Clinical trial NCT01595321
Conditions: Pancreatic Cancer
Keywords: Adjuvant therapy Immunotherapy Cytoxan Cyclophosphamide Pancreatic Vaccine Stereotactic radiation therapy SBRT FOLFIRINOX GVAX
Sponsor: Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
Start date: 2012-10-29; Completion date: 2023-10-18
Enrollment: 19 participants; Allocation: NON_RANDOMIZED; Intervention model: SEQUENTIAL

Brief summary:
The purpose of this study is to estimate safety of GVAX Pancreas Vaccine (GVAX) with immune modulating doses of cyclophosphamide (Cy) followed by SBRT and FOLFIRINOX chemotherapy in pancreatic cancer patients after surgery.

Detailed description:
This study enrolled patients with surgically resected adenocarcinoma of the pancreas who had titanium clips placed at the time of surgery in order to guide SBRT treatment.

Enrollment was based on traditional 3+3 design with grade 3-4 diarrhea and/or neutropenia defined as the dose limiting toxicity (DLT) within the first 2 cycles (8 weeks) of FOLFIRINOX. The first group of 3 patients (Cohort 1) received SBRT and full dose FOLFIRINOX. The second group of 4 patients (Cohort 2) received SBRT and modified FOLFIRINOX, and the third group of 12 patients (Cohort 3) received SBRT and modified FOLFIRINOX as well as Cy/GVAX vaccinations.

Cy/GVAX (patients 8-19): cyclophosphamide (Cy) at 200 mg/m\^2 intravenously over 30 minutes the day before each vaccine. Each vaccination (GVAX) consists of six total intradermal injections of vaccine, two each in the upper right and left thighs, and two in the upper non-dominant arm. Each injection consists of approximately 2.5x10\^8 cells of each cell line (PANC 6.03/PANC 10.05) for a total of 5x10\^8 cells. The first dose of Cy/GVAX was given within 6-10 weeks from surgery.

Adjuvant SBRT was given 13-17 days after the first dose of Cy/GVAX. Patients receive 5 days of SBRT (6.6 gray (Gy) daily for 33 Gy total) to the tumor bed as delineated by surgical clips placed by the surgeon.

Six 28-day cycles of FOLFIRINOX, starting at least one week after completion of SBRT.

This was permitted to be given locally. Patients were evaluated for dose limiting toxicities (DLTs) within the first 2 cycles (8 weeks).

Cy/GVAX #2-5 was given every 28 days (+/- 3 days), starting 35 days (+/- 7 days) after completion of FOLFIRINOX. Patients without evidence of recurrence could then qualify for additional Cy/GVAX boosts every 6 months (every 12 months with Amendment #10) until disease recurrence, toxicity, withdrawal, or death.

Arms: arm 1: The initial 3 patients were treated with SBRT and full dose FOLFIRINOX and observed for the first 2 cycles (8 weeks) for dose limiting toxicities (DLTs). If 2-3 patients are observed with uncontrolled grade 3-4 diarrhea, 2-3 patients are observed with grade 3-4 thrombocytopenia, or if 3 patients are observed with grade 3-4 neutropenia within the first 2 cycles of FOLFIRINOX administration (8 weeks) then the dose level will be deemed unacceptable. arm 2: The next 4 patients were treated with SBRT and modified FOLFIRINOX and observed for the first 2 cycles (8 weeks) for dose limiting toxicities (DLTs). If no patients are observed with grade 3-4 diarrhea, thrombocytopenia, or neutropenia, then the next cohort of patients will receive SBRT, modified FOLFIRINOX, and GVAX (with Cy). arm 3: The last 12 patients will receive Cy, GVAX, SBRT, and modified FOLFIRINOX.
Interventions: intervention 1: Cyclophosphamide intervention 2: GVAX Pancreas Vaccine intervention 3: Stereotactic Body Radiation intervention 4: FOLFIRINOX
Intervention descriptions: intervention 1: Cyclophosphamide (Cy) 200 mg/m\^2 administered one day prior to GVAX (day 0). One dose will be given prior to SBRT and FOLFIRINOX and four additional doses after FOLFIRINOX completion for a total of 5 doses. Additional CY/GVAX boosts may be given every 6 months thereafter until disease recurrence. intervention 2: GVAX administered one day after Cy (day 1). One dose will be given prior to SBRT and FOLFIRINOX and four additional doses after FOLFIRINOX completion for a total of 5 doses. Additional CY/GVAX boosts may be given every 6 months thereafter until disease recurrence. intervention 3: Cohort 1 and 2: SBRT (6.6 Gy per day, 33 Gy total dose) will be administered over 5 days within 6-10 weeks of pancreas surgery (Whipple).

Cohort 3: SBRT (6.6 Gy) will be administered over 5 days starting between 13-17 days after the first dose of CY/GVAX. intervention 4: FOLFIRINOX is given over six 28-day cycles, starting at least 1 weeks after SBRT.

