from women with 
ovarian cancer are 
equally effective as 
healthy donors. 
Monocytes were isolated 
from women with ovarian 
cancer (n=42) or healthy 
donors (n=23). Viability of 
ovarian cancer cell line 
CaOV3 was assessed in 
the presence of 
interferons alone or in 
combination with 
monocytes from individual 
sources. *p<0.05, 
**p<0.01, ****p<0.0001.
Based upon the observations that: (1) the immune system can mount a long and durable response 
to tumors, (2) human IFNα-2 and IFNγ-1b and monocytes have strong anti-neoplastic response 
in vitro and in vivo, (3) the IP route of administration is safe, and (4) ovarian cancer is largely 
confined to the peritoneal cavity, it is likely that the administration of IFNs and monocytes IP 
will create a strong anti-tumor environment and can overcome the immunosuppressive 
environment of epithelial ovarian cancer. We hypothesize that the monocyte and interferon 
administration will be tolerable to women with relapsed ovarian cancer.  If successful, this 
regimen can create a backbone on which to add novel agents such as TRAIL agonists or PD-L1 
blockade, in order to increase immune-mediated killing of ovarian cancer.
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
2.1
ELIGIBILITY CRITERIA
2.1.1
Inclusion Criteria
2.1.1.1
Patients must have histologically or cytologically confirmed advanced metastatic or 
unresectable epithelial ovarian cancer, primary peritoneal cancer or fallopian tube 
cancer that is relapsed and resistant (recurred less than 6 months after chemotherapy) or 
refractory (progressed on chemotherapy) to prior platinum- and taxane-based standard 
care systemic regimen. Or patients who are not eligible for additional platinum therapy. 
Histopathologic diagnosis must be confirmed in the Laboratory of Pathology (LP), NCI.
2.1.1.2
Patients must have measurable or evaluable disease. Measurable disease is defined as at 
least one lesion that can be accurately measured in at least one dimension (longest 
diameter to be recorded for non-nodal lesions and short axis for nodal lesions) as >20 
mm with conventional techniques or as >10 mm with spiral CT scan.  See Section 6.3 
for the evaluation of measurable disease. Evaluable disease includes CA125, ascites, 
peritoneal carcinomatosis, as defined in Section 6.3.1.

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2.1.1.3
Patients must be at least 4 weeks from previous therapy (chemotherapy, hormonal 
therapy, and radiation therapy, immunotherapy and monoclonal antibodies, alternative 
therapy or investigational therapeutic agents). There is no limitation on the amount of 
prior therapies allowed. Patients with ovarian cancer 4 weeks from previous therapy 
have been found to have normal monocyte function (unpublished). 
2.1.1.4
Patients who have had cranial radiation therapy need to have completed it ≥8 weeks 
prior to enrollment. 
2.1.1.5
Patients are permitted to receive investigational imaging agents while on study.
2.1.1.6
Patients who have had major surgery must be fully recovered and require a recovery 
period of ≥4 weeks prior to enrolling on study.
2.1.1.7
Age >18 years. Because no dosing or adverse event data are currently available on the 
use of intraperitoneal monocytes, IFNα2 or IFNγ in patients <18 years of age, children 
are excluded from this study, but will be eligible for future pediatric trials.
2.1.1.8
ECOG performance status <1 (Karnofsky >70%, see Appendix A).
2.1.1.9
Adequate renal function, defined as serum creatinine ≤ 1.5 X upper limit of normal 
(ULN), or measured creatinine clearance ≥ 60 mL/min/1.73m2.
2.1.1.10 Adequate hepatic function, defined as AST and ALT levels ≤ 3 X ULN and total 
bilirubin < 1.5 X ULN, unless known diagnosis of Gilbert‘s syndrome, where bilirubin 
≤ 5 mg/dl will be permitted. Gilbert’s syndrome will be defined as elevated 
unconjugated bilirubin, with conjugated (direct) bilirubin within the normal range and 
less than 20% of the total. Total bilirubin will be permitted up to 5 mg/dl, if patients 
have historical readings consistent with the definition of Gilbert’s syndrome prior to 
entering study.
2.1.1.11 Adequate bone marrow function, defined as absolute neutrophil (ANC) ≥ 1,500/mm3 
(≥1.5 X106/L), platelet count ≥ 75,000/mm3 (≥ 75 X106/L), and hemoglobin ≥ 8 g/dL 
(transfusion to obtain hemoglobin ≥ 8 g/dL is allowed).
2.1.1.12 The effects of intraperitoneal monocytes, IFNα2, and IFNγ on the developing human 
fetus are unknown.  For this reason and because interferons based on animal data may 
cause fetal harm, women of child-bearing potential (excludes women with recurrent 
ovarian cancer) and men must agree to use adequate contraception (hormonal or barrier 
method of birth control; abstinence) prior to study entry and for the duration of study 
participation.  Should a woman become pregnant or suspect she is pregnant while she is 
participating in this study, she should inform her treating physician immediately.
2.1.1.13 Ability of subject to understand and the willingness to sign a written informed consent 
document.
2.1.2
Exclusion Criteria
2.1.2.1
Patients who are receiving any other investigational agents (with exception of imaging 
agents as indicated above in section 2.1.1.5).
2.1.2.2
Patients cannot have previously been treated with interferons (e.g., for chronic active 
hepatitis). 
2.1.2.3
Lack of recovery of prior adverse events to Grade ≤1 severity (National Cancer Institute 
Common Terminology Criteria for Adverse Events [NCI CTCAE] v 4.03) (except 
alopecia) due to therapy administered prior to the initiation of study drug dosing. Stable 

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persistent grade 2 peripheral neuropathy may be allowed as determined on a case-by-
case basis at the discretion of the Investigator as interferon has not been shown to cause 
or exacerbate peripheral neuropathy.
2.1.2.4
Patients with active infection will not be eligible, but may become eligible once 
infection has resolved and at least 7 days have elapsed after antibiotics use was 
completed.
2.1.2.5
Concomitant chronic (daily or almost daily for ≥1 month prior) use of steroids or non-
steroidal anti-inflammatory drugs (NSAIDS). 
2.1.2.6
Patients with a recent history (within last 5 years) of autoimmune disease or 
inflammatory diseases will be excluded, because interferons may worsen these 
conditions. Exceptions will be allowed for vitiligo and hypothyroidism that has been 
stable on thyroid replacement medications for >6 weeks.
2.1.2.7
Impaired cardiac function or clinically significant cardiac disease including the 
following:
▪
New York Heart Association class III or IV congestive heart failure
▪
Myocardial infarction within the last 12 months 
▪
Subjects known to have impaired LVEF according to institutional standards 
2.1.2.8
History of allergic reactions attributed to compounds of chemical or biologic 
composition similar to interferons or other agents used in the study.
2.1.2.9
Uncontrolled intercurrent illness including, but not limited to, ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac 
arrhythmia, or psychiatric illness/social situations within the last 12 months that would 
limit compliance with study requirements. Patients with history of neuropsychiatric 
disorders or Major Depressive Disorder (DSM 5 definition: 
http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm04) 
requiring medical treatment will not be eligible to enroll, based on the black box 
warning (SYLATRON™ (peginterferon alfa-2b) for injection, for subcutaneous use. 
Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse Station, 
NJ). Exception to this is if patients experienced transient post-partum depression that 
resolved and patient has been off treatment for >10 years. Patients who are taking oral 
anti-depressants for normal sadness, bereavement, or grief will not be excluded. 
2.1.2.10 Pregnant women are excluded from this study because interferons based on animal data 
may cause fetal harm.  Because there is an unknown but potential risk for adverse 
events in nursing infants secondary to treatment of the mother with interferons, 
breastfeeding should be discontinued if the mother is treated with intraperitoneal 
interferons.  These potential risks may also apply to other agents used in this study.

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2.1.2.11 Patients on combination antiretroviral therapy for the treatment of HIV are ineligible 
because of the potential for pharmacokinetic interactions with interferons alfa and 
gamma.  
2.1.2.12 Patients receiving any medications or substances that are potent inhibitors or inducers of 
CYP1A2 or CYP2D6 are ineligible.  Lists including such medications and substances 
are provided in Appendix C.
2.1.3
Recruitment Strategies
This protocol may be abstracted into a plain language announcement posted on NIH websites 
and on NIH social media platforms. 
2.2
SCREENING EVALUATION 
2.2.1
Screening activities performed prior to obtaining informed consent
Minimal risk pre-screening activities that may be performed before the subject has signed a 
consent for this study include the following: 
•
Email, written, in person or telephone communications with prospective subjects 
•
Review of existing medical records to include H&P, laboratory studies, etc.  
•
Review of existing  MRI, x-ray, or CT images
•
Review of existing photographs or videos
•
Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes
A waiver of consent for these activities has been requested in section 12.6.1.
2.2.2
Screening activities performed after a consent for screening has been signed (Registration 
Part 1)
The following activities will be performed only after the subject has signed the consent for this 
study for screening.  Assessments performed at outside facilities or on another NIH protocol 
within the timeframes below may also be used to determine eligibility once a patient has signed 
the consent.  For baseline evaluations, please see section 2.5.
 
Screening Assessments – Part 1
The following screening activities to determine eligibility may be performed any time prior to 
Registration Part 2.
Medical history, including age, performance status, and dates of prior treatment regimens.
Confirmation of tumor histology in NCI Laboratory of Pathology
(Archival tumor samples will be requested; if unavailable, the subject may choose to undergo 
fresh biopsy)
Assessment of disease by physical exam and imaging

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Screening Assessments – Part 1
The following screening activities to determine eligibility may be performed any time prior to 
Registration Part 2.
(may include CT chest, abdomen and pelvis or MRI; report from outside institution is 
acceptable).
Screening Assessments – Part 2
Once patient eligibility has been established according to the results of the Screening 
Assessments Part 1 above, the following Screening Part 2 activities will be performed to 
determine final patient eligibility prior to Registration Part 2. Scans and x-rays must be done 
within 28 days (- 7 days) prior to the initiation of study therapy.  All other studies should be 
performed within 7 days prior to initiation of study therapy, unless otherwise specified.
Timeframe (calendar days)
Assessment
Within 7 days prior to treatment 
(unless otherwise noted)
History and physical examination
X
Assessment of disease by imaging   (may include CT 
chest, abdomen and pelvis)
Within 28 days prior to treatment
Ophthalmic evaluation including visual acuity and 
funduscopy performed by an ophthalmologist
Within 180 days (-14 days) prior to 
treatment
Assessment of venous access in Department of 
Transfusion Medicine 
Anytime prior to apheresis
Intraperitoneal catheter placement in Interventional 
Radiology, if not already placed OR surgical 
implantation of intraperitoneal port by Gynecologic 
Oncology if not already placed OR verification by 
clinicians of functional IP catheter or IP port (if pre-
existing)
X
CBC with differential and platelet count
X
Metabolic panel (magnesium, calcium, albumin, 
phosphorus)
X
Acute care panel (electrolytes, glucose, BUN, 
creatinine)
X

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Timeframe (calendar days)
Assessment
Within 7 days prior to treatment 
(unless otherwise noted)
Hepatic function tests (AST/ALT/total bilirubin)
X
CA125
X
β-HCG in women of childbearing potential
X
2.3
REGISTRATION PROCEDURES
Registration and status updates (e.g., when a participant is taken off protocol therapy and when a 
participant is taken off-study) will take place per CCR SOP ADCR-2, CCR Participant 
Registration & Status Updates found at: https://nih.sharepoint.com/sites/NCI-CCR-OCD-
Communications/SitePages/OEC-Administrative---Clinical-Research-(ADCR).aspx?Mode=Edit
2.3.1
Screen Failures
Screen failures are defined as participants who consent to participate in the clinical trial but are 
not subsequently assigned to the study intervention or entered in the study. A minimal set of 
screen failure information is required to ensure transparent reporting of screen failure 
participants, to meet the Consolidated Standards of Reporting Trials (CONSORT) publishing 
requirements and to respond to queries from regulatory authorities. Minimal information 
includes demography, screen failure details, eligibility criteria, and any serious adverse event 
(SAE).
Individuals who do not meet the criteria for participation in this trial (screen failure) may be 
rescreened at the discretion of the PI. Rescreened participants should be assigned a different 
participant number as for the initial screening.
2.4
TREATMENT ASSIGNMENT AND RANDOMIZATION/STRATIFICATION PROCEDURES
Cohorts
Number
Name
Description
ES1
Phase I, Dose Escalation 
Cohort 1
Patients with epithelial ovarian cancer, primary peritoneal cancer 
or fallopian tube cancer that is relapsed and platinum resistant or 
refractory
EX1
Dose Expansion Cohort 1
10 additional patients will be treated at the MTD
Arms
Number
Name
Description

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ES1
Phase 1, Dose Escalation 
Arm
The autologous monocytes cell product in 250ml total volume of 
investigational combination (monocytes + ACTIMMUNE + 
SYLATRON) is infused via the intraperitoneal catheter or port over 
30-60 min +/- 10 min every 28 days +/- 7 days until disease 
progression, limiting toxicity, intercurrent medical issues, or 
patient withdrawal. 
EX1
Dose Expansion Arm
10 additional patients will be treated at the MTD, defined as Dose 
Level 4:  autologous monocytes cell product in 250ml total volume 
of investigational combination: Monocytes (750 x 106  20%)  + 
ACTIMMUNE 50 mcg (0.2 g/mL) + SYLATRON 250 mcg (1 
g/mL) is infused via the intraperitoneal catheter or port over 30-
60 min +/- 10 min every 28 days +/- 7 days until disease 
progression, limiting toxicity, intercurrent medical issues, or 
patient withdrawal.
Randomization and Arm Assignment
Randomization and stratification procedures do not apply to this trial.
Patients in Cohort ES1 will be directly assigned to Arm ES1.
Patients in Cohort EX1 will be directly assigned to Arm EX1.
2.5
BASELINE EVALUATION
Scans and x-rays must be done within 28 days (- 7 days) prior to the initiation of study therapy.  
All other studies should be performed within 7 days prior to initiation of study therapy, unless 
otherwise specified.  If the activities performed during Screening Part 2 fall within these 
designated timeframes, they will not need to be repeated at baseline.
Timeframe (calendar days)
Baseline Assessments
Within 7 days prior to treatment 
(unless otherwise noted)
History and physical examination
X
Assessment of disease by imaging   (may include CT 
chest, abdomen and pelvis)
Within 28 days prior to treatment
Assessment of venous access in Department of 
Transfusion Medicine 
Anytime prior to apheresis
CBC with differential and platelet count
X
Metabolic panel (magnesium, calcium, albumin, 
phosphorus)
X

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Timeframe (calendar days)
Baseline Assessments
Within 7 days prior to treatment 
(unless otherwise noted)
Acute care panel (electrolytes, glucose, BUN, 
creatinine)
X
Hepatic function tests (AST/ALT/total bilirubin)
X
CA125
X
β-HCG in women of childbearing potential
X
3
STUDY IMPLEMENTATION
3.1
STUDY DESIGN 
This is a single arm dose escalation study including an expansion cohort at the MTD.
A 3+3 phase I trial of monocytes with Sylatron® (Peginterferon alfa-2b) and Actimmune® 
(Interferon gamma-1b) dose escalation will proceed to determine the MTD. The dose-limiting 
toxicity (DLT) period will be during the first cycle (28 days). For each dose level, three patients 
will be enrolled. There will be a 2 week wait from the time of cell infusion from one patient until 
apheresis and cell infusion of the next patient. If any patient assigned to a particular dose level 
experiences DLT, then up to three additional patients (up to a total of six patients) will be 
enrolled at that dose level. All patients on a dose-level must complete the 28-day cycle prior to 
beginning enrollment on the next dose level. If any patient experiences DLT-like adverse events 
related to experimental agents or study procedures in subsequent cycles, enrollment will be 
placed on hold until evaluated by the IRB and FDA.
Following Registration Part 2, patients will have intravenous access assessment in the 
Department of Transfusion Medicine (DTM) Dowling Clinic and a tunneled IP catheter will be 
placed in interventional radiology (IR) using ultrasound guidance. The tunneled IP catheter will 
be placed prior to start of the protocol therapy. If the patient already has an existing IP port for 
prior IP chemotherapy, this can be used for IP infusion, and a new tunneled catheter will not be 
placed. The patient will also be given the option to have an IP port placed instead of a tunneled 
catheter. If she prefers the IP port, she will be evaluated and if the procedure is deemed safe and 
feasible, it will be performed using direct visualization in the operating room (laparascopic 
camera).  Research blood will be collected, and ascites will be collected if present. In the 
expansion cohort, solid tumor will be biopsied if amenable at the time of catheter or port 
placement. The purpose of the biopsy is to assess monocyte and other immune cell infiltration 
and differentiation related to treatment. 
On Day 0, the patient will undergo intravenous line placement and apheresis in DTM. PBMCs 
will be stored according to standard operating procedures of DTM (Appendix B). For patients 
on DL1 and DL3b, there will be no Day 0 in the calendar as they will not be apheresed. 