FOLFIRINOX consists of the following drugs given IV on days 1 and 15 of each cycle:

Oxaliplatin (85 mg/m\^2), Irinotecan (180 mg/m\^2), Leucovorin (400 mg/m\^2), Fluorouracil (400 mg/m\^2 bolus followed by 2,400 mg/m\^2 continuous infusion over 46-48 hours);

modified FOLFIRINOX consists of the same regimen described above but without the 400 mg/m\^2 Fluorouracil bolus.

Protocol documents:
Prot_SAP_000.pdf: 
Cover Page for Protocol – J1179 
NCT Number: 
NCT01595321 
Official Title of Study 
Pilot Study Evaluating an Allogeneic GM-
CSF-Transduced Pancreatic Tumor Cell 
Vaccine (GVAX) and Low Dose 
Cyclophosphamide Integrated with 
Fractionated Stereotactic Body 
Radiation Therapy (SBRT) and FOLFIRINOX 
chemotherapy in Patients with Resected 
Adenocarcinoma of the Pancreas 
Document Date: 
August 4, 2020 


1 
 
 
Pilot Study Evaluating An Allogeneic GM-CSF-Transduced Pancreatic Tumor Cell Vaccine 
(GVAX) and Low Dose Cyclophosphamide Integrated with Fractionated Stereotactic Body 
Radiation Therapy (SBRT) and FOLFIRINOX chemotherapy in Patients with Resected 
Adenocarcinoma of the Pancreas 
 
Principal Investigator:  
 Daniel Laheru, M.D., 
 
 
IND Sponsor (IND#:  BB IND 7136):   Elizabeth Jaffee, M.D., 
 
 
Research Nurse:                                                                   Beth Onners, R.N.,MSN(
 
 
Statistician:                                                                                  Elizabeth Sugar, Ph.D., (
 
 
External Regulatory Affairs:                          Jennifer Durham, Ph.D., 
 
 
Data Management & Regulatory:   Xiaowei (Nancy) Sun 
 
 
 
Research Facility:  
The Sidney Kimmel Comprehensive Cancer Center at 
Johns Hopkins 
 
 
 
IRB: 
                                                       Johns Hopkins Medicine- Institutional Review Board 
                                 
 
 
                                                      
 
Last Revised:  
May 3, 2011 (v1), November 7, 2011 (v2), December 15, 2011 (v3) 
Amendment 1, April 30, 2012 (V 4)  
 Amendment 2, July 2, 2012 (V 5) 
Amendment 3, November 9, 2012 (V 6) 
Amendment 4, January 14, 2013 (V 7) 
Amendment 5, February 28, 2013 (v8) 
Amendment 6, April 9, 2013 (v9) 
 Amendment 7, October 11, 2013 (v10) 
Amendment 8, August 18, 2016 (v11) 
Amendment 9, January 9, 2019 (v12) 
Amendment 10, April 6, 2019 (v13) 
Amendment 11, October 9, 2019 (v14) 
Amendment 12, August 4, 2020 (v15) 
 
 
 


2 
 
TITLE 
 
Pilot Study Evaluating An Allogeneic GM-CSF-Transduced Pancreatic Tumor Cell Vaccine (GVAX) 
and Low Dose Cyclophosphamide Integrated with Fractionated Stereotactic Body Radiation Therapy 
(SBRT) and FOLFIRINOX chemotherapy in Patients with Resected Adenocarcinoma of the Pancreas. 
 
 
Protocol Synopsis 
 
Title 
Pilot Study Evaluating An Allogeneic GM-CSF-Transduced 
Pancreatic Tumor Cell Vaccine (GVAX) and Low Dose 
Cyclophosphamide Integrated with Fractionated Stereotactic 
Body 
Radiation 
Therapy 
(SBRT) 
and 
FOLFIRINOX 
chemotherapy in Patients with Resected Adenocarcinoma of 
the Pancreas. 
 
 
Sponsor 
Pending 
 
 
Investigational Product 
Whole Cell Vaccine (Allogeneic GM-CSF secreting pancreas 
vaccine, GVAX). 
 
 
Objectives 
Primary:  To evaluate the toxicity of the whole cell vaccine 
(GVAX) 
administered 
along 
with 
cyclophosphamide; 
fractionated SBRT, and FOLFIRINOX. Enrollment is based on 
traditional 3+3 design with grade 3-4 diarrhea and/or 
neutropenia defined as the dose limiting toxicity (DLT) within 
the first 2 cycles (8 weeks) of FOLFIRINOX. 
Patient Population 
Patients with resected pancreas head, neck, and/or uncinate 
adenocarcinoma. 
 
R0 or R1 pancreatic resection 
 
AJCC stage I-IIB (T1-3, N0-1, M0) 
 
No evidence of metastatic disease 
 
ECOG PS 0-1 
 
Surgery within 10 weeks of study enrollment  
 
≥ 18 years of age 
 
 
Pretreatment 
Requirements 
Pathology report available for review 
 
Operative report available for review 
 
CT chest/abdomen/pelvis (If allergic to CT scan contrast, 
obtain abdominal/pelvic MRI with contrast and non-contrast 
chest CT) showing no disease recurrence 
 
 
Required Laboratory Tests 
Platelets ≥ 100,000/mm3 
 
Absolute neutrophil count ≥ 1,000/mm3 
 
Total bilirubin ≤ 1.5 x ULN 
 
Alkaline phosphatase, ALT, and AST ≤ 2.5 x ULN 
 
Serum Creatinine ≤ 1.5 x ULN 
 
CA 19-9 ≤ 180 (drawn at least 3 weeks out from surgery) 
 
 
Study Design 
Pilot study SBRT, FOLFIRINOX ± GVAX 
 
Accrual goal N= 18 
 
 


3 
 
Treatment Plan 
Clip placement:  Per the standard of care, all resected 
patients will have titanium clips placed at the time of surgery 
outlining 
the 
superior 
and 
inferior 
aspect 
of 
the 
retroperitoneal/superior mesenteric artery margin.  This will 
be used to guide SBRT treatment. 
 
Restaging: Within 3-8 weeks of surgery, patients will be 
restaged with a history and physical exam, standard 
bloodwork (including CA 19-9), and a CT of the chest, 
abdomen, and pelvis (or if IV contrast allergic will have a non-
contrast chest CT and abdomen/pelvic MRI).  If performance 
status (ECOG performance status 0-1), incision is healed, 
drains removed, and no signs of metastatic disease or local 
recurrence, patients will be considered candidates for the trial 
(see eligibility section). 
Protocol Treatment:  
 
Cyclophosphamide and Vaccine #1: 
Note: **First cohort of patients will not get GVAX or Cy (They 
will get SBRT and FOLFIRINOX only). 
 
(After the first cohort) Vaccine must be initiated within 6-10 
weeks from surgery. Patients will receive Cyclophosphamide 
(Cy) IV over 30 minutes followed by vaccine (GVAX) #1 one day 
after cyclophosphamide.  The dose of Cyclophosphamide will 
be 200 mg/m2 intravenously the day prior to each vaccination. 
Each vaccine will consist of 6 intradermal injections for a total 
of approximately 5 X 108 cells per dose. 
 
Each vaccination cycle consisting of cyclophosphamide and 
vaccine can be referred to as (Cy/Vaccine). 
 
 
Stereotactic Body Radiation (SBRT) (6.6 Gy x 5 days) 
 
Patients in the cohort NOT receiving vaccine will start SBRT 
6-10 weeks post-surgery  
 
Patients receiving vaccine will start 13-17 days after Vaccine.  
 
SBRT must be started within 12 weeks from the date of 
surgery.  SBRT must be administered at JHU.  At least 2 
fractions of SBRT will need to be given per week and SBRT 
must be completed within 2 weeks of initiation.  
 
FOLFIRINOX:   
Patients will 
begin FOLFIRINOX 
7-28 days following 
completion of SBRT. Each patient will receive a total of 6 cycles 
of FOLFIRINOX. 
 
Restaging CT or MRI after 3 cycles and following completion of 
FOLFIRINOX chemotherapy 
 
Cy/Vaccine #2-5: 
Cy/Vaccine #2 will be given 35 days (+/- 7 days) after 
completion of FOLFIRINOX. Cy/Vaccine will be given every 25-
31 days for vaccines #3, #4, and #5. 
 
Continue Cy/Vaccine every 6 months +/- 30 days until 
progression, toxicity, or subject withdrawal 


4 
 
(restage prior to each vaccine). As of Amendment #10, boost 
vaccinations will be administered annually (+/- 30 days). 
 
Restaging CT (chest/abd/pelvis)or MRI of the abd/pelvis (If IV 
contrast allergic and non-contrast chest CT) every 6 months 
following completion of FOLFIRINOX therapy 
 