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On Day 1, monocytes will be elutriated, quantified, and mixed with interferons. The final 
product will be infused in the inpatient setting through the IP catheter/port, as per standard 
operating procedure described in Appendix D. Patient will be observed overnight for adverse 
events. 
Patient will be discharged on Day 2, if well, with IV lines removed.  IP catheter can be left in 
place or removed at physician discretion. Cycle will be repeated every 28 days.  A new product 
will be manufactured for each treatment cycle.
In the expansion cohort, solid tumor will be biopsied again, if amenable, on C2D1 and at the 
time of disease progression. The purpose of these biopsies is to assess monocyte and other 
immune cell infiltration and differentiation related to treatment.
After 2 cycles, the patient may be treated as an outpatient per physician discretion. 
Imaging will be performed at baseline and every 2 cycles.
3.1.1
Dose Limiting Toxicity
Dose-limiting toxicity (DLT) evaluation period is the first cycle. DLT is defined as:
•
≥Grade 3 fatigue (defined as fatigue not relieved by rest, limiting self-care ADLs) 
lasting > 7 days
•
≥Grade 3 cytopenias lasting >7 days
•
≥Grade 3 transaminitis lasting >7 days
•
≥Grade 3 depression lasting >7 days
•
≥Grade 3 abdominal pain lasting >7 days
•
Any other grade ≥ 3 toxicity lasting >72 hours despite maximal medical intervention
3.1.2
Dose Escalation
Patients who do not complete treatment in cycle 1 for reasons other than study drug-related 
toxicity will be replaced. If 1 of 3 patients experiences DLT, the dose level will be expanded to 6 
patients. If 2 patients in a dose level of 3 to 6 patients experience DLT, then the MTD will have 
been exceeded and the next lower dose level will be expanded to 6 patients. MTD will be the 
highest dose at which 0-1 of 6 patients experience DLT. If the planned highest dose level is 
reached and determined to be safe after expansion to 6 patients, it will be considered the MTD. 
An expansion cohort of 10 additional patients will be treated at the MTD and the results 
combined with those of patients at the MTD to obtain improved estimates of safety and toxicity 
as well as to perform analyses to address secondary objectives. If either dose level 3 or dose level 
4 exceeds the MTD ( ≥2 patients on either dose level experience a DLT) then we will enroll 3-6 
patients on dose level 3b.
Total Volume (250 mL)
Dose 
Level
Monocytes
total number
SYLATRON ®
Peginterferon alfa2b, mcg 
(final concentration)
ACTIMMUNE ®
Interferon gamma-1b, mcg 
(final concentration)
1
0
25 mcg (0.1 g/mL)
5 mcg (0.02 g/mL)

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2
75 x 106  20%
25 mcg (0.1 g/mL)
5 mcg (0.02 g/mL)
3
750 x 106  20%
25 mcg (0.1 g/mL)
5 mcg (0.02 g/mL)
3b*
0
250 mcg (1 g/mL)
50 mcg (0.2 g/mL)
4
750 x 106  20%
250 mcg (1 g/mL)
50 mcg (0.2 g/mL)
*DL3b will enroll if ≥2 subjects enrolled on DL3 or DL4 experience DLT
Number of Patients with 
DLT
at a Given Dose Level
Escalation Decision Rule
0 out of 3
Enter up to 3 patients at the next dose level
> 2
Dose escalation will be stopped.  This dose level will 
be declared the maximally administered dose 
(highest dose administered).  Up to three (3) 
additional patients will be entered at the next lowest 
dose level if only 3 patients were treated previously 
at that dose.
1 out of 3
Enter up to 3 more patients at this dose level.
•
If 0 of these 3 patients experience DLT, proceed 
to the next dose level.
•
If 1 or more of this group suffer DLT, then dose 
escalation is stopped, and this dose is declared 
the maximally administered dose.  UP to three (3) 
additional patients will be entered at the next 
lowest dose level if only 3 patients were treated 
previously at that dose.
<1 out of 6 at highest dose 
level below the maximally 
administered dose
This is the MTD and is generally the recommended 
phase 2 dose.  At least 6 patients must be entered at 
the recommended phase 2 dose.
3.1.3
Maximum Tolerated Dose (MTD)
The Dose Escalation Phase has concluded, and the MTD is defined as Dose Level 4 
(Amendment I, version date 02/11/2020).

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3.2
DRUG ADMINISTRATION
Monocytes are collected, elutriated and mixed with interferons according to Appendix B. 
The cell product is delivered to the inpatient ward, and infused within 4 hours after preparation. 
The cell product in 250 mL is infused via the intraperitoneal catheter/port over 30-60 min +/- 10 
min. 
After 2 cycles, per physician discretion, the infusion can be given as an outpatient in the day 
hospital/infusion center. 
The administration is repeated every 28 days +/- 7 days to accommodate for holidays, inclement 
weather, or other scheduling conflicts. 
Interactions between interferon gamma-1b and other drugs have not been fully evaluated. 
Caution should be exercised when administering interferon gamma-1b in combination with other 
potentially myelosuppressive agent. Preclinical studies in rodents using species-specific 
interferon-gamma have demonstrated a decrease in hepatic microsomal cytochrome P-450 
concentrations. This could potentially lead to a depression of the hepatic metabolism of certain 
drugs that utilize this degradative pathway.
Peginterferon alfa-2b inhibits CYP1A2 and CYP2D6 activity. Monitor for potential increased 
toxicities of drugs metabolized by CYP1A2 and/or CYP2D6 with a low therapeutic index or a 
narrow therapeutic range when they are administered concomitantly with peginterferon alfa-2b.
Patients will continue therapy until documentation of progressive disease, limiting toxicity, 
intercurrent medical issues, or patient withdrawal
Participants will be contacted remotely or assessed in person at least once weekly during the first 
cycle of treatment. Subsequent follow up will be at least monthly, with the start of each new 
cycle, and then during follow up according to the defined schedule (see Study Calendar, Section 
3.4).
Pre-cycle and off-treatment AE assessments will be done at a scheduled clinic visit. Post-therapy 
follow-up assessments will be performed within 30 days of stopping study treatment over the 
phone or at a clinic visit.
3.3
DOSE MODIFICATIONS
3.3.1
General Management of Toxicities 
•
In the case of toxicity, appropriate medical treatment should be used (including anti-emetics, 
anti-diarrheals, etc.). 
•
Once a patient has a dose reduction for toxicity, the dose will not be increased.  
•
Participants continuing to experience toxicity at the off study visit may be contacted for 
additional assessments until the toxicity has resolved or is deemed irreversible.
•
For AEs that are unrelated to the study drugs, study drug may be held for up to 14 days at the 
discretion of the PI. 
3.3.2
General Recommendations for Dose Modification and Management of Hematologic 
Adverse Events occurring after the DLT period
Table 2. Dose Modification and Management of Hematologic Adverse Events
Observation
Action

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Absolute neutrophil count (ANC) ≥ 
1000/mcL
AND
Platelets ≥ 75,000/mcL
AND
Hemoglobin ≥ 8 g/dL
No interruption.
ANC < 1000/mcL
OR
Platelets < 75,000/mcL
OR
Hemoglobin < 8 g/dL
On first occurrence, hold treatment for up to 14 days 
until ANC ≥ 1000/mcL, platelets ≥ 75,000/mcL, and 
hemoglobin ≥ 8 g/dL. Initiate appropriate medical 
therapy (per Section 3.3.2.1) and no change in dose 
upon re-initiation.
On second occurrence, hold treatment for up to 14 
days until ANC ≥ 1000/mcL, platelets ≥ 75,000/mcL, 
and hemoglobin ≥ 8 g/dL. Initiate appropriate 
medical therapy (per Section 3.3.2.1). Treatment may 
be restarted at one dose level (DL) lower for the 
drug(s) causing the toxicity.
Patients whose counts have not recovered to ANC ≥ 
1000/mcL, platelets ≥ 75,000/mcL, and hemoglobin 
≥ 8 g/dL after 14 days should be removed from 
treatment.
Grade 4 hematologic AE 
On first occurrence, hold treatment for up to 14 days 
until ANC ≥ 1000/mcL, platelets ≥ 75,000/mcL, and 
hemoglobin ≥ 8 g/dL. Initiate appropriate medical 
therapy (per Section 3.3.2.1). Treatment may be 
restarted at one DL lower for the drug(s) causing the 
toxicity.
On second occurrence, discontinue all three 
experimental agents and follow the patient for 
adverse events as described in section 3.5 until 
resolution/stabilization of toxicity. 
3.3.2.1
Hematologic toxicities
•
Treatment may be delayed for a maximum of 2 weeks after holding the treatment for 
toxicities that develop and do not resolve as defined above (exemptions: lymphopenia, or 
leukopenia in the absence of grade 3 or higher neutropenia).

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3.3.2.2
Neutropenia
•
Growth factors to prevent neutropenia will not be administered prophylactically, but can be 
used to assist the recovery.
•
Filgrastim/Pegfilgrastim will be used only if the patient has neutropenia with sepsis for the 
purpose of facilitating recovery of the neutropenic sepsis.
3.3.2.3
Thrombocytopenia
•
Thrombocytopenia will be treated conservatively. In the absence of bleeding, or a necessary 
invasive procedure, platelet transfusions should be given for a platelet count ≤ 10,000/mcL.
•
If invasive procedure(s) is (are) planned, or the patient develops bleeding, platelet 
transfusions should be administered in accordance with the standard of practice, usually 
maintaining a platelet count above 50,000/mcL.
3.3.2.4
Anemia
•
Symptomatic anemia should be treated with red blood cell transfusion and is recommended if 
the hemoglobin falls below 8 g/dL or the patient is symptomatic.
•
The initiation of erythropoietic therapy for the management of chemotherapy-induced anemia 
follows the American Society of Hematology/ASCO clinical practice guidelines 
(http://www.asco.org).
3.3.3
General Recommendations for Dose Modification and Management of Non-Hematologic 
Adverse Events 
•
The management of general AEs not otherwise specified should be as per Table 3.
•
At the discretion of the investigator, the study drugs or monocytes may be held or dose 
modified independently if the observed toxicity is attributed to only one of the agents, while 
the patient continues to receive the agent(s) not associated with the observed toxicity. 
•
Dose modifications for nausea, vomiting, and diarrhea will be made only if they are 
refractory to treatment. The time a given drug is held should not exceed 14 days.
•
Asymptomatic electrolyte abnormalities with optimal repletion will not require dose 
reduction if resolution to grade 1 or less is documented within 72 hours.
Table 3. General Management of Adverse Events (Non-Hematologic)
Observation
Action
Grade 1 or 2 AEs resolves promptly 
(within 48 hours) with supportive care 
Maintain dose level (DL)
Any ≥ grade 3 non-hematologic >72h 
(excluding those mentioned in Section 
3.1.1, Dosing Limiting Toxicity)
During DLT evaluation period: 
Patient will be removed from treatment
At any other time
Hold study regimen for up to 14 days until toxicity 
resolves to ≤ grade 1. Treatment may be restarted 
at one DL lower according to PI discretion. 

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Any grade 2 non-hematologic AE 
lasting > 7 days despite maximal 
support. 
Hold study regimen for up to 14 days until toxicity 
resolves to ≤ grade 1. 
Treatment may be restarted at one DL lower 
according to PI discretion
Patients whose toxicity has not resolved after 14 
days will be removed from treatment. 
3.3.4
Safety Protocol Stopping Rules
The study may be halted if any of the following safety conditions are met:
1.  If one or more deaths occur, we will immediately stop accrual and we will promptly 
discuss this with the NCI IRB and the FDA. In addition, the study will be halted if 
any death occurs within 30 days of treatment regimen.
2.  If 2 DLTs occur on dose level 1.