Summary (protocol): Surgery (clips placed)→ → Cy/Vaccine 
(2 days) → → SBRT (radiation/5 days) → → FOLFIRINOX 
(chemotherapy, 24 weeks) → →Cy/Vaccine (once a month for 
4 months) → →booster Cy/Vaccine every 6 months (every 12 
months as of Amendment #10) until recurrence or stop.  
***First 3 enrolled patients will not get Cy/Vaccine. 
Duration of Participation 
All patients will continue on study treatment until disease 
recurrence and be followed for overall survival thereafter. 
Statistical Rationale 
The primary endpoint is safety.  The toxicity profile of 
FOLFIRINOX (F) in the metastatic setting and standard 
radiation therapy (RT) in the adjuvant setting has been well 
established.  Approximately 20% of patients experience 
diarrhea, 50% experience non-recoverable neutropenia, and 
10% experience thrombocytopenia.  We are interested in 
exploring the combination of FOLFIRINOX with stereotactic 
body radiation therapy (SBRT) plus GVAX.  Toxicity rates of 
grade 3-4 diarrhea, grade 3 neutropenia, and grade 3-4 
thrombocytopenia would be considered unacceptable (dose 
limiting toxicity-DLT) if they were 40%, 60%, and 40% 
respectively.   Although GVAX is not expected to contribute 
to these two types of toxicity, we will enroll patients into two 
cohorts so that only one factor in the therapy is modified at 
each step. The first cohort will receive FOLFIRINOX plus SBRT 
in place of standard radiation therapy.  The second cohort 
will receive the same combination plus GVAX.   
 
A decision rule similar to the traditional 3+3 design will be 
used to determine whether or not it is safe to continue on to 
the next cohort.  An initial 3 patients will be treated with 
F+SBRT.  If no toxicities are observed after the first 2 cycles 
(8 weeks) of adjuvant FOLFIRINOX then the next group of 3 
patients will be treated with F+SBRT+GVAX.  If 2-3 patients 
are observed with uncontrolled grade 3-4 diarrhea, 2-3 
patients are observed with grade 3-4 thrombocytopenia, or if 
3 patients are observed with grade 3-4 neutropenia after the 
first 2 cycles of FOLFIRINOX then the trial will be halted.  
Otherwise (i.e. if 1 patient is observed with grade 3-4 diarrhea, 
1 patient is observed with thrombocytopenia, or 1-2 patients 
are observed with neutropenia), then an additional 3 patients 
will be treated with F+SBRT.  If 0-1/6 patients experience 
grade 3-4 diarrhea, 0-1/6 patients experience grade 3-4 
thrombocytopenia, and 
0-3/6 
experience 
 
grade 3-4 
neutropenia after 2 cycles of FOLFIRINOX, then the next 
group of patients will receive F+SBRT+GVAX.  Treatment 
groups for which < 40% experience grade 3-4 diarrhea (i.e. < 
2/6), <40% experience grade 3-4 thrombocytopenia (i.e. <2/6), 
and < 60% experience grade 3-4 neutropenia (i.e. < 4/6) will 
be considered tolerable.  An expansion cohort of 6 patients 
will be treated with F+SBRT+GVAX, if tolerable, in order to 


5 
 
refine estimates of toxicity and initial efficacy for a total sample 
size of 15-18 patients. 
 
-Any grade 3-4 toxicity occurring in the first 2 cycles (8 weeks) 
of FOLFIRINOX and within the context of the decision rule 
described above will be dose limiting with the exception of 1) 
nausea, vomiting or diarrhea that improves to ≤ grade 2 with 
maximal medical management within 5 days; 2) neutropenia 
that resolves within 5 days; or 3) thrombocytopenia that 
resolves within 7 days.   
 
-Patients who get DLT-qualifying diarrhea but do not adhere 
to appropriate medical management will be considered 
inevaluable for DLTs and an additional 3 patients will be 
enrolled. 
 
We hypothesize that the utilization of SBRT instead of 
standard 
chemoradiation 
should 
result 
in 
1) 
less 
immunosuppression 2) less delay in administering full dose 
chemotherapy (FOLFIRINOX) 3) less toxicity thus improving 
compliance with subsequent FOLFIRINOX 4) equivalent or 
improved 
local 
control 
when 
compared 
to 
standard 
chemoradiation (~20-25% local recurrence).   
 
Secondary endpoints:  
 
1) To estimate the overall survival (OS), disease-free survival 
(DFS), freedom from local progression (FFLP), and distant 
metastases free survival (DMFS) 
2) To estimate the association of specific in vivo parameters 
of immune response with time to progression in patients 
with resected pancreas cancer. The specific immune 
parameters include vaccine-induced changes in the 
number, function, avidity, size and diversity of the 
mesothelin-specific T cell repertoire. 
 


6 
 
Figure 1:  Study Schema 
 
 
 
 
 
 
 
Figure 1: Study Schema.  Eligibility will be determined after 
surgery.  All candidates will have clips placed at the time of 
surgery for SBRT.  Pre-treatment PBL and serum will be 
banked 1-2 days prior to each vaccine and 28-32 days after 
each vaccine.  Toxicities will be monitored as part of this study 
during parts 1, 4, and 5.  Safety and efficacy data will be 
requested and reviewed after SBRT and FOLFIRINOX therapy.  
Unvaccinated patients will still be asked to donate serum to 
compare correlates with vaccinated patients.  *First 3 patients 
will not receive GVAX or Cy (FOLFIRINOX and SBRT only). 


7 
 
TABLE OF CONTENTS   
 
Protocol Synopsis ............................................................................................................ 2 
TABLE OF CONTENTS ...................................................................................................... 7 
1.0  
Introduction ................................................................................................ 9 
1.1 
Background....................................................................................................... 9 
1.2 
Inclusion of Women and Minorities .................................................................. 17 
2.0 
Objectives .................................................................................................. 18 
2.1 
Primary Objective ............................................................................................ 18 
2.2 
Secondary Objective(s) ..................................................................................... 18 
3.0 
On-Study Guidelines .................................................................................. 18 
4.0 
Eligibility Criteria ...................................................................................... 18 
5.0 
Enrollment Requirements .......................................................................... 20 
6.0 
DATA SUBMISSION AND MODALITY REVIEW ............................................. 20 
6.1 
Surgical Protocol Quality Assurance Requirements ........................................... 20 
6.2  Pathologic Protocol Quality Assurance Requirements........................................ 20 
6.3 
Radiation Quality Assurance Requirements ...................................................... 21 
7.0  
Required Data ............................................................................................ 22 
7.1 
Screening visit ................................................................................................. 22 
8.0 
Treatment Plan .......................................................................................... 28 
8.1 
Surgery ........................................................................................................... 29 
8.2 
Cyclophosphamide and Vaccine Dose #1 .......................................................... 29 
8.3 
SBRT administration ....................................................................................... 30 
8.4 
FOLFIRINOX 24 weeks .................................................................................... 32 
8.5 
Cyclophosphamide/Vaccine #2-5 and Beyond (following completion of 24 weeks 
of FOLFIRINOX chemotherapy) ........................................................................ 33 
8.6 
Off Study and Follow-up .................................................................................. 34 
8.7 
General Concomitant Medication and Supportive Care Guidelines .................... 35 
9.0 
Dose Modifications And Management of Toxicity ....................................... 37 
9.1 
Cyclophosphamide Dose Modifications ............................................................. 37 
9.2 
Vaccine Dose Modifications .............................................................................. 37 
9.3 
Dose Modifications for Obese Patients .............................................................. 37 
9.4 
FOLFIRINOX Dose Modifications ...................................................................... 37 
9.5 
FOLFIRINOX Toxicities .................................................................................... 41 
10.0 
Companion Studies .................................................................................... 44 
10.1 Correlative Science .......................................................................................... 44 
11.0 
Drug Formulation, Availability, And Preparation........................................ 48 
11.1 Cyclophosphamide .......................................................................................... 48 
11.2 Whole Cell Vaccine .......................................................................................... 50 
12.0 
Ancillary Therapy ...................................................................................... 51 


8 
 
13.0 
CRITERIA FOR RESPONSE, PROGRESSION AND RELAPSE (SOLID TUMORS)
 
52 
13.1 Definition of Progression .................................................................................. 52 
13.2 Evaluation of Immune Responses .................................................................... 52 
14.0 
Statistical Considerations .......................................................................... 52 
15.0 
Adverse and Problem Event Reporting ....................................................... 54 
15.1 Recording of an adverse event .......................................................................... 54 
15.2 Reporting guidelines ........................................................................................ 55 
15.3 Special considerations for AEs that occur during local FOLFIRINOX treatment . 57 
16.0 
Clinical Trial Monitoring ............................................................................ 58 
16.1 Internal review ................................................................................................ 58 
16.2 External review ................................................................................................ 58 
17.0 
References ................................................................................................. 60 
Appendix I: Vaccine Administration Standard Operating Procedure ............................... 64 
Appendix II: Patient Documentation for Vaccination ..................................................... 67 
Appendix III: Oxaliplatin Prescribing Information .......................................................... 68 
Appendix IV: 5-Fluorouracil Prescribing Information ..................................................... 69 
Appendix V: Leucovorin Prescribing Information ........................................................... 70 
Appendix VI: Irinotecan Prescribing Information ........................................................... 71 
Appendix VII: Serious Adverse Event Reporting Form .................................................... 72 


9 
 
1.0  Introduction 
 
1.1 Background 
 
1.1.1  Adjuvant Therapy for Pancreatic Cancer 
 
Pancreas cancer is the tenth leading cause of cancer in the United States with an 
estimated incidence of 43,140 new cases in 2010(1). The low median survival rates and 
cure rates for resectable pancreatic cancer imply residual local and systemic microscopic 
disease that is potentially amenable to adjuvant therapy.  
 