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3.4
STUDY CALENDAR
Baseline evaluations are to be conducted within 7 days prior to start of protocol therapy, 
unless otherwise specified.  Scans and x-rays must be done within 28 days (- 7 days)   prior 
to the start of therapy.  In the event that the patient’s condition is deteriorating, laboratory 
evaluations should be repeated within 48 hours prior to initiation of the next cycle of therapy.
1 cycle = 28 days
Cycle 11
Cycle 2
Subsequent 
cycles
Post 
Therapy 
Follow-
up2
Procedure
Screening/ 
Baseline15. 
17
Day -2 
or 
-1
Day 
05
Day 
114
Day 
212
Day 
274
Day 
1
Day 
212
D1
Clinical 
Assessment 
X
X
X
Physical
Exam
X
X
X
X
X
X
X
X
Vital signs
X
X
X
X
X
X
X
X
X
X
Performance 
Score
X
X
X
X
X
Offer NIH 
Advanced 
Directives 
Form10
X
Ophthalmic 
evaluation6
X
Tunneled IP 
catheter or IP 
port 
placement7
X
Venous 
access 
assessment
X
Establish 
venous 
access prior 
to each 
apheresis 
X
X
Apheresis13
X
X
Autologous 
monocytes 
mixed with 
Sylatron® 
(Interferon 
Alfa-2b) and 
Actimmune® 
(Interferon 
Gamma-1b), 
IP infusion
X
X
X
Labs (See 
Section 2.2 
and 2.5)11
X
X
X
X
X
X
X
X
X

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1Weekly phone calls will be made during cycle 1.
2Post therapy follow up will be at one month following the last dose of treatment; however, AEs due to toxicity or 
research will be followed until resolution to ≤ grade 1 . If the patient cannot return to the Clinical Center for this 
visit, a request will be made to collect required clinical labs (specify as needed) from a local physician or laboratory.  
If this is not possible, patients may be assessed by telephone for symptoms.  If patient has begun another treatment 
regimen or palliative care, follow up may be done by telephone, and exam/labs will be omitted.
3Must be done prior to administration of study agents.
4Flexibility +/- 7 days permitted for Days 27-28 of each cycle.
5 Day 0 procedures do not apply for patients in the Dose Level 1 or Dose Level 3b cohort 6Ophthalmic evaluation 
including visual acuity and funduscopy by an ophthalmologist within 180 days (-14 days) prior to treatment.
7 IP catheter or port can be placed at any time prior to the start of protocol therapy.  If patient has pre-existing IP 
catheter or IP port, this will be assessed by the clinician for determination of function within the same time frame as 
other baseline studies.  See Section 3.1 for additional information.
8 Research blood, ascites and biopsy testing will be performed in the NIH laboratory, Building 10, RM 4B55. Phone: 
617-905-0922. 
9 Restaging should be performed within +/- 7 days of completion of previous cycle.
10 As indicated in section 12.3, all subjects ≥ age 18 will be offered the opportunity to complete an NIH advanced 
directives form.  This should be done preferably at baseline but can be done at any time during the study as long as 
the capacity to do so is retained.  The completion of the form is strongly recommended, but is not required.
11 CA125 lab will be drawn at the beginning of each cycle. Day 2 labs will include only CBC with differential and 
platelet count, unless other labs are clinically indicated.
Cycle 11
Cycle 2
Subsequent 
cycles
Post 
Therapy 
Follow-
up2
Procedure
Screening/ 
Baseline15. 
17
Day -2 
or 
-1
Day 
05
Day 
114
Day 
212
Day 
274
Day 
1
Day 
212
D1
Research 
blood 
collection 8
X
X
X3
X
X3
Ascites 
collection8
X
X3
Biopsy 
(expansion) 8
X
X
X
X
Radiological 
Assessments 
(may include 
CT-C/A/P or 
MRI; report 
from outside 
institution is 
acceptable)16
X
Restaging 
imaging9
Every 2 cycles
X
Adverse 
Events
X
X
Concomitant 
Medications
X
X

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12 Day 2 activities apply to the first two cycles only. 
13 Apheresis collection will be done every 1-3 months provided there is an adequate monocyte population at the time 
of apheresis collection. If the apheresis collection is inadequate, apheresis can be done as frequently as each cycle to 
obtain the desired number of monocytes. 
14 Do not repeat labs if already done within 1 week. 
15 Performance score (ECOG) will be performed at the beginning of each cycle.
16 MRI isperformed only as clinically indicated if patient cannot tolerate CT scan with IV contrast.
17 Screening and Baseline activities will be performed according to Sections 2.2 and 2.5 respectively.
3.5
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 30 days following the last dose of study therapy.
3.5.1
Criteria for removal from protocol therapy
•
Progressive disease
•
Participant requests to be withdrawn from active therapy
•
Unacceptable Toxicity as defined in Section 3.1
•
Investigator discretion
•
Positive pregnancy test
•
Procedure failure (incapacity to do apheresis or obtain intraperitoneal access)
•
Lost to follow-up
•
Intercurrent illness
3.5.2
Off-Study Criteria
•
Completed study follow-up period
•
Participant requests to be withdrawn from study
•
Death
•
Starting alternative therapy
•
Refused follow-up 
•
Procedure failure 
•
Screen failure
•
Lost to follow-up
3.5.2.1
Lost to Follow-up
A participant will be considered lost to follow-up if he or she fails to return for two scheduled 
visits and is unable to be contacted by the study site staff. 

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The following actions must be taken if a participant fails to return to the clinic for a required 
study visit:
•
The site will attempt to contact the participant within 72 business hours in order to 
reschedule the missed visit and will counsel the participant on the importance of 
maintaining the assigned visit schedule and ascertain if the participant wishes to and/or is 
eligible to continue in the study.
•
Before a participant is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the participant (where possible, 3 telephone calls and, 
if necessary, a certified letter to the participant’s last known mailing address or local 
equivalent methods). These contact attempts should be documented in the participant’s 
medical record or study file. 
•
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
4
CONCOMITANT MEDICATIONS/MEASURES
4.1
PROHIBITED MEDICATIONS
•
No concomitant use of alternative, complementary therapies or over-the-counter agents will 
be allowed without approval of the PI. All medications must be recorded in the case report 
form and be reviewed by the treating physician at each visit. 
•
Oral anticoagulants such as warfarin are not contraindicated provided that there is increased 
vigilance with respect to monitoring INR. If medically appropriate, low molecular weight 
heparin may be considered preferable to warfarin, due to shorter half-life and more 
predictable anticoagulant effect.  
•
Caution should be exercised in the concomitant use of any medication that may markedly 
affect renal or hepatic function. Such medications may be used with caution as deemed 
essential for treatment, or if already in use prior to entry in the study without any effect on 
renal or hepatic function. 
•
Potent inhibitors or inducers of CYP1A2 or CYP2D6 (wash out period 7 days) – see 
Appendix C.
5
BIOSPECIMEN COLLECTION
5.1
CORRELATIVE STUDIES FOR RESEARCH/PHARMACOKINETIC STUDIES
5.1.1
Peripheral blood and ascites
Blood will be acquired to study both the functionality of the patient’s monocytes (in vitro killing 
assay), and to analyze the peripheral blood mononuclear cell (PBMC) compartment. 20 mL of 
whole blood will be collected into 10 mL EDTA lavender-top tubes. Blood will be diluted 1:1 in 
RPMI and placed on a Ficoll density gradient, and the PBMC buffy coat will be removed. 
Further isolation of monocytes will be performed using negative magnetic bead based isolation, 
which will result in negatively isolated (untouched) monocytes. Based on our experiences 
isolating monocytes from the peripheral blood of patients with ovarian cancer (20 mL), we 
usually isolated between 2-4 million monocytes. 1.7 million monocytes are needed to assay them 
for cytotoxicity of target ovarian cancer cell lines (CaOV3 and OVCAR5) at four different 
concentrations of Sylatron® (Peginterferon alfa-2b) and Actimmune® (Interferon gamma-1b).

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Another 20 mL of whole blood will be collected for the immune-phenotyping of the patients 
circulating immune system and PBMC will be isolated as stated above. Plasma will be stored for 
cytokine analysis and interferon antibodies. In our previous studies 20 mL of peripheral blood 
resulted in a range of 13 million to 27 million total PBMC. Using multi-parameter flow 
cytometry (FC) we will analyze T cell subsets, B cell subsets, myeloid compartment 
(macrophages, monocytes, dendritic cells), and NK cells (Table 4). We will use 5 separate 
panels with 10-12 antibodies per panel, with special emphasis on the detection of molecules 
associated with checkpoint blockade (PD1, PD2, PDL1, PDL2, CTLA4) to establish hypotheses 
for future clinical trials. In total, the panels will allow for the analysis of 137 distinct populations 
of immune cells. Blood from healthy donors acquired from the DTM will also be analyzed. The 
analysis of PBMC from healthy controls will allow comparisons between women affected with 
ovarian cancer and those without cancer. Using fluorescence minus one (FMO) gating strategy 
we will quantify the number of background events counted. These events will be subtracted from 
the total events counted to produce a quantification of true events. Measurement of 100,000 
events per sample will enable us to perform statistical comparison of changes between healthy 
and affected, and changes within patients due to treatment. Counting a large number of events 
and using healthy age matched controls will allow us to statistically determine if there is a 
significant change between healthy donors, treatment groups, and between patients. When 
available, cells from ascites will be analyzed similarly.
Table 4. Cell Populations Analyzed by Flow Cytometry
Cell Type
Subsets
T cell
CD4, CD8, naïve, central memory, peripheral memory, effector, regulatory
B Cell
Naïve, memory, plasma
Monocyte
Classical, intermediate, non-classical
Dendritic Cell
cDC1, cDC2, pDC
Macrophages
M1, M2
NK Cell
Cytokine producers, cytotoxic
Excess apheresis fractions and ascites (if available) will be viably frozen for future functional 
studies. 
Testing will be performed in the NIH laboratory, Building 10, RM 4B55.  Specimen processing 
and storage will be performed by the Blood Processing Core (BPC).  See Section 5.2.

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5.1.2
Plasma
5.1.2.1
Anti-interferon antibodies
At baseline and at the last cycle on study, patients will be monitored for the development of 
antibodies against interferons. Although IFNα and IFNγ are recombinant human proteins, 
repeated administration of these drugs can result in the development of antibodies against them 
[37, 38]. We will use two assays in our study to measure in participants the amount of: (a) 
binding antibodies to Sylatron® (Peginterferon alfa-2b) and Actimmune® (Interferon gamma-
1b), and (b) neutralizing antibodies to both IFNs (antibodies that block the antiviral and 
antiproliferative function of the IFNs). 
We will assay for IFN binding antibodies using a high-throughput multiplex assay [39]modified 
ELISA technique [38]. Briefly, plasma will be diluted 1:100 in PBS and incubated for 30 
minutes with differentially fluorescing magnetic beads that have been covalently coupled to 
2.5ug recombinant human IFNa (PBL Biomedical Laboratories; catalog 11101-2) or IFNg (R&D 
Systems; catalog 285-IF-100/CF). Beads will be washed then incubated with 1ug/mL PE-labeled 
goat anti-human IgG (eBioscience; catalog 12-4998) for an additional 30 minutes before being 
washed again and run in a multiplex assay on the BioPlex X200 instrument (BioRad). Serum and 
ascitic fluid isolated from the patients and serum isolated from healthy age matched controls will 
be added and serially diluted as a negative control. For positive controls antibodies (WHO 
reference reagents) to IFNα-2b and IFNγ-1b will be used.  
To detect IFN neutralizing antibody, plasma or ascites (when present) samples which are positive 
for IFN binding antibodies will be mixed with serial dilutions of Sylatron or Actimmune and 
then added to 96-well tissue culture plates seeded with 1x104 target cells (immortalized lung 
epithelial alveolar cells A549) [37]. WHO IFN international standards for IFNs α and γ and 
WHO neutralizing IFN antibody reference reagents will be used as controls. After 15-24 h 
incubation, encephalomyocarditis virus (EMCV) will be added to the cultures and incubated for 
an additional 24 h. If IFNs are present the virus will be unable to replicate allowing the cells to 
grow. If IFNs are not present (neutralized by antibody) the EMCV will kill the target cells. 
Percent cell viability of cell control can then be correlated to the WHO IFN international 
standards to calculate how much neutralizing antibody is present.
5.1.2.2
Multiplex Arrays
Plasma will be used for analysis of circulating cytokines. We will use multiplex cytokine arrays 
to analyze fluids compartment of blood and ascites. Multiplex allows for the analysis of up to 45 
proteins including cytokines, chemokines, and growth factors with relatively small volumes of 
samples. We will use the Human ProcartaPlex Human Panel from eBioscience, or similar 
product.

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5.1.3
Tissue biopsies (expansion phase) 
Biopsies will be requested from all study participants in the expansion phase and will be 
obtained if clinically feasible. Tumor amenable to biopsy is not required for enrollment. If 
determined to be amenable to biopsy, however, tissue will be harvested by 18g core needle by an 
interventional radiologist. Up to 4 cores will be stored – 2 will be frozen immediately in OCT 
medium, and 2 will be formalin fixed and paraffin embedded. An amendment to this protocol 
(Amendment I, version date 02/11/2020) was submitted for Radiation Safety Committee and 
IRB approval prior to implementation of the expansion phase.
5.1.3.1
Multiparameter Microscopy
Correlative studies will include evaluation for in vivo evidence that interferons promote 
differentiation of monocytes to M1 macrophages resulting in tumor infiltration and death. 
Current advances in histology have enabled us to analyze up to 14 different proteins on a single 
histology slide. This technology can be used to study different cell populations and their 
interactions on the same section of tissue, instead of protein expression on serial sections. We 
will section biopsies and stain for: CD68, IL-12, CXCL10, NOS2, IL-10, and Arginase-1 
(macrophage/monocyte); TRAIL, CD3, CD4, CD8 (T cell markers); FoxP3, PDL1, and PDL2 
(Lymphocyte Inhibitory Markers). This analysis will allow us to quantify the presence and 
phenotype of immune cells in tissue before and after exposure to study agents. 
5.1.4
Sampling Schedule
Test/assay
Volume blood 
(approx) or 
ascites
Type of 
tube
Collection point 
(+/- 48hrs)
Location of 
specimen analysis
Cellular 
component: 
40 mL
EDTA * 
(10 mL 
tubes x 3)
D2 (cycles 1 and 
2 only), 
Final visit
Women’s 
Malignancies Branch 
(WMB; formerly Dr. 
Annunziata’s lab)
Plasma or ascites 
fluid:
Anti-IFN 
antibodies
3 mL
EDTA **
(from 
above 
tubes)
C1D1,  Final 
Visit
Dr. Steve Holland’s 
lab, NIAID
Multiplex cytokine 
arrays
10 mL
(from 
above 
tubes)
D1 each cycle
FNLCR clinical 
services program
Biopsy (expansion 
cohort only)
NA
NA
D1 cycles 1 and 
2, and at 
progression
WMB (formerly Dr. 
Annunziata’s lab)

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* first 2 cycles, collect 30 mL (3 x 10-mL tubes)
** subsequent cycles, collect 1 x 10-mL tube only
5.2
SAMPLE STORAGE, TRACKING AND DISPOSITION
Research samples will be obtained from patients, as described in the protocol.  Samples will be 
ordered in CRIS and tracked through a Clinical Trial Data Management system. Should a CRIS 
screen not be available, the CRIS downtime procedures will be followed. Samples will not be 
sent outside NIH without appropriate approvals and/or agreements, if required.
All specimens obtained in the protocol are used as defined in the protocol. Any specimens that 
are remaining at the completion of the protocol will be stored in the conditions described below. 
The study will remain open so long as sample or data analysis continues. Samples from 
consenting subjects will be stored until they are no longer of scientific value or if a subject 
withdraws consent for their continued use, at which time they will be destroyed. 
If the patient withdraws consent the participant’s data will be excluded from future distributions, 
but data that have already been distributed for approved research use will not be able to be 
retrieved.
The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will 
be per the requirements of section 7.2.
5.2.1
Figg Lab Blood Processing Core (BPC)
5.2.1.1
Sample Collection
Samples will be collected as described above.  Record the date and exact time of draw on the 
tube. Please page 102-11964 (Figg lab) for sample pick-up. 
Please e-mail NCIBloodcore@mail.nih.gov at least 24 hours before transporting samples (the 
Friday before is preferred).
For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 
240-760-6190 (main clinical pharmacology lab number).
For questions regarding sample processing, contact NCIBloodcore@mail.nih.gov.
The samples will be processed, barcoded, and stored in Dr. Figg’s lab until requested by the 
investigator.
5.2.1.2
Sample Data Collection
All samples sent to the Blood Processing Core (BPC) will be barcoded, with data entered and 
stored in the Labmatrix utilized by the BPC. This is a secure program, with access to Labmatrix 
limited to defined Figg lab personnel, who are issued individual user accounts. Installation of 
Labmatrix is limited to computers specified by Dr. Figg. These computers all have a password 
restricted login screen. 
Labmatrix creates a unique barcode ID for every sample and sample box, which cannot be traced 
back to patients without Labmatrix access. The data recorded for each sample includes the 
patient ID, name, trial name/protocol number, time drawn, cycle time point, dose, material type, 
as well as box and freezer location. Patient demographics associated with the clinical center 

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patient number are provided in the system. For each sample, there are notes associated with the 
processing method (delay in sample processing, storage conditions on the ward, etc.).
5.2.1.3
Sample Storage and Destruction
Barcoded samples are stored in barcoded boxes in a locked freezer at either -20 or -80°C 
according to stability requirements.  These freezers are located onsite in the BPC and offsite at 
NCI Frederick Central Repository Services in Frederick, MD. Visitors to the laboratory are 
required to be accompanied by laboratory staff at all times. 
Access to stored clinical samples is restricted. Samples will be stored until requested by a 
researcher named on the protocol. All requests are monitored and tracked in Labmatrix. All 
researchers are required to sign a form stating that the samples are only to be used for research 
purposes associated with this trial (as per the IRB approved protocol) and that any unused 
samples must be returned to the BPC. It is the responsibility of the NCI Principal Investigator to 
ensure that the samples requested are being used in a manner consistent with IRB approval.
Following completion of this study, samples will remain in storage as detailed above. Access to 
these samples will only be granted following IRB approval of an additional protocol, granting 
the rights to use the material. 
Sample barcodes are linked to patient demographics and limited clinical information. This 
information will only be provided to investigators listed on this protocol, via registered use of the 
Labmatrix. It is critical that the sample remains linked to patient information such as race, age, 
dates of diagnosis and death, and histological information about the tumor, in order to correlate 
genotype with these variables.
5.2.2
NCI-Frederick Leidos Biomedical, Inc. Laboratory
Blood and tissue collected during the course of this study will follow storage, handling and labeling 
procedures to ensure that security, confidentiality and sample integrity are maintained. All samples 
(blood or tissue) are tracked by distinct identification labels that include a unique patient identifier 
and date of specimen collection. Thus, samples will be coded and linked, with access to personal 
data restricted to the study investigators.  
All cryopreserved samples are tracked for freezer location and storage criteria. All samples are 
stored in a locked freezer at -70C according to stability requirements.  These freezers are located 
offsite at NCI-Frederick, at the Leidos Biomedical, Inc. Lab in Frederick, MD.  Samples will be 
stored until requested by a researcher named on the protocol.  All use and requests for use will be 
recorded by the Leidos Biomedical, Inc. Lab.  Any unused samples must be returned.
Some samples as indicated below may be stored in monitored freezers/refrigerators in the 
investigator’s laboratory at specified temperatures with alarm systems in place. 
At the termination of this protocol, samples will remain in storage as detailed above.  If additional 
studies are to be performed on any samples retaining patient identifiers, obtained during the 
conduct of this trial, a Request to Conduct Research for Stored Human Samples Specimens, or 
Data Collected in a Terminated NIH-IRB Protocol will be submitted.  Otherwise, access to these 
samples will only be granted following IRB approval of an additional protocol, granting the rights 
to use the material.  If specimens are to be discarded at any point, they will be disposed of in 
accordance with the environmental protection laws, regulations and guidelines of the Federal 
Government and the State of Maryland.

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5.2.3
Women’s Malignancies Branch (formerly Annunziata Laboratory)
Barcoded samples will be processed and stored by the Blood Processing Core (BPC) 
immediately after collection, and will remain with the BPC until requested for research use by 
the laboratory for planned analyses.   
5.2.4
Holland Laboratory, NIAID
Access to patient identifying information will be restricted to appropriately trained members of 
the lab; samples will be deidentified by the lab before transfer to the Holland laboratory. Samples 
will be processed immediately by the Holland laboratory using validated SOPs in order to ensure 
specimen quality.  All laboratory personnel will be trained to adhere to SOPs and will be 
monitored for high-quality performance.  Using a computerized inventory system and a backup 
hardcopy process, all specimen collection and processing steps will be documented and the 
specific location of each specimen will be tracked. Each new specimen collected will be assigned 
a unique barcode identifier that can be linked to the original specimen collected and other 
relevant information within the inventory system.  After processing, samples will not be stored in 
the Holland lab, but will be transferred back to the Women’s Malignancies Branch (WMB) for 
storage.  
6
DATA COLLECTION AND EVALUATION 
6.1
DATA COLLECTION
The PI will be responsible for overseeing entry of data into a 21 CFR Part 11-compliant data 
capture system provided by the NCI CCR and ensuring data accuracy, consistency and 
timeliness. The principal investigator, associate investigators/research nurses and/or a contracted 
data manager will assist with the data management efforts. Primary and final analyzed data will 
have identifiers so that research data can be attributed to an individual human subject participant.
All adverse events will be collected as required in accordance with FDA regulations.
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event.  
Document AEs from the first study intervention, Study Day 0, through 30 days after the 
agent/intervention was last administered. Beyond 30 days after the last intervention, only adverse 
events which are serious and related to the study intervention need to be recorded.
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following:
•
Results in discontinuation from the study
•
Is associated with clinical signs or symptoms 
•
Requires treatment or any other therapeutic intervention
•
Is associated with death or another serious adverse event, including hospitalization. 
•
Is judged by the Investigator to be of significant clinical impact
•
If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the patient’s 
outcome.
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH 
Intramural Records Retention Schedule as applicable. 

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Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in section 7.2.1.
6.2
DATA SHARING PLANS
6.2.1
Human Data Sharing Plan
What data will be shared?
I will share human data generated in this research for future research as follows:
•
Coded, linked data in an NIH-funded or approved public repository.  
•
Coded, linked data in BTRIS (automatic for activities in the Clinical Center)
•
Coded, linked or identified data with approved outside collaborators under appropriate 
agreements.
How and where will the data be shared? 
Data will be shared through:
•
An NIH-funded or approved public repository: clinicaltrials.gov.
•
BTRIS (automatic for activities in the Clinical Center)
•
Approved outside collaborators under appropriate individual agreements.
•
Publication and/or public presentations.
When will the data be shared?
•
Before publication.
•
At the time of publication or shortly thereafter.
6.3
RESPONSE CRITERIA
For the purposes of this study, patients should be re-evaluated for response every 8 weeks.  In 
addition to a baseline scan, confirmatory scans should also be obtained 4-8 (not less than 4) 
weeks following initial documentation of objective response.
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1)[40].  Changes in the largest diameter (unidimensional measurement) of the tumor 
lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST 
criteria.
6.3.1
Definitions
Evaluable for toxicity:  All patients who signed consent will be evaluable.
Evaluable for objective response: Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response.  These patients will have their response classified 
according to the definitions stated below.  (Note:  Patients who exhibit objective disease 
progression prior to the end of cycle 1 will also be considered evaluable.)
Evaluable Non-Target Disease Response:  Patients who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 

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disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions. 
6.3.2
Disease Parameters
Measurable disease:  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as:
•
By chest x-ray>20 mm
•
By CT scan:
o
Scan slice thickness 5 mm or under: as >10 mm 
o
Scan slice thickness >5 mm: double the slice thickness 
•
With calipers on clinical exam > 10 mm
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters).
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph 
node must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm).  At baseline and in follow-up, only the short axis will 
be measured and followed.
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses 
(not followed by CT or MRI), are considered as non-measurable.
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not 
be considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts.
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, 
if they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions.
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded 
and measured at baseline.  Target lesions should be selected on the basis of their size (lesions 
with the longest diameter), be representative of all involved organs, but in addition should be 
those that lend themselves to reproducible repeated measurements.  It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be selected.  A 
sum of the diameters (longest for non-nodal lesions, short axis for nodal lesions) for all target 
lesions will be calculated and reported as the baseline sum diameters.  If lymph nodes are to be 
included in the sum, then only the short axis is added into the sum.  The baseline sum diameters 
will be used as reference to further characterize any objective tumor regression in the measurable 
dimension of the disease.
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up. 

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6.3.3
Methods for Evaluation of Measurable Disease
All measurements should be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations should be performed as closely as possible to the beginning of treatment and 
never more than 4 weeks before the beginning of the treatment.
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam.
Clinical lesions:  Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed using calipers 
(e.g., skin nodules).  In the case of skin lesions, documentation by color photography, including a 
ruler to estimate the size of the lesion, is recommended. 
Chest x-ray:  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung.  However, CT is preferable. 
Conventional CT and MRI:  This guideline has defined measurability of lesions on CT scan 
based on the assumption that CT slice thickness is 5 mm or less.  If CT scans have slice thickness 
greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness.  
MRI is also acceptable in certain situations (e.g. for body scans).  
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal 
resolution; however, there are many image acquisition variables involved in MRI, which greatly 
impact image quality, lesion conspicuity, and measurement.  Furthermore, the availability of 
MRI is variable globally.  As with CT, if an MRI is performed, the technical specifications of the 
scanning sequences used should be optimized for the evaluation of the type and site of disease.  
Furthermore, as with CT, the modality used at follow-up should be the same as was used at 
baseline and the lesions should be measured/assessed on the same pulse sequence.  It is beyond 
the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all 
scanners, body parts, and diseases.  Ideally, the same type of scanner should be used and the 
image acquisition protocol should be followed as closely as possible to prior scans.  Body scans 
should be performed with breath-hold scanning techniques, if possible.
PET-CT:  At present, the low dose or attenuation correction CT portion of a combined PET-CT 
is not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if 
the site can document that the CT performed as part of a PET-CT is of identical diagnostic 
quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be 
used for RECIST measurements and can be used interchangeably with conventional CT in 
accurately measuring cancer lesions over time.  Note, however, that the PET portion of the CT 
introduces additional data which may bias an investigator if it is not routinely or serially 
performed.  
Ultrasound:  Ultrasound is not useful in assessment of lesion size and should not be used as a 
method of measurement.  Ultrasound examinations cannot be reproduced in their entirety for 
independent review at a later date and, because they are operator dependent, it cannot be 
guaranteed that the same technique and measurements will be taken from one assessment to the 
next.  If new lesions are identified by ultrasound in the course of the study, confirmation by CT 

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or MRI is advised.  If there is concern about radiation exposure at CT, MRI may be used instead 
of CT in selected instances.
Endoscopy, Laparoscopy:  The utilization of these techniques for objective tumor evaluation is 
not advised.  However, such techniques may be useful to confirm complete pathological 
response when biopsies are obtained or to determine relapse in trials where recurrence following 
complete response (CR) or surgical resection is an endpoint.
Tumor markers:  Tumor markers alone cannot be used to assess response.  If markers are initially 
above the upper normal limit, they must normalize for a patient to be considered in complete 
clinical response.  Specific guidelines for both CA-125 response (in recurrent ovarian cancer) 
and PSA response (in recurrent prostate cancer) have been published [41-43].  In addition, the 
Gynecologic Cancer Intergroup has developed CA-125 progression criteria which are to be 
integrated with objective tumor assessment for use in first-line trials in ovarian cancer [44].
Cytology, Histology:  These techniques can be used to differentiate between partial responses 
(PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as 
germ cell tumors, where known residual benign tumors can remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease.
FDG-PET:  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in 
assessment of progression (particularly possible 'new' disease).  New lesions on the basis of 
FDG-PET imaging can be identified according to the following algorithm: 
•
Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion.
•
No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If the 
positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan).  If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not PD.
•
FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in 
cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring.  The use of FDG-PET in this circumstance should be prospectively described in 
the protocol and supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity.
 Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image.

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6.3.4
Response Criteria
6.3.4.1
Evaluation of Target Lesions
Complete Response (CR): Disappearance of all target lesions.  Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm.
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, 
taking as reference the baseline sum of diameters.
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the 
smallest on study).  In addition to the relative increase of 20%, the sum must also demonstrate an 
absolute increase of at least 5 mm.  (Note:  the appearance of one or more new lesions is also 
considered progressions).
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum of diameters while on study.
6.3.4.2
Evaluation of Non-Target Lesions
Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor 
marker level.  All lymph nodes must be non-pathological in size (<10 mm short axis).
Note:  If tumor markers are initially above the upper normal limit, they must normalize for a 
patient to be considered in complete clinical response.
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal 
progression of existing non-target lesions.  Unequivocal progression should not normally trump 
target lesion status.  It must be representative of overall disease status change, not a single lesion 
increase.    
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the 
treating physician should prevail in such circumstances, and the progression status should be 
confirmed at a later time by the review panel (or Principal Investigator).
6.3.4.3
Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment until 
disease progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).  The patient's best response assignment will 
depend on the achievement of both measurement and confirmation criteria.
For Patients with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Response
Best Overall Response when 
Confirmation is Required*
CR
CR
No
CR
>4 wks. Confirmation**

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CR
Non-
CR/Non-PD
No
PR
CR
Not 
evaluated
No
PR
PR
Non-
CR/Non-
PD/not 
evaluated
No
PR
>4 wks. Confirmation**
SD
Non-
CR/Non-
PD/not 
evaluated
No
SD
Documented at least once >4 
wks. from baseline**
PD
Any
Yes or 
No
PD
Any
PD***
Yes or 
No
PD
Any
Any
Yes
PD
no prior SD, PR or CR
*
See RECIST 1.1 manuscript for further details on what is evidence of a new lesion.
**
Only for non-randomized trials with response as primary endpoint.
***
In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as 
disease progression.
Note:
Patients with a global deterioration of health status requiring discontinuation of treatment without 
objective evidence of disease progression at that time should be reported as “symptomatic 
deterioration.”  Every effort should be made to document the objective progression even after 
discontinuation of treatment.
For Patients with Non-Measurable Disease (i.e., Non-Target Disease)
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD

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*  ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since SD is increasingly used 
as an endpoint for assessment of efficacy in some trials so to assign this category when no lesions can be 
measured is not advised
6.3.5
Duration of Response
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started).
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented.
Duration of stable disease:  Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements. 
6.3.6
Progression-Free Survival
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first.
6.4
TOXICITY CRITERIA
The following adverse event management guidelines are intended to ensure the safety of each 
patient while on the study.  The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE 
reporting.  All appropriate treatment areas should have access to a copy of the CTCAE version 
4.0.  A copy of the CTCAE version 4.0 can be downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm
7
NIH REPORTING REQUIREMENTS/DATA AND SAFETY MONITORING PLAN
7.1
DEFINITIONS
Please refer to definitions provided in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/hrpp-policy-guidelines/.
7.2
OHSRP OFFICE OF COMPLIANCE AND TRAINING /  IRB REPORTING
7.2.1
Expedited Reporting
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802 Non-Compliance Human Subjects Research found at: https://irbo.nih.gov/hrpp-policy-
guidelines/.
Note: Only IND Safety Reports that meet the definition of an unanticipated problem will need to 
be reported per these policies.