The standard of care of adjuvant therapy has been in flux due to the inconsistent and 
modest signal seen in trials.  Adjuvant chemoradiation has been studied due to the high 
rate of positive margins and local regional recurrence seen in surgical series.  The benefit 
of 5-fluorouracil based chemoradiation was first seen in a small, randomized trial 
performed by the Gastrointestinal Tumor Study Group (GITSG)(2). This study showed a 
striking benefit in median survival and 5-year overall survival compared with observation 
with the use of post-operative concurrent 5-FU and radiation (40 Gy, split course) 
followed by 2 years of 5-FU alone in spite of no difference in locoregional control. The 
EORTC trial seemed to support these findings with a trend towards improved survival 
with adjuvant chemoradiation alone(3, 4).  Additionally, two very large retrospective 
series, one from Johns Hopkins University (n=616) and one from the Mayo Clinic (n=472), 
have demonstrated median survival benefits consistent with the GITSG and EORTC 
studies(5, 6) 
 
The comparative benefit of chemotherapy and chemoradiation was challenged by the 
European Study Group for Pancreatic Cancer (ESPAC) study, which randomized 541 
patients with pancreatic adenocarcinoma to the following four treatment arms under a 
two-by-two factorial design: a) Observation; b) concomitant chemoradiotherapy alone (20 
Gy in 10 fractions over 2 weeks) with 500 mg/m2 5-FU IV bolus during the first three 
days of radiation therapy(7). The module is repeated after a planned 2 week break 
followed by no additional chemotherapy; c) chemotherapy alone (leucovorin 20 mg/m2 
bolus followed by 5-FU 425 mg/m2 administered for 5 consecutive days repeated every 
28 days for 6 cycles); 4) chemoradiotherapy followed by chemotherapy. For the same 
subset randomized through the original two by two design, chemotherapy alone 
demonstrated a trend towards improved survival alone (median survival 17.4 months) 
versus observation alone (15.9 months) but was not statistically significant (p=0.19). The 
study 
authors 
concluded 
that 
there 
was 
no 
survival 
benefit 
for 
adjuvant 
chemoradiotherapy. In addition, the authors concluded that a potential benefit existed 
for adjuvant chemotherapy alone following surgical resection.  Unfortunately the trial’s 
many 
flaws 
such 
as 
questionable 
study 
design 
and 
lack 
of 
surgical/pathological/radiation quality when compared with institutional outcomes, 
render the results of this study difficult to interpret.  However, ESPAC does highlight the 
importance of adjuvant chemotherapy. 
 
While the above-mentioned adjuvant studies were being conducted, gemcitabine had 
emerged as a more effective chemotherapy than 5-FU in the setting of advanced 
disease(8).  Because of this, gemcitabine was evaluated in the post-operative setting.  
The Radiation Therapy Oncology Group (RTOG) reported on a phase III study of 518 
resected pancreatic cancer patients randomized to either 5-FU continuous infusion (250 
mg/m2/d for 3 weeks), followed by 5-FU continuous infusion (250 mg/m2/d) during 
radiation therapy (50.4 Gy in 1.8 Gy/fractions), followed by 2 cycles 5-FU continuous 
infusion.  This was compared to Gemcitabine 1000 mg/m2 weekly X 3, followed by 5-FU 
continuous infusion during radiation therapy, followed by 3 cycles of Gemcitabine 
alone(9). While there was a higher incidence of grade 3-4 neutropenia for patients in the 


10 
 
Gemcitabine arm, the median survival was 20 months for the Gemcitabine treated 
patients versus 16.3 months for 5-FU treated patients (p=.03). In the final manuscript, 
RTOG reported a survival benefit on multivariable analysis of 20.6 versus 16.9 months 
(p=.03) in favor of the Gemcitabine chemotherapy arm, restricted to patients with cancer 
of the pancreatic head.  In contrast, the European CONKO-1 study recently published a 
phase III study of 354 patients randomized to observation or 6 months of Gemcitabine 
chemotherapy(10). The primary endpoint of this study was DFS with an improvement for 
the treatment arm (13.4 months v. 6.9 months, p<.001). Further follow-up has shown a 
survival benefit to chemotherapy.  
 
From these studies, it is evident that a standard adjuvant treatment approach for patients 
with resected disease has not yet been determined.  However, given the above data, 
gemcitabine or 5-FU based CRT (RTOG 9704) or gemcitabine/bolus 5-FU(CONKO-
1/ESPAC-3) can both be viewed as a reasonable standard of care in the adjuvant setting. 
 
1.1.2 Rationale for Cell-Based Immunotherapy of Pancreatic Adenocarcinoma 
 
Immunotherapy is a novel therapeutic approach that has the ability to recruit and 
activate tumor specific T-cells and induce a cytotoxic response. The potential of this 
approach is attractive for several reasons: (1) the activation of tumor specific T-cells acts 
via a mechanism that is distinct from chemotherapy or radiation therapy and would 
represent a non-cross resistant treatment with an entirely different spectrum of toxicities, 
(2) the immune system is capable of recognizing a broad diversity of potential antigens 
while orchestrating selective as well as specific cytotoxic responses.  
 
Rationale for the use of a GM-CSF secreting whole cell vaccine approach 
 
Johns Hopkins University has developed a cytokine secreting tumor vaccine approach 
that can cure mice of pre-existing tumors. This approach is based on the concept that 
certain cytokines are required at the site of the tumor to effectively prime cancer-specific 
immunity. In the only study to directly compare a large number of immune stimulating 
cytokines, GM-CSF stood out as the most potent cytokine capable of inducing systemic 
anti-tumor immunity when expressed by the tumor cells for the initial 24-72 hrs of 
immune priming.  GM-CSF is now recognized to be the critical growth and differentiation 
factor for dendritic cells, the most potent professional antigen presenting cell responsible 
for priming immune responses against infectious agents and tumor antigens.  
 
Both autologous and allogeneic GM-CSF secreting vaccines have been tested in phase I 
and II trials in subjects with melanoma, renal cell, prostate, lung, breast and pancreatic 
cancers. Most of these studies demonstrated evidence of immune activation associated 
with clinical responses in 10-40% of treated subjects. An allogeneic pancreatic cancer 
vaccine has completed phase I and II testing at Johns Hopkins University.  The results 
of these studies have been reported and are described below.  
 
While the use of autologous tumor cells may preserve unique antigens expressed by each 
subject’s cancer, the development of an autologous vaccine requires that extensive 
processing, in vitro expansion, and regulatory testing be performed for each individual 
subject vaccine. These limitations preclude the use of autologous cellular vaccine for most 
cancers including pancreatic adenocarcinoma. A growing body of evidence supports the 
immunologic rationale for using allogeneic tumor cells rather than autologous cells as 
the source of antigen used for the vaccination. First, studies evaluating human melanoma 
antigens have demonstrated that most of the human tumor antigens identified are shared 
among at least 50% of known human melanoma tumor cell lines, regardless of whether 
or not they share the same human leukocyte antigen (HLA) type.  In addition, there is 
now both pre-clinical and human data in pancreatic cancer subjects treated with a GM-


11 
 
CSF vaccine to support host-derived professional antigen presenting cells (APCs) as the 
critical cells required to present immunogen to T cells in the context of MHC.  Therefore, 
the vaccine cells do not need to be HLA compatible with the host’s immune system as 
long as they can release cellular proteins (the tumor antigens) for uptake by professional 
APCs (macrophages and dendritic cells) that are attracted to the vaccine site by GM-CSF.  
Taken together, the data suggest that relevant tumor antigens can be delivered by an 
allogeneic tumor and still sufficiently mount an effective immune response.  
 
Two allogeneic cell lines have been developed from neoplastic tissue harvested from the 
surgical specimens of subjects undergoing pancreaticoduodenectomy at The Johns 
Hopkins Hospital. These cell lines have been characterized as 100% epithelial by 
cytokeratin staining. In addition, these cell lines carry the same k-ras mutation as the 
original tumor specimen, which supports the conclusion that these lines are derived from 
malignant pancreatic tumor cells. The cell lines Panc 10.05 and Panc 6.03 both contain 
the most common k-ras mutation at codon 12 found in greater than 90% of pancreatic 
cancer. These lines have undergone extensive regulatory testing and have been shown to 
maintain GM-CSF secretion, MHC class I levels, cytokeratin positive staining and the 
original K-ras mutation. These lines also express 2 new immunogenic pancreatic tumor 
antigens, mesothelin and PSCA. These lines have already been demonstrated to be safe 
and feasible to produce and administer in a phase I and two phase II studies in both the 
adjuvant and metastatic setting(11, 12).  
 
 
1.1.3  Adjuvant studies of the whole cell vaccine (allogeneic GM-CSF secreting 
pancreatic tumor cell lines) 
 
Results of a Phase I Adjuvant Study at Johns Hopkins 
This study was the first clinical trial to test the hypothesis that the allogeneic GM-CSF 
secreting pancreatic tumor cell lines, hereafter called whole cell vaccine, can prime a 
systemic immune response in subjects with resected pancreatic adenocarcinoma(13). 
Fourteen subjects with stage II or III disease received an initial vaccination 8 weeks 
following resection. This was a dose escalation study in which 3 subjects each received 1 
X 107, 5 X 107, and 1 X 108 vaccine cells.  An additional 5 subjects received 5 X 108 
vaccine cells.  Study subjects were jointly enrolled in an adjuvant chemoradiation 
protocol for 6 months. Following the completion of adjuvant chemoradiation, subjects 
were re-assessed and those who were still in remission were treated with 3 additional 
vaccinations given one month apart at the same original dose that they received for the 
first vaccination. Toxicities were limited to grade I/II local reactions at the vaccine site, 
and self-limited systemic rashes, including one documented case of Grover's syndrome.  
Systemic GM-CSF levels were evaluated as an indirect measure of the longevity of vaccine 
cells at the immunizing site. As was observed in pre-clinical studies, GM-CSF levels 
peaked at 48 hours following vaccination.  In addition, serum GM- CSF levels could be 
detected for up to 96 hours following vaccination. These data, together with data from 
pre-clinical models, would suggest that detectable serum GM-CSF levels may serve as a 
bio-marker of immune response.  The vaccine sites were also evaluated as a measure of 
the local immune reaction to the vaccine. Eleven of 14 subjects demonstrated a similar 
local inflammatory response to what has been observed in pre-clinical models and 
autologous GM-CSF vaccine clinical trials. Post-vaccination DTH responses to autologous 
tumor cells have been used in previously reported vaccine studies as a surrogate to 
identify and characterize specific immune responses that are associated with vaccination. 
In the pancreatic cancer vaccine trial, post-vaccination DTH responses to autologous 
tumor cells were observed in 1 of 3 subjects receiving 1X 108 and in 2 of 5 subjects 
receiving 5X108 vaccine cells. As of December 2010, three long term survivors are still 
disease-free more than 12 years. 
 