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7.2.2
IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found at: 
https://irbo.nih.gov/hrpp-policy-guidelines/.
7.3
NCI CLINICAL DIRECTOR REPORTING 
Problems expeditiously reviewed by the OHSRP in the NIH eIRB system will also be reported to 
the NCI Clinical Director/designee; therefore, a separate submission for these reports is not 
necessary. 
In addition to those reports, all deaths that occur within 30 days after receiving a research 
intervention should be reported via email unless they are due to progressive disease.  
To report these deaths, please send an email describing the circumstances of the death to 
NCICCRQA@mail.nih.gov within one business day of learning of the death.
7.4
NIH REQUIRED DATA AND SAFETY MONITORING PLAN
7.4.1
Principal Investigator/Research Team 
The clinical research team will meet on a regular basis when patients are being actively treated 
on the trial to discuss each patient. Decisions about dose level enrollment and dose escalation if 
applicable will be made based on the toxicity data from prior patients. 
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Events meeting requirements for expedited reporting as described in 
section 7.2.1 will be submitted within the appropriate timelines. 
The principal investigator will review adverse event and response data on each patient to ensure 
safety and data accuracy. The principal investigator will personally conduct or supervise the 
investigation and provide appropriate delegation of responsibilities to other members of the 
research staff. 
7.4.2
Data Safety Monitoring Board (DSMB)
This protocol does not require monitoring by a DSMB.
8
SPONSOR PROTOCOL/SAFETY REPORTING
8.1
DEFINITIONS
8.1.1
Adverse Event 
Any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the 
use of a medicinal (investigational) product, whether or not related to the medicinal 
(investigational) product (ICH E6 (R2))
8.1.2
Serious Adverse Event (SAE)
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following:
•
Death,

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•
A life-threatening adverse event (see section 8.1.3)
•
Inpatient hospitalization or prolongation of existing hospitalization 
o
A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery 
arranged prior to the start of the study), a planned hospitalization for pre-existing 
condition, or a procedure required by the protocol, without a serious deterioration in 
health, is not considered a serious adverse event.
o
A hospitalization/admission that is solely driven by non-medical reasons (e.g., 
hospitalization for patient or subject convenience) is not considered a serious adverse 
event. 
o
Emergency room visits or stays in observation units that do not result in admission to 
the hospital would not be considered a serious adverse event. The reason for seeking 
medical care should be evaluated for meeting one of the other serious criteria.
•
Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions
•
A congenital anomaly/birth defect
•
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition.
8.1.3
Life-threatening 
An adverse event or suspected adverse reaction is considered "life-threatening" if, in the view of 
either the investigator or sponsor, its occurrence places the patient or subject at immediate risk of 
death. It does not include an adverse event or suspected adverse reaction that, had it occurred in a 
more severe form, might have caused death. (21CFR312.32)
8.1.4
Severity
The severity of each Adverse Event will be assessed utilizing the CTCAE version 4.0.
8.1.5
Relationship to Study Product
All AEs will have their relationship to study product assessed using the terms:  related or not 
related.  
•
Related – There is a reasonable possibility that the study product caused the adverse 
event. Reasonable possibility means that there is evidence to suggest a causal relationship 
between the study product and the adverse event.
•
Not Related – There is not a reasonable possibility that the administration of the study 
product caused the event.
8.1.6
Adverse Events of Special Interest (AESI)
Not applicable.

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8.2
ASSESSMENT OF SAFETY EVENTS
AE information collected will include event description, date of onset, assessment of severity 
and relationship to study product and alternate etiology (if not related to study product), date of 
resolution of the event, seriousness and outcome. The assessment of severity and relationship to 
the study product will be done only by those with the training and authority to make a diagnosis 
and listed on the Form FDA 1572 as the site principal investigator or sub-investigator.  AEs 
occurring during the collection and reporting period will be documented appropriately regardless 
of relationship.  AEs will be followed through resolution.
SAEs will be:
•
Assessed for severity and relationship to study product and alternate etiology (if not 
related to study product) by a licensed study physician listed on the Form FDA 1572 as 
the site principal investigator or sub-investigator.
•
Recorded on the appropriate SAE report form, the medical record and captured in the 
clinical database.
•
Followed through resolution by a licensed study physician listed on the Form FDA 1572 
as the site principal investigator or sub-investigator.
For timeframe of recording adverse events, please refer to section 6.1. All serious adverse events 
recorded from the time of first investigational product administration must be reported to the 
sponsor with the exception of any listed in section 8.4. 
8.3
REPORTING OF SERIOUS ADVERSE EVENTS
Any AE that meets protocol-defined serious criteria or meets the definition of Adverse Event of 
Special Interest that require expedited reporting must be submitted immediately (within 24 hours 
of awareness) to OSRO Safety using the CCR SAE report form.  Any exceptions to the 
expedited reporting requirements are found in section 8.4.
All SAE reporting must include the elements described in section 8.2.
SAE reports will be submitted to the Center for Cancer Research (CCR) at: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator.  CCR SAE report form 
and instructions can be found at: https://nih.sharepoint.com/:u:/r/sites/NCI-CCR-OCD-
Communications/SitePages/Forms-and-Instructions.aspx?csf=1&web=1&e=uWBXtI.Following 
the assessment of the SAE by OSRO, other supporting documentation of the event may be 
requested by the OSRO Safety and should be provided as soon as possible.
8.4
WAIVER OF EXPEDITED REPORTING TO CCR 
Not applicable.
8.5
SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL COLLABORATORS
8.5.1
Horizon Pharma, Inc.
All events listed below must be reported in the defined timelines to OSROSafety@mail.nih.gov. 
OSRO will send all reports to the manufacturer as described below.

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8.5.1.1
To be reported by the Office of Sponsor and Regulatory Oversight (OSRO)
Copies of all safety reports will be sent to Horizon concurrently with their submission to the FDA, 
along with any other information affecting patient safety, including the following:
•
Information on any pregnancy and its outcome occurring in a subject participating in the 
Study within two working days after becoming aware of the information.
8.5.1.2
To be reported by study team
•
Any premature termination of the study for safety reasons;
•
Any urgent safety measure (e.g. stop/hold recruitment);
•
Any amendment of the protocol for safety reasons; and
•
Any communication of safety concern from competent authorities and a Data Safety 
Monitoring Board (DSMB), if applicable.
All safety communication to Horizon will be sent to:
Email:    AdverseEvents@horizonpharma.com
Fax:    1-800-860-7836
8.5.2
Merck Sharp & Dohme Corp.
All safety communications will be sent to Merck within two business days of but not longer than 
three calendar days of receipt of the information, regardless of whether or not a causal 
relationship with the Merck product exists.  All FDA communications, including annual reports, 
will be sent to Merck concurrently with their submission to the FDA, along with any other 
information affecting patient safety, including the following:
8.5.2.1
To be reported by the Office of Sponsor and Regulatory Oversight (OSRO)
All events listed below must be reported in the defined timelines to OSROSafety@mail.nih.gov. 
The OSRO will send all reports to the manufacturer as described below.
•
All reports of Merck study drug exposure during pregnancy or lactation (including a 
female partner of a male study subject, whether associated with an AE or not) within the 
same timeline for an SAE.  The Principal Investigator will follow to term to obtain the 
outcome of the pregnancy, which will also be reported to Merck.
8.5.2.2
To be reported by study team
•
Notification of a possible defect in the Merck product within one business day of first 
becoming aware of the possible defect.
•
Notification within 24 hours of first becoming aware when the FDA or any other 
regulatory authority notifies the site of a pending inspection.
8.5.2.3
All safety communication to Merck will be sent to:
Email:  aer_mailbox@merck.com
Fax:  215-661-6229
8.6
REPORTING PREGNANCY
All required pregnancy reports/follow-up to OSRO will be submitted to: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator.  Forms and instructions 

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can be found here: https://nih.sharepoint.com/:u:/r/sites/NCI-CCR-OCD-
Communications/SitePages/Forms-and-Instructions.aspx?csf=1&web=1&e=uWBXtI
8.6.1
Maternal exposure
If a patient becomes pregnant during the course of the study, the study treatment should be 
discontinued immediately and the pregnancy reported to the Sponsor no later than 24 hours of 
when the Investigator becomes aware of it. The Investigator should notify the Sponsor no later 
than 24 hours of when the outcome of the Pregnancy becomes known. 
Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects 
and spontaneous miscarriages that meet serious criteria (section 8.1.2) should be reported as 
SAEs. 
The outcome of all pregnancies should be followed up and documented.
8.6.2
Paternal exposure
Not applicable to this trial, as men are not included in the patient population.
8.7
REGULATORY REPORTING FOR STUDIES CONDUCTED UNDER CCR-SPONSORED IND
Following notification from the investigator, CCR, the IND sponsor, will report any suspected 
adverse reaction that is both serious and unexpected in expedited manner to the FDA in 
accordance to 21 CFR 312.32.  CCR will report an AE as a suspected adverse reaction only if 
there is evidence to suggest a causal relationship between the study product and the adverse 
event.  CCR will notify FDA and all participating investigators (i.e., all investigators to whom 
the sponsor is providing drug under its INDs or under any investigator’s IND) in an IND safety 
report of potential serious risks from clinical trials or any other source, as soon as possible, in 
accordance to 21 CFR Part 312.32. 
All serious events will be reported to the FDA at least annually in a summary format.
8.8
SPONSOR PROTOCOL DEVIATION REPORTING
A Protocol Deviation is defined as any non-compliance with the clinical trial Protocol, Manual 
of Operational Procedures (MOP) and other Sponsor approved study related documents, GCP, or 
protocol-specific procedural requirements on the part of the participant, the Investigator, or the 
study site staff inclusive of site personnel performing procedures or providing services in support 
of the clinical trial.
It is the responsibility of the study Staff to document any protocol deviation identified by the 
Staff or the site Monitor in the CCR Protocol Deviation Tracking System (PDTS) online 
application. The entries into the PDTS online application should be timely, complete, and 
maintained per CCR PDTS user requirements. 
In addition, any deviation to the protocol should be documented in the participant’s source 
records and reported to the reviewing IRB per their guidelines. OSRO required protocol 
deviation reporting is consistent with E6(R2) GCP: Integrated Addendum to ICH E6(R1): 4.5 
Compliance with Protocol; 5.18.3 (a), and 5.20 Noncompliance; and ICH E3 16.2.2 Protocol 
deviations.

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9
CLINICAL MONITORING PLAN
As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring 
program. The CCR’s program allows for confirmation of: study data, specifically data that could 
affect the interpretation of primary and secondary study endpoints; adherence to the protocol, 
regulations, ICH E6, and SOPs; and human subjects’ protection. This is done through 
independent verification of study data with source documentation focusing on:
•
Informed consent process
•
Eligibility confirmation
•
Drug administration and accountability
•
Adverse events monitoring
•
Response assessment.
The monitoring program also extends to multi-site research when the CCR is the coordinating 
center.
This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified 
by training and experience to monitor the progress of clinical trials. Personnel monitoring this 
study will not be affiliated in any way with the trial conduct. 
10 STATISTICAL CONSIDERATIONS  
Patients will be accrued in standard 3+3 dose escalation design, with expansion to 6 patients at 
the MTD and 10 additional patients at the MTD to allow for sufficient patients to perform 
correlative studies.
The 16 patients treated at the MTD (6 from dose escalation /MTD determination plus 10 
additional patients) will be used to evaluate biologic correlates. With 16 patients, there would be 
80% power to detect a change (either actual change or fold/relative change as appropriate) in the 
number of activated monocytes from baseline to after one cycle of treatment which would be 
equal to ¾ of a standard deviation of the difference measured (effect size 0.75) with a two-tailed 
0.05 significance level paired t-test. If there are usable paired results from 10 patients instead of 
16, this would result in the ability to detect a change with a 1.0 effect size based on the same 
parameters. In addition, a large number of other parameters will be obtained via flow cytometry 
and the changes from baseline to after one cycle of therapy will be determined. Given the large 
number of possible tests performed and the exploratory nature of the evaluation, there will not be 
any formal adjustment for multiple comparisons for these parameters. However, with 16 patients, 
there would be 80% power for any of the tests comparing baseline to post-treatment to detect a 
one SD difference between the two time points (effect size 1.0) with a two-tailed 0.01 
significance level paired t-test; if there are 10 patients, there would be 80% power to detect a 1.0 
effect size with a two-tailed 0.05 significance level paired t-test. The results of these exploratory 
tests will be reported in the context of the number of such tests performed.
The clinical response rate (in patients with measurable disease) and time to progression (in all 
patients) will also be estimated in a preliminary fashion. Appropriate confidence intervals will be 
provided along with fractions responding and a Kaplan-Meier curve of TTP.
It is estimated that up to 24 patients will be required to complete all 4 dose levels plus 10 
additional patients will be needed at the MTD. Thus up to 34 evaluable patients may be required. 

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In order to allow for a small number of inevaluable patients, the accrual ceiling will be set at 40 
patients. Expected accrual rate is 1-2 patients per month. The DLT period is one cycle.
11 COLLABORATIVE AGREEMENTS
A Clinical Trials Agreement (CTA #1042-17) was executed between the National Cancer 
Institute (NCI)/National Institutes of Health (NIH) and Horizon Pharma, Inc. to receive 
Actimmune.
A Clinical Trials Agreement (CTA #01047) was executed between the National Cancer Institute 
(NCI)/National Institutes of Health (NIH) and Merck Sharp & Dohme Corp. to receive 
Sylatron®.
12 HUMAN SUBJECTS PROTECTIONS 
12.1 RATIONALE FOR SUBJECT SELECTION
This study will be open to all women with recurrent epithelial ovarian, fallopian, and peritoneal 
cancer regardless of ethnicity, or race provided that the aforementioned inclusion and exclusion 
criteria are met. This study will be recruited through internal referral, our local physician referral 
base, and through various websites such as clinicaltrials.gov.  All individuals with epithelial 
ovarian, fallopian, and peritoneal cancer that is refractory to standard care are eligible according 
to the eligibility criteria within section 2.1.
Female patients all racial /ethnic groups are eligible for this study if they meet the eligibility 
criteria outlined in section 2.1. To date, there is no information that suggests that differences in 
drug metabolism or disease response would be expected in one ethnic group compared to 
another.  Efforts will be made to extend accrual to each representative population, but in this 
preliminary study, a balance must be struck between patient safety considerations and limitations 
on the number of individuals exposed to potentially toxic and/or ineffective treatments on the 
one hand and the need to explore racial/ethnic aspects of clinical research on the other hand.  If 
differences in outcome that correlate to ethnic identity are noted, accrual may be expanded or a 
follow-up study may be written to investigate those differences more fully.
12.2 PARTICIPATION OF CHILDREN
Epithelial cancer of the ovary, fallopian tubes, or peritoneum in children is an exceedingly rare, 
reportable disease. Patients under the age of 18 will be excluded from study.
12.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT
Adults unable to give consent are excluded from enrolling in the protocol.  However, re-consent 
may be necessary and there is a possibility, though unlikely, that subjects could become 
decisionally impaired. For this reason and because there is a prospect of direct benefit from 
research participation (section 12.5), all subjects ≥ age 18 will be offered the opportunity to fill 
in their wishes for research and care, and assign a substitute decision maker on the “NIH 
Advance Directive for Health Care and Medical Research Participation” form so that another 
person can make decisions about their medical care in the event that they become incapacitated 
or cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH 
Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an 
independent assessment of whether an individual has the capacity to provide consent; assistance 

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in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the 
capacity to appoint a surrogate.  For those subjects that become incapacitated and do not have 
pre-determined substitute decision maker, the procedures described in  NIH HRPP SOP 14E for 
appointing a surrogate decision maker for adult subjects who are (a) decisionally impaired, and 
(b) who do not have a legal guardian or durable power of attorney, will be followed.
12.4 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS
The potential benefit to a patient who enters study is a reduction in the bulk of her tumor, which 
may or may not have a favorable impact on symptoms and/or survival.  Potential risks include 
the possible occurrence of any of a range of side effects that are listed in the pharmaceutical 
section and the consent document.  The procedure for protecting against or minimizing risks will 
be to medically evaluate patients on a regular basis as described earlier, including initial 
eligibility screening prior to enrollment on the protocol.
12.5 RISKS/BENEFITS ANALYSIS
This risk/benefits analysis applies to all adult subjects on study (i.e., including those who may 
become decisionally impaired/unable to consent during participation).
12.5.1 Potential Risks
12.5.1.1 Risk of Treatment:  Details of the risk of drug therapy are detailed in section 14.
12.5.1.2 Blood draws: Side effects of blood draws include pain and bruising, lightheadedness, 
and rarely, fainting.
12.5.1.3 Apheresis: Side effects of apheresis include pain and bruising, lightheadedness, and 
rarely, fainting.
12.5.1.4 Ascites collection:  The risks associated with colleting ascites are pain and bleeding at 
the catheter site. In order to minimize pain, local anesthesia will be used. Rarely, there 
is a risk of infection at the sampling site. Ultrasound guidance may be used in obtaining 
ascites.
12.5.1.5 CT scans:  In addition to the radiation risks discussed below, risks associated with CT 
scans are allergic reaction to and kidney damage from the contrast dye, nausea, 
vomiting, and anxiety.
12.5.1.6 IP catheter/port placement:  Risks associated with IP catheter/port placement include 
intestinal perforation,  abdominal fluid collection, and death.  With port placement, 
there is an added risk from general anesthesia, if done by a surgeon. The risks of general 
anesthesia could include an allergic reaction to the drugs used, pneumonia, stroke and 
heart attack.  The risk associated with local anesthesia is an allergic reaction to the 
agent.
12.5.1.7 Biopsies:  The risks associated with the biopsy procedure include pain, swelling and/or 
bleeding at the biopsy site; infection; and allergic reaction to the local anesthetic used.  
All care will be taken to minimize risks that may be incurred by catheter placement or tumor 
sampling.  However, there are procedure-related risks (such as bleeding, infection and visceral 
injury) that will be explained fully during informed consent. If patients suffer any physical injury 
as a result of the procedures, immediate medical treatment is available at the NIH’s Clinical 
Center in Bethesda, Maryland.  Although no compensation is available, any injury will be fully 

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evaluated and treated in keeping with the benefits or care to which patients are entitled under 
applicable regulations.
12.5.1.8 Risks of Radiation
The study will involve radiation from the following sources:
•
Up to 3 CT scans as referenced above for the collection of optional biopsies
•
Up to 7 CT scans per year for disease assessment
Subjects in this study may be exposed to approximately 10.1 rem. This amount is more than 
would be expected from everyday background radiation. Being exposed to excess radiation can 
increase the risk of cancer. The risk of getting cancer from the radiation exposure in this study is 
1 out of 100 (1%) and of getting a fatal cancer is 0.5 out of 100 (0.5%). 
12.5.2 Benefits
The benefits include a possible decrease in the size of the tumor and the scientific knowledge 
that could be acquired through this trial.
12.6 CONSENT PROCESS AND DOCUMENTATION
An associate or principal investigator on the trial will inform patients of the purpose, alternatives, 
treatment plan, research objectives and follow-up of this trial.  The patient will be provided an 
IRB-approved consent for review and signature and his/her questions will be answered.  After a 
decision is made to enroll into the study, a signature will be obtained from the patient at a 
subsequent visit.  A copy of the signed informed consent will be placed in the patient's medical 
record.
All patients must have a signed informed consent form and an on-study (confirmation of 
eligibility) form filled out and signed by a participating investigator before entering on study.
For the optional biopsies performed on the protocol, the patient will consent at the time of the 
procedure. If the patient refuses the optional biopsy at that time, the refusal will be documented 
in the medical record and in the research record.
12.6.1 Request for Waiver of Consent for Screening Activities
Prior to the subject signing the consent for this study pre-screening activities listed in section 
2.2.1 may be performed. 
We request a waiver of consent for these activities as they involve only minimal risk to the 
subjects.  A waiver will not adversely affect the rights and welfare of the subjects given that the 
activities are only intended to determine suitability for screening for participation in research 
protocols.  These activities could not practicably be carried out without the wavier as central 
recruiting services, utilized in the NIH Clinical Center, perform pre-screening activities for 
multiple studies and obtaining consent for each one is beyond their resources.  The subjects will 
be provided with additional pertinent information after participation as they will be informed 
whether are or not they are eligible to sign a consent for additional screening.

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12.6.2 Telephone reconsent: 
Telephone reconsent will be permitted for amendments requiring reconsent when it isn’t feasible 
for the participant to return to the Clinical Center for that purpose. Telephone consent will be 
obtained and documented per OHSRP/IRBO and CCR policies and procedures.
13 REGULATORY AND OPERATIONAL CONSIDERATIONS
13.1 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause.  Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study participants, 
investigator, funding agency, the Investigational New Drug (IND) or Investigational Device 
Exemption (IDE) sponsor and regulatory authorities.  If the study is prematurely terminated or 
suspended, the Principal Investigator (PI) will promptly inform study participants, the 
Institutional Review Board (IRB), and sponsor and will provide the reason(s) for the termination 
or suspension.  Study participants will be contacted, as applicable, and be informed of changes to 
study visit schedule.
Circumstances that may warrant termination or suspension include, but are not limited to:
•
Determination of unexpected, significant, or unacceptable risk to participants
•
Demonstration of efficacy that would warrant stopping   
•
Insufficient compliance to protocol requirements
•
Data that are not sufficiently complete and/or evaluable
•
Determination that the primary endpoint has been met
•
Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA).
13.2 QUALITY ASSURANCE AND QUALTIY CONTROL
The clinical site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion.  An individualized quality management 
plan will be developed to describe a site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry system and 
data QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that the 
clinical trial is conducted, and data are generated, and biological specimens are collected, 
documented (recorded), and reported in compliance with the protocol, International Council on 
Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., 
Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). 
The investigational site will provide direct access to all trial related sites, source data/documents, 
and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local 
and regulatory authorities.

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13.3 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical.  Therefore, any actual conflict of interest of persons who 
have a role in the design, conduct, analysis, publication, or any aspect of this trial will be 
disclosed and managed. Furthermore, persons who have a perceived conflict of interest will be 
required to have such conflicts managed in a way that is appropriate to their participation in the 
design and conduct of this trial.  The study leadership in conjunction with the National Cancer 
Institute has established policies and procedures for all study group members to disclose all 
conflicts of interest and will establish a mechanism for the management of all reported dualities 
of interest.
13.4 CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological 
samples and genetic tests in addition to the clinical information relating to participants. 
Therefore, the study protocol, documentation, data, and all other information generated will be 
held in strict confidence. No information concerning the study or the data will be released to any 
unauthorized third party without prior written approval of the sponsor. 
All research activities will be conducted in as private a setting as possible.
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical 
records (office, clinic, or hospital) and pharmacy records for the participants in this study. The 
clinical study site will permit access to such records.
The study participant’s contact information will be securely stored at the/each clinical site for 
internal use during the study. At the end of the study, all records will continue to be kept in a 
secure location for as long a period as dictated by the reviewing IRB, Institutional policies, or 
sponsor requirements.
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, will be transmitted to and stored at the NCI CCR. This will not include the 
participant’s contact or identifying information. Rather, individual participants and their research 
data will be identified by a unique study identification number. The study data entry and study 
management systems used by the clinical site and by CCR research staff will be secured and 
password protected. At the end of the study, all study databases will be archived at the NIH.
To further protect the privacy of study participants, a Certificate of Confidentiality has been 
issued by the National Institutes of Health (NIH).  This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any 
civil, criminal, administrative, legislative, or other proceeding, whether at the federal, state, or 
local level. By protecting researchers and institutions from being compelled to disclose 
information that would identify research participants, Certificates of Confidentiality help achieve 
the research objectives and promote participation in studies by helping assure confidentiality and 
privacy to participants.

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14 PHARMACEUTICAL INFORMATION  
14.1 PEGINTERFERON ALFA-2B (SYLATRON)
Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Whitehouse Station, NJ
Source: The agent will be obtained from Merck through Clinical Trials Agreement (CTA) 
#01047.
For the commercial product given subcutaneously, product labeling is prefaced by a boxed 
warning that identifies adverse reactions, including: depression and other neuropsychiatric 
disorders. The most common adverse reactions described in product labeling (>60%) include: 
fatigue, increased AST, increased ALT, pyrexia, anorexia, myalgia, nausea, chills and injection 
site reactions.
Contraindications include known hypersensitivity reactions to peginterferon alfa-2b or interferon 
alfa-2b, autoimmune hepatitis, and hepatic decompensation with Child-Pugh scores >6 (classes 
B and C).
Drug interactions: Drug metabolized by cytochrome P-450 (CYP) enzymes: Monitor closely 
when used in combination with drugs metabolized by CYP1A2 and/or CYP2D6.
Formulation and Preparation: commercially marketed SYLATRON™ vials nominally labeled to 
contain 200-mcg and 300-mcg vials are overfilled to contain 296 mcg and 444 mcg lyophilized 
peginterferon alfa-2b, respectively. When each vial is reconstituted with 1 mL Sterile Water for 
Injection, USP, the resulting concentrations are approximately 296 mcg/mL and 444 mcg/mL, 
respectively.
Refer to the package insert for additional information.
14.1.1 DTM preparation (dose levels 2, 3, 4)
The process is performed aseptically, inside a biological safety cabinet, using a sterile pipette tip 
in a control, monitored environment. The detailed process for reconstitution and adding of 
SYLATRON™ into an infusion bag is in detail in the DTM SOP developed for this protocol and 
submitted as part of the IND package. A syringe will not be used to transfer calculated volume of 
peginterferon alfa-2b.
For dose level 4, two vials will be needed if the 296-mcg/mL concentration is used and only one 
vial if the 444-mcg/mL concentration is used. Therefore, the procedure was written to specify 
use of one vial of the 444-mcg/mL product for the entire protocol. The experiments outlined in 
the validation process were performed using vials containing 444 mcg peginterferon alfa-2b 
(vials nominally labeled to contain 300 mcg).
Refer to Appendix B for additional information.
14.2 INTERFERON GAMMA-1B 
ACTIMMUNE, Horizon Pharma, Inc.
Source: The agent will be obtained from Horizon Pharma through Clinical Trials Agreement 
(CTA) #1042-17.
Formulation: The commercially marketed product (ACTIMMUNE®) is available as a solution in 
single-use vials containing 100 mcg interferon gamma-1b (2 x106 International Units), 
formulated with 20 mg mannitol, 0.37 mg disodium succinate hexahydrate, 0.14 mg succinic 

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acid, 0.05 mg polysorbate 20, and Sterile Water for Injection.  Each vial permits extraction of up 
to 0.5 mL of solution containing interferon gamma-1b at a concentration of 200 mcg/mL.
Adverse reactions include AST/ALT elevation, exacerbation of a previous cardiac condition, 
reversible neutropenia and thrombocytopenia, gait disturbance, seizure. Other adverse effects 
include pyrexia, headache, rash, chills, injection site erythema or tenderness, fatigue, diarrhea, 
vomiting, nausea, myalgia and arthralgia.
Contraindications include patients who develop or have known hypersensitivity to interferon-
gamma, E. coli derived products, or any component of the product.
Drug interactions: Cautiously monitor neutrophil and platelet counts when administering 
interferon gamma-1b concomitantly with other potentially myelosuppressive agents. Interferon 
gamma-1b use may decrease the concentrations of hepatic cytochrome P-450 enzymes.
Refer to the package insert for additional information.
14.2.1 DTM preparation (dose levels 2, 3, 4)
An automatic pipet capable of accurately measuring volumes as low as one microliter will be 
used to transfer the calculated volume of INTERFERON gamma-1b (shown in table below).
 
Dose 
levels
Cell suspension 
volume
(*before sample 
testing removed)
Volume of 200 mcg/mL 
Interferon gamma-1b to 
add
Amount of Interferon 
gamma-1b
250 mL infusion volume
2
*383 mL
0.038 mL
5 mcg
3
*383 mL
0.038 mL
5 mcg
4
*383 mL
0.383 mL
50 mcg
 
Refer to Appendix B for additional information. 
14.3 PREPARATION OF PEGINTERFERON ALFA-2B AND INTERFERON GAMMA-1B IN THE 
CLINICAL CENTER PHARMACY (FOR DOSE LEVELS 1 AND 3B)
In pharmacy practice, commercial hypodermic syringes will be used for transferring diluent 
between vials and for secondarily diluting peginterferon alfa-2b and for solution transfers and for 
secondarily diluting interferon gamma-1b.  All product manipulations will be completed within 
the aseptic environment of a biological safety cabinet per standard pharmacy practices.
Vials nominally labeled to contain peginterferon alfa-2b 300 mcg will be reconstituted as 
described above (section 14.1) to a concentration of 444 mcg/mL.
Dose Level
PLASMA-
LYTE-A 
Injection
Albumin 
(Human) 
25%
Peginterferon 
alfa-2b 
(SYLATRON™)
Interferon 
gamma-1b 
(ACTIMMUNE®)
1
25 mcg 
209.3 mL
39.9 mL
0.56 mL of a 
0.25 mL of a

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Peginterferon 
alfa-2b +
5 mcg 
Interferon 
gamma-1b
in PLASMA-
LYTE-A 
Injection +
4% Albumin 
(Human)
Total Volume 
= 250 mL
44.4-mcg/mL* 
solution
20-mcg/mL* 
solution
3b
250 mcg 
Peginterferon 
alfa-2b +
50 mcg 
Interferon 
gamma-1b
in PLASMA-
LYTE-A 
Injection +
4% Albumin 
(Human)
Total Volume 
= 250 mL
209.3 mL
39.9 mL
0.56 mL of a 
444-mcg/mL 
solution
0.25 mL of a
200-mcg/mL 
solution
*
Dilution Instructions for Dose Level 1:
To prepare a Peginterferon alfa-2b 44.4-mcg/mL solution from a 444-mcg/mL solution:
•
Add 6 mL PLASMA-LYTE-A Injection plus 1.2 mL Albumin, (Human) 25% to a 10-mL 
empty sterile vial, and gently invert the vial to mix the solutions.
•
To the same vial, add 0.8 mL Peginterferon alfa-2b (444 mcg/mL), and gently invert the vial 
to mix the solutions.
To prepare an Interferon gamma-1b 20-mcg/mL solution from a 200-mcg/mL solution:
•
Add 3.8 mL PLASMA-LYTE-A Injection plus 0.7 mL Albumin, (Human) 25% to a 10-mL 
empty sterile vial, and gently invert the vial to mix the solutions.
•
To the same vial, add 0.5 mL Interferon gamma-1b (200 mcg/mL), and gently invert the vial 
to mix the solutions.
The final product containing Peginterferon alfa-2b + Interferon gamma-1b in PLASMA-LYTE-
A Injection + 4% Albumin (Human) should be stored at room temperature (15-25° C) and 
infused within 4 hours after preparation.

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14.4 AUTOLOGOUS MONOCYTES
Source: The agent will be prepared at and obtained from the Department of Transfusion 
Medicine (DTM)
Formulation and Preparation: Refer to Appendix B for detailed procedures.

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Baron, S., et al., Near eradication of clinically relevant concentrations of human tumor 
cells by interferon-activated monocytes in vitro. J Interferon Cytokine Res, 2011. 31(7): 
p. 569-73.
35.
Johnson, C.L., D.S. Green, and K.C. Zoon, Human monocytes in the presence of 
interferons alpha2a and gamma are potent killers of serous ovarian cancer cell lines in 
combination with paclitaxel and carboplatin. J Interferon Cytokine Res, 2015. 35(1): p. 
55-62.
36.
Nakashima, H., et al., Potent antitumor effects of combination therapy with IFNs and 
monocytes in mouse models of established human ovarian and melanoma tumors. Cancer 
Immunol Immunother, 2012. 61(7): p. 1081-92.
37.
Bell, J.B., et al., Neutralising antibodies in patients with multiple myeloma receiving 
maintenance therapy with interferon alpha 2b. Br J Cancer, 1994. 70(4): p. 646-51.
38.
Doffinger, R., et al., Autoantibodies to interferon-gamma in a patient with selective 
susceptibility to mycobacterial infection and organ-specific autoimmunity. Clin Infect 
Dis, 2004. 38(1): p. e10-4.
39.
Ding, L., et al., Determination of human anticytokine autoantibody profiles using a 
particle-based approach. J Clin Immunol, 2012. 32(2): p. 238-45.
40.
Eisenhauer, E.A., et al., New response evaluation criteria in solid tumours: revised 
RECIST guideline (version 1.1). Eur J Cancer, 2009. 45(2): p. 228-47.
41.
Rustin, G.J., et al., Re: New guidelines to evaluate the response to treatment in solid 
tumors (ovarian cancer). J Natl Cancer Inst, 2004. 96(6): p. 487-8.
42.
Scher, H.I., et al., Design and end points of clinical trials for patients with progressive 
prostate cancer and castrate levels of testosterone: recommendations of the Prostate 
Cancer Clinical Trials Working Group. J Clin Oncol, 2008. 26(7): p. 1148-59.
43.
Bubley, G.J., et al., Eligibility and response guidelines for phase II clinical trials in 
androgen-independent prostate cancer: recommendations from the Prostate-Specific 
Antigen Working Group. J Clin Oncol, 1999. 17(11): p. 3461-7.
44.
Vergote, I., et al., Re: new guidelines to evaluate the response to treatment in solid 
tumors [ovarian cancer]. Gynecologic Cancer Intergroup. J Natl Cancer Inst, 2000. 
92(18): p. 1534-5.

Abbreviated Title:  Phase 1 IFN + monocytes
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64
16 APPENDICES
16.1 APPENDIX A: PERFORMANCE STATUS CRITERIA
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Description
100
Normal, no complaints, no 
evidence of disease.
0
Normal activity.  Fully active, 
able to carry on all pre-disease 
performance without restriction.
90
Able to carry on normal activity; 
minor signs or symptoms of 
disease.
80
Normal activity with effort; 
some signs or symptoms of 
disease.
1
Symptoms, but ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work).
70
Cares for self, unable to carry on 
normal activity or to do active 
work.
60
Requires occasional assistance, 
but is able to care for most of 
his/her needs.
2
In bed <50% of the time.  
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities.  Up and 
about more than 50% of waking 
hours.
50
Requires considerable assistance 
and frequent medical care.
40
Disabled, requires special care 
and assistance.
3
In bed >50% of the time.  
Capable of only limited self-care, 
confined to bed or chair more 
than 50% of waking hours.
30
Severely disabled, 
hospitalization indicated.  Death 
not imminent.
20
Very sick, hospitalization 
indicated. Death not imminent.
4
100% bedridden.  Completely 
disabled.  Cannot carry on any 
self-care.  Totally confined to bed 
or chair.
10
Moribund, fatal processes 
progressing rapidly.
5
Dead.
0
Dead.

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16.2 APPENDIX B: DTM STANDARD OPERATING PROCEDURES 
A. PRODUCT MANUFACTURING AND CHARACTERIZATION INFORMATION
1. PRODUCT MANUFACTURING – COMPONENTS AND MATERIALS
1. Cells
Patients will undergo up to 15 liter PBMNC apheresis (autologous), as estimated by 
weight and target cell dose in the Dowling Apheresis Clinic of the DTM, per standard 
operating procedure.  Bilateral peripheral venous access will be used whenever possible.  
Alternatively, a temporary central venous catheter (CVL) may be placed for collection.  
The CVL will be inserted by Critical Care or Interventional Radiology staff with the 
assistance of anesthesiology as indicated.
Cells will be processed for further manufacturing in CPS/DTM according to SOPs (see 
Product Manufacturing section 2: Procedures).
A. Donor Screening and Testing 
Cells manufactured in the current protocol are of AUTOLOGOUS nature and donor 
eligibility determinations are not required (21 CFR 1271.90(a)(1)). However, 
eligibility requirements for product handling in CPS manufacturing facility require 
that subjects be HIV seronegative, hepatitis C seronegative and negative for Hepatitis 
B surface antigen.  In addition, on the day of product collection, peripheral blood is 
submitted for testing: HIV 1 and 2 (antibody and NAT), HTLV I and II (antibody), 
Hepatitis C (antibody and NAT), Hepatitis B (surface antigen), West Nile Virus 
(NAT), T cruzi (antibody), and Treponema pallidum (antibody).  Should any of these 
results be positive, DTM isolation procedures as defined in BB-DMF 11054 will be 
followed.
B. Cell Bank System
No feeder cells or cell lines were used in this protocol. 
2. Reagents
1. Tabulation of Reagents Used in Manufacture: (see Table 5)
3. Excipients
a.
Final product is infused freshly and contains monocytes and Peginterferon alfa-2b 
(Sylatron) and Interferon gamma-1b (Actimmune) suspended in Plasmalyte-A, 
4% human serum albumin. 
b. The concentration, source and qualifying documents of all excipients are listed in 
Table 1 and Appendix 3.
4. Additional Considerations (none)

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66
Table 5: Reagents used for the manufacture of autologous monocytes with Interferon (IFN)
Product Name
Trade Name
Vendor
NDC
Qualification
Use
Regulatory 
Status
Product 
Manufacture
Human Serum 
Albumin
Flexbumin 25%
Baxter Healthcare 
Corp.
0944-
0493-
02
Package 
insert
Buffer additive
FDA 
approved
Final product 
preparation
Hanks Buffered 
Salt Solution
HBSS
American 
Pharmaceutical 
partners, 
Schaumbur, IL
NA
Certificate of 
Analysis
Buffer additive, 
elutriation 
procedure
GMP grade 
ancillary 
reagent
Intermediate 
product, elutriation
Sodium Chloride 
Injections USP
0.9% sodium 
chloride
Saline
B.Braun Medical 
Inc. Irvine CA
0264-
7800-
00
Package  
insert
Buffer additive, 
elutriation 
procedure
FDA   
approved
Intermediate 
product, elutriation
Sodium Citrate 
Concentrate 
46.7%
Tricitrasol
Citra Labs, LLC
23731-
6030-3
Package  
insert
Prevent cell 
clumping,  
elutriation 
procedure
FDA   
approved
Intermediate      
product, elutriation
Dornase alpha 
(DNAse)
Pulmozyme
Genentech, Inc.
50242-
100-40
Package  
insert
Prevent cell 
clumping, 
storage
FDA   
approved
Intermediate 
product, elutriation 
PLASMA-LYTE-
A
PLASMA-LYTE-A 
injection pH 7.4
Baxter Healthcare 
Corp.
0338-
0221-
03
Package 
insert
Infusion 
Solution
FDA 
approved
Final product 
preparation
Peginterferon 
alfa-2b
SYLATRONTM
Schering Corp.
0085-
4348-
01
Package               
insert
Activate 
monocytes
FDA 
approved
Final product     
preparation
Interferon 
gamma-1b
ACTIMMUNE®
Horizon Pharma, 
Inc.
42238-
111-01
Package 
insert
Activate 
monocytes
FDA 
approved
Final product 
preparation

Abbreviated Title:  Phase 1 IFN + monocytes
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2. Product Manufacturing – Procedures
Figure 5. Manufacture of Autologous Monocytes in combination with SylatronTM and 
Actimmune®
 Manufacturing Schema for Dose levels 2-4 

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68
Figure 5. Manufacturing process schema. (Day 0) Autologous Peripheral Blood Mononuclear 
Cells (PBMNCs) will be collected by apheresis in DTM Dowling Clinic and transported to the 
Cell Processing Section (CPS) of DTM. The PBMNC product will undergo counter flow 
centrifugation elutriation (CCE) to enrich for monocytes in the product. After elutriation, all 
fractions except the monocyte fraction will be issued to PI laboratory. The monocytes will be 
washed and re-suspended at the appropriate concentration with 1-3 aliquots cryopreserved for 
future infusions. On the day of infusion, the monocytes will be washed, filtered, counted and re-
suspended at dose level with Peginterferon alfa-2b (SylatronTM) and Interferon gamma-1b 
(Actimmune®) as described below. Assays for safety, purity, and identity will be performed 
before the product is issued for infusion.
•
Preparation of AUTOLOGOUS cells
1. Method of cell collection/Processing
1. Day 0 - Mononuclear cells will be collected by apheresis (up to 15 L) to reach a target 
cell number of monocytes. Apheresis will be performed in the Dowling Apheresis 
Clinic, Department of Transfusion Medicine (DTM) using a Cobe Spectra or an 
equivalent cell separator device using current standard operating procedures. 
2. Counter flow centrifugation elutriation (CCE) will be performed using the Elutra 
device. 
3. All products, intermediate and final, will be contained within a closed system using 
bags and sterile connection devices. 
4. The monocytes are contained in the rotor off (RO) fraction from elutriation. The 
monocytes will be stored overnight at refrigerated temperature before further 
processing on day of infusion.
5. 1-3 aliquots will be cryopreserved for future infusions
6. Day 1 – the monocytes are prepared for infusion, with final testing including FACS to 
assess percent of CD14 (cell purity), cell counts, viability, and sterility testing, 
including Gram stain. 
2. Irradiation
Not Applicable
3. Day of infusion
7. On Day 1, day of infusion, cells are taken from refrigerated storage (4°C), mixed, and 
allowed to warm to room temperature for 30 minutes. Cells are filtered, washed, and 
re-suspended in infusion solution.
8. For cryopreserved monocytes, cells will be washed twice and resuspended at 8 x10e6 
CD14+/16+/mL in Plasmalyte A+ 4% Albumin (Human), USP (HSA) and 10mcg/mL 
DNAse
9. Samples are taken for cell count, viability and FACS to determine subset components. 
10. Cells are filtered and diluted in Plasmalyte A+ 4% Albumin (Human), USP (HSA) at 
a concentration in accordance with Dose Level according to SOP:
11. Dose level 1 and 3b: No cells will be given.  
12. Dose level 2: cells are diluted to 0.3x106/mL ( 20%). 
13. Dose levels 3 and 4: cells are diluted to 3x106 cells/mL ( 20%). 

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14. Peginterferon alfa-2b (Sylatron™) and Interferon gamma-1b (Actimmune®) are 
added in quantities according to SOP to achieve the doses specified in the treatment 
protocol. 
15. Dose levels 1, 2, and 3 will contain 25 mcg Peginterferon alfa-2b (Sylatron) and 
5 mcg Interferon gamma-1b (Actimmune); 
16. Dose level 4 and 3b will contain 250 mcg Peginterferon alfa-2b (Sylatron) and 50 mcg 
Interferon gamma-1b (Actimmune).
17. Monocyte cell suspension, in Plasmalyte-A and 4% HSA, with Peginterferon alfa-2b 
and Interferon gamma-1b, is issued for intraperitoneal infusion.
•
 Process Timing and Intermediate Product Storage
 (See Table 6)
•
Final Formulation
Final product is autologous monocytes suspended in Plasmalyte-A + 4% HSA + 
Peginterferon alfa-2b (Sylatron) + Interferon gamma-1b (Actimmune). 

Abbreviated Title:  Phase 1 IFN + monocytes
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Table 6.  Timeline and Lot Release Criteria for the manufacture of autologous monocytes 
with Peginterferon alfa-2b (SylatronTM) and Interferon gamma-1b (Actimmune®).
Da
y
Time 
require
d 
(hours)
Process 
Step
Product (or 
Intermediat
e Fraction)
Sample 
Designati
on
Sample 
Type 
(Cells/Su
p)
Assay
Lot 
release 
(Yes/N
o)
0
NA
Patient 
sampling
Patient Pre- 
Apheresis
Patient PB
CBC, 
TTD1,
ABO/Rh
Yes (TTD)
0
NA
Patient 
sampling
Patient Post- 
Apheresis
Patient PB
CBC
No
0
1
Apheresis 
product 
receipt
PBMNC 
product
Bag
Cells + Sup
Cell 
count,
volume,
Flow 
differenti
l
No
0
2-3
Elutriation
Post-
Elutriation
RO Fraction
Cells+Sup
Cell 
count,
Volume, 
Flow 
phenotyp
e
No
0
1
Supplement
ed bag
Supplement
ed monocyte 
bag
D0 (RO tube)
Cells+Sup
Cell 
count, 
viability
No
  
  1
2
Stored bag
Stored 
monocyte 
bag
D1 or PT (post 
thaw)
Cells+Sup
Cell 
count, 
viability
Volume, 
FACs
Yes (FACs)
 1
2
Final 
resuspensio
n
Final product
FN
Cells+Sup
Cell 
count, 
viability, 
FACS, 
gram 
stain, 
sterility, 
endotoxi
Yes
1Transfusion Transmitted Disease Testing
 

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B. PRODUCT TESTING
1. MICROBIOLOGICAL TESTING:  BACTERIAL AND FUNGAL TESTING
1
Sterility Testing:
Samples for sterility testing will be taken from Final product (FN) (see Figure 5).
The sterility sample will be prepared per CPS-SOP-5008 for bacterial and fungal testing 
which is performed by the Department of Laboratory Medicine, Clinical Center, NIH 
(See Appendix 4 for applicable CPS SOPs). Sterility tests comply with 21 CFR 610.12.
In addition to samples inoculated into the Bactec bottles, a sample is submitted for fungal 
testing, consisting of plating onto solid media, for incubation for 14 days.
2. IDENTITY
Identity will be tested on Final product (FN) by flow phenotype and cell count. The final 
release criteria on the final product will include Trypan blue viability: ≥ 70%, CD14+ of 
viable: ≥ 40%
3. POTENCY
CD14 will be used as a surrogate marker for potency since the addition of monocytes to 
IFN therapy correlates with a reduction in tumor size in animal models with xenografted 
human ovarian tumors (Nakashima et al. 2012). 
4. OTHER
•
General Safety Testing
Action plans for positive results on safety testing
General action plans for dealing with positive tests for sterility testing are presented in 
our Master File BB-MF-11054.  See Cross reference letter for BB-MF-11054 
contained in Section I.
•
Viability
Viability testing will be performed on the Final product (FN). Trypan blue viability on 
the final product must be ≥ 70%.
•
Cell Number/Dose
The cell number target will be based on the following dose levels.
Dose level 1 and 3b:
No cells will be given
Dose level 2:  
75 x 106   ( 20%)   viable CD14+ monocytes total 
Dose levels 3 and 4:  
750 x 106  ( 20%)  viable CD14+ monocytes total
C. FINAL PRODUCT RELEASE CRITERIA TESTING
Product Testing: See CPS-SOP-[15-CPS-05]
Product Release Criteria:  final product testing is performed on the day of infusion (Day 
1). On day of infusion, samples for trypan blue viability, STAT gram stain, and FACS 
will be submitted and results used for release criteria.  Sterility culture will also be 

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72
performed on the final product but results will not be available at the time of infusion. 
These results will be reported on the Certificate of Analysis listed below. 
Test
Method
Acceptable
Limit
Appearance
Visual check
Normal - milky;
no aggregates
% Viable monocytes 
(CD14+)
FACs
≥ 40%
% Viability
Trypan Blue
≥ 70%
Sterility on final product
Bactec
*
Gram stain
Gram stain
No organism seen
Donor eligibility
NA
Auto
*sent on the day of infusion. Result available 14 days later. 
D. PRODUCT STABILITY
The final product will be delivered to the patient care unit immediately after required 
assays for release. Expiration time is 4 hours post final product sampling.
E. OTHER ISSUES
➢PRODUCT TRACKING
Manufacturers of cellular therapy products are required to maintain traceability of the 
products received, processed and stored in the facility through the final disposition of 
the product. CPS-SOP-5107 describes the procedures for receipt of products in the 
Cell Processing Section (see Drug Master File: 11054). CPS-SOP-5105 outlines the 
requirements for distribution and documentation of products to administration sites, 
research or discard (see Drug Master File: 11054). At final disposition, the product is 
assigned a status of infused, shipped, allocated to research or discarded.
➢PRODUCT LABELING:
The following is an example of the product label for final product, autologous monocyte 
cell suspension, in Plasmalyte-A and 4% HSA, with Peginterferon alfa-2b and Interferon 
gamma-1b 

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
73
➢CONTAINER/CLOSURE:
The starting apheresis material, intermediate products, and final product will be contained 
within a closed system using sterile transfer pack containers. All connections will be 
made using a Sterile Tube Welder (TerumoBCT). 
➢ENVIRONMENTAL IMPACT:
The Women’s Malignancies Branch of the National Cancer Institute, National 
Institutes of Health requests a claim for categorical exclusion for this proposed clinical 
trial as provided for in 21 CFR 25.31(e), in that the agents studied under this IND are 
intended to be used in clinical trials in which the amount of waste expected to enter 
the environment may reasonably be nontoxic. Furthermore, it is understood that the 
clinical supplies of the investigational agents are to be used under the direction of 
qualified investigators (physicians, pharmacists and nurses) knowledgeable in the use 
and handling of investigational agents, including the professional staff in the 
Department of Transfusion, Cell Processing Section, NIH.
All waste is disposed in accordance with the environmental protection laws, regulations 
and guidelines of the Federal Government and the State of Maryland.
➢QUALIFICATION OF THE MANUFACTURING PROCESS:
Validation Summary: 
Preparation of monocytes in combination with Peginterferon alfa-2b (SYLATRONTM) and 
Interferon gamma-1b (ACTIMMUNE®) 

Abbreviated Title:  Phase 1 IFN + monocytes
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The NCI protocol entitled ‘Phase I study of intraperitoneal infusion of autologous monocytes 
with Sylatron (Interferon alpha 2b) and Actimmune (Interferon gamma) in women with 
recurrent or refractory ovarian cancer, fallopian tube cancer, or primary peritoneal 
cancer’ (17-C-0011), utilizes an elutriated apheresis product to obtain monocytes which are 
mixed with varying doses of interferons before being administered to patients. Here, patients 
undergo an apheresis procedure each time they are admitted, which can be up to every 4 weeks. 
In the following study, we designed and validated a new process that would allow us to prepare 
one initial fresh dose of monocytes and cryopreserve the remaining cells so that they may be 
thawed and infused at a later date. This new modification would reduce unnecessary stress to the 
patient due to having to undergo multiple apheresis and it will also relieve the burden of 
performing many of these aphereses altogether by Dowling Clinic. Three separate samples were 
tested independently, two samples from healthy donors and one sample taken from a patient with 
ovarian cancer. Each sample was processed as a fresh and as a cryopreserved specimen as they 
would be during clinical manufacturing. Results below compare multiple attributes of each of 
these specimens. 
First, we examined cell recovery following cryopreservation to ensure the cells were capable of 
surviving the cryopreservation process. Cells from all three donors were cryopreserved in 
aliquots >330x106 TNC (or >260x106 CD14/CD16 monocytes) (Table 7). These aliquots 
represent the typical cell number that would be cryopreserved for dose level 2 and one-third of 
dose level 3 and 4. Upon thaw, cells were counted and recovery was calculated. TNC recovery 
from all three samples was >88% (>91% for CD14/CD16 monocytes). We conclude that there is 
no detrimental effect of the cryopreservation procedure on the TNC or monocyte recovery. 
Table 7 Cryopreserved cell recovery
Next, we compared the frequency of CD14/CD16 cells that were in the starting product (bag), 
fresh sample, and cryopreserved sample. After elutriation, we observed a consistent increase in 
the frequency of monocytes that were within the RO fraction. The frequency ranged from 14-
43% in the starting bag to >75% post elutriation (Table 8). There was <5% difference when 
comparing the frequency of monocytes between SM and day 1 of fresh sample and 
cryopreserved sample. Similarly, there was <9% difference when comparing the frequency of 
monocytes between FN samples of fresh vs. cryopreserved samples. Together, this data indicate 
that cryopreservation of the intermediate product did not significantly affect the monocyte 
frequency. 
Pre Thaw
Post Thaw 
Recovery
Pre Thaw
Post Thaw 
Recovery
PD17060149 B
3.50E+08
3.50E+08
100.0%
2.85E+08
2.94E+08
103.3%
PD17060190 B
4.22E+08
3.97E+08
94.1%
3.16E+08
3.12E+08
98.6%
PD17060193 B
3.33E+08
2.93E+08
88.0%
2.60E+08
2.37E+08
91.3%
Sample 
TNC 
CD14+/CD16+

Abbreviated Title:  Phase 1 IFN + monocytes
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75
Table 8 Frequency of CD14/CD16 monocytes
Loss of CD14/CD16 monocytes that occurred during processing from day 1 until the FN was 
packaged was minimal. Fresh sample recovery during this time point was >93% and 
cryopreserved sample recovery was >86% (Table 9). 
Table 9 Absolute cell number and recovery of CD14/CD16 monocytes from day 1 through 
FN
Functional assays were performed in Dr. Annunziata’s laboratory using the final product from 
both the fresh and cryopreserved samples. Monocytes plus IFN’s (per protocol) were mixed with 
ovarian cancer cells as outlined in the validation plan and allowed to incubate together for 3 
days. Monocyte and IFN cytotoxicity is measured as percent survival compared to untreated 
controls. Percent killing is calculated as (100-% survival). There were no significant differences 
in % killing between fresh and cryopreserved samples. All samples were highly efficient in their 
ability to lyse target tumor cells. The percent killing from all samples was >94%, and the 
difference of percent killing between individual fresh vs. cryopreserved samples was <2% 
(Table 10). This data indicate that there was no loss of function that occurred within the 
cryopreserved samples. 
Table 10 Functional assay (% Killing)
Monocyte viability pre and post cryopreservation was examined next. Samples were taken at day 
1 and in the final product after resuspension with cytokines and assessed for viability using 
AO/PI uptake on the cellometer instrument. The viability of all samples >92% (Table 11). In 
addition, we examined the stability of the monocytes post thaw at 2 hour and 4 hour time points 
after final packaging with cytokines to ensure that they remained stable while they are 
Bag
SM
FN
Day 1
FN
PD17060149 
15.30%
81.40%
79.10%
84.10%
87.60%
PD17060190 
14.00%
74.80%
79.10%
78.40%
74.80%
PD17060193 
43.50%
78.10%
76.80%
81.00%
80.60%
Sample 
Fresh  sample (A)
Cryo  sample (B)
Day 1
FN
Recovery
Day 1
FN
Recovery
PD17060149 
7.50E+07
7.55E+07
100.67%
2.45E+08
2.25E+08
91.84%
PD17060190 
2.16E+08
2.20E+08
101.85%
2.80E+08
2.43E+08
86.82%
PD17060193 
7.50E+07
7.03E+07
93.73%
2.61E+08
2.36E+08
90.34%
Sample 
Fresh  sample (A)
Cryo  sample (B)
Sample
Fresh sample (A) Cryo sample (B)
PD17060149 
94.1%
95.8%
PD17060190 
96.1%
94.7%
PD17060193 
95.7%
95.3%

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76
transferred to the clinic for administration to the patient. We found that the viability at these time 
points was not significantly different than the viability at the 0 hour time point (all >93%) and 
conclude that the monocytes would remain stable for up to 4 hours (Table 12). 
Table 11 Cell Viability
Table 12 Stability of Cryopreserved Monocytes
Conclusion: We validated a new manufacturing process for the preparation of cryopreserved 
monocytes and found that the cell product was extremely consistent between cryopreserved 
fraction vs. fresh fraction and also consistent among the three different donors tested here. All 
samples tested passed the validation criteria set forth in the validation plan, which also included 
product safety testing (sterility, endotoxin). We therefore approve the implementation of this 
process within DTM Cell Processing Section. 
F. Quality Assurance Practices
For a complete description of Quality Assurance and Quality Control practices in CPS 
DTM refer to BB-MF 11054.
Day 1
FN
Day 1
FN
PD17060149 
99.0%
98.0%
99.6%
98.9%
PD17060190 
97.0%
94.5%
92.8%
93.8%
PD17060193 
99.0%
99.0%
96.4%
98.8%
Sample 
Fresh  sample (A)
Cryo  sample (B)
Sample 
FN (0hr) 
FN (2hr) 
FN (4hr) 
PD17060149 B
98.9%
98.6%
99.0%
PD17060190 B
93.8%
94.8%
93.6%
PD17060193 B
98.8%
98.3%
98.2%

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16.3 APPENDIX C: LIST OF DRUGS INTERACTING WITH CYP1A2OR CYP2D6
Patients receiving any medications or substances that are strong inhibitors or inducers of 
CYP1A2 and CYP2D6 are ineligible.  Because the lists of these agents are constantly changing, 
it is important to regularly consult a frequently-updated list. We will refer to 
http://medicine.iupui.edu/clinpharm/ddis/; medical reference texts such as the Physicians’ Desk 
Reference may also be consulted.  As part of the enrollment/informed consent procedures, the 
patient will be counseled on the risk of interactions with other agents, and what to do if new 
medications need to be prescribed or if the patient is considering a new over-the-counter 
medicine or herbal product.

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16.4 APPENDIX D: STANDARD OPERATING PROCEDURE FOR INTRAPERITONEAL INFUSION
If patient has existing intraperitoneal catheter, this will be used. If not, then a tunneled 6F or 9F 
catheter will be placed in interventional radiology. 
1)
Access Port-a-Cath or peritoneal infusion catheter 
2)
Place patient on complete bed rest in semi-Fowler’s position throughout administration of 
IP infusion. Head of bed must be no higher than 30 degrees to prevent dislocation of port needle 
or kinking of infusion catheter, and to allow IP fluid to flow freely. A flat position during 
infusion may increase pressure on diaphragm, causing respiratory compromise/GI upset in 
patients receiving IP infusions. If any significant movement of patient occurs during IP infusion, 
the nurse must assure proper needle positioning is maintained.
3)
In this protocol, 0.9% Sodium Chloride Injection is administered warmed or at room 
temperature per patient preference.  If warming is preferred, place 500 mL 0.9% Sodium 
Chloride Injection in warm water bath (keeping outer manufacturer wrapping intact) for 
approximately 15 minutes. RATIONALE: Warmed fluid is more comfortable for patient during 
infusion and decreases the incidence of cramping associated with IP infusions.
4)
Prime IV tubing with attached Y port with 0.9% Sodium Chloride Injection, either 
warmed or room temperature per patient preference. Attach to port or peritoneal infusion 
catheter. 
5)
Infuse 200-250 mL of 0.9% Sodium Chloride Injection, as rapidly as possible via gravity. 
6)
Observe catheter site for swelling, leakage, or redness. Observe entire abdominal surface 
for unusual local swelling. Observe patient for complaints of pain, SOB, dyspnea, respiratory 
distress, and cramping. Stop infusion and notify physician if any of above conditions occurs. 
RATIONALE: Migration of catheters or dislodging of right angled needle may occur.
7)
If no adverse effects noted after completion of 0.9% Sodium Chloride infusion, attach 
primed Monocyte infusion agent to free Y connector. Clamp 0.9% Sodium Chloride infusion line 
and infuse monocytes as rapidly as possible, via gravity. Monocytes should be infused at room 
temperature. NOTE: IP monocyte infusion may take as little as 30 minutes or as long as 1 hour 
(+/- 10 min) to infuse. If infusion takes longer than 1 hour, 10 min (70 min), RN should notify 
physician for troubleshooting.
8)
After infusion of monocytes is complete, clamp monocyte tubing and open 0.9% Sodium 
Chloride tubing. Infuse an additional 50-100 mL of 0.9% Sodium Chloride Injection as rapidly 
as possible by gravity.
9)
Flush port needle or catheter with 10 mL of low strength heparinized (10 Units/mL) 0.9% 
Sodium Chloride. De-access Port-a-Cath or clamp catheter.
10)
After de-accessing needle or clamping catheter, begin turning protocol: reposition patient 
every 15 minutes clockwise, (i.e.: from side, to back, to other side, if possible prone (abdomen), 
Fowler’s, Trendelenburg and knee chest) for a total of two hours. RATIONALE: Repositioning 
disperses fluid throughout the peritoneal cavity.
11)
Patient may ambulate after turning protocol is complete. 
12)
 Document chemotherapy administration according to institutional policy

Abbreviated Title:  Phase 1 IFN + monocytes
Version Date:  12/04/2025
79
16.5 APPENDIX E: SAMPLE CHEMOTHERAPY/BIOTHERAPY  TREATMENT NOTE 
IF APPLICABLE:
Paracentesis will be done prior to treatment regimen and repeated after at least 24 hours 
following treatment have elapsed. 
DOSE LEVEL 1 or 3B (Put in dose depending on dose level at asterisks):
 
➢200-250 mL warmed 0.9% Sodium Chloride Injection (or room temperature per patient 
preference) will be given intraperitoneally first followed by:
➢Peginterferon alfa-2b ** mcg 
Interferon gamma-1b ** mcg 
The drug will be mixed with PLASMA-LYTE-A, HSA, and IFN in a total quantity of 
248 ±2 mL
Infuse by gravity over 30-60 min
➢Infuse an additional 50-100 mL of 0.9% Sodium Chloride Injection, flush port with 
heparin flush of 10 Units/mL (10 mL)
➢The patient will then be repositioned for a total of 2 hours to allow for maximal 
distribution of the treatment. 
DOSE LEVEL 2, 3, or 4 (Put in dose depending on dose level at asterisks):
•
200-250 mL warmed 0.9% Sodium Chloride Injection (or room temperature per patient 
preference) will be given intraperitoneally first followed by:
•
Monocyte cell suspension (**) in PLASMA-LYTE-A + 4% HSA and will be mixed with:
Peginterferon alfa-2b **mcg 
Interferon gamma-1b **mcg 
The infusion will be in a total quantity of 248 ±2 mL
Infuse by gravity over 30-60 min
•
Infuse an additional 50-100 mL of 0.9% Sodium Chloride Injection, flush port with heparin 
flush of 10 Units/mL (10 mL)
•
The patient will then be repositioned for a total of 2 hours to allow for maximal distribution 
of the treatment.