12 
 
Follow-up phase II study integrating the whole cell vaccine with chemoradiation for resected 
pancreatic adenocarcinoma  
 
Johns Hopkins has also recently completed a follow-up phase II study of 60 patients with 
resected pancreatic adenocarcinoma based on the results of their phase I experience(12). 
The highest dose of vaccine from the phase I study (5 X 108 vaccine cells) was used and 
the adjuvant chemotherapy regimen given in sequence with the vaccine was modified to 
eliminate mitomycin-C as this drug was thought to depress immune function as 
measured by a decrease in vaccine induced mesothelin specific T cells following 
chemoradiation.  The common toxicities associated with the vaccine in this study 
included: local vaccine site skin reactions and systemic rashes similar in severity (grade 
1-2) to what was observed in the phase I trial. A full description of toxicities is provided 
in the Investigator’s Brochure. The results from this study include the following: 
 
  The administration of the whole cell vaccine is safe and well-tolerated. Treatment 
related side effects included transient vaccine injection site reactions. 
  Systemic GM-CSF levels were evaluated as an indirect measure of the longevity of 
vaccine cells at the immunizing site. As was observed in the phase I study, GM-CSF 
levels peaked at 48 hours following the first and second vaccination but peaked earlier 
following the 3rd and 4th vaccination with diminution in amplitude. Serum GM-CSF 
levels following vaccine 5 peaked again at 48 hours and returned to vaccine 1 serum 
levels. The results would suggest the possibility that the potency of an allogeneic 
vaccine is diminished with repeated monthly vaccinations, but returns to pre-
treatment levels with an extended time interval between boosts.  
  As recently reported, (88% node (+), 30% margin (+)) the median survival was 24.8 
months (12). 
  Post-Immunotherapy induction of mesothelin-specific CD8+ T cells with higher 
avidity and increased mesothelin epitope recognition (T cell repertoire expansion) 
correlates with disease free survival (DFS). 
 
The data also support additional boost immunotherapies beyond one year post surgery 
in future studies. 
 
1.1.4 Rationale for Combining Immune Modulating Doses of Chemotherapy 
with Vaccine 
 
A large body of murine and human data exists demonstrating that tumors grow despite 
the simultaneous existence of tumor-specific immune responses. To explain this 
observation, it has long been hypothesized that subjects with cancer demonstrate 
peripheral tolerance to their tumor. There is specific data to suggest that immune 
modulating doses of cyclophosphamide enhances vaccine induced anti-tumor immune 
responses by inhibiting suppressor T-cell activity.  Several clinical trials have since 
combined cyclophosphamide with vaccination. Recent murine data from our group 
strongly suggests that cyclophosphamide inhibits the CD4+/CD25+ regulatory T cells 
from functionally inactivating the high avidity HER-2/neu specific T cell population that 
is required for effective treatment of mammary tumors(14).  These data together with 
earlier studies provide the rationale to integrate tumor vaccines into current treatment 
modalities.  In addition, since the cyclophosphamide exerts its effect on the regulatory T 
cells of the immune system rather than on the cancer cell itself, this approach can be 
applied to treat any type of cancer. 
 
Phase II Trial of whole cell vaccine alone and in sequence with immune modulating doses 
of cyclophosphamide in subjects with advanced pancreatic cancer 
 


13 
 
Johns Hopkins University completed a feasibility study of the whole cell vaccine 
administered alone or in sequence with cyclophosphamide in subjects with advanced 
pancreatic cancer(11).  This study was an open label multi-center study sponsored by 
Cell Genesys, Inc in collaboration with US Oncology with two cohorts: Cohort A- 30 
subjects administered a maximum of six doses of vaccine using two pancreas cancer cell 
lines each to deliver 2.5 X 108 cells intradermally administered at 21 day intervals; Cohort 
B- 20 subjects administered cyclophosphamide 250 mg/m2 IV one day prior to vaccine 
as in Cohort A. The primary objective was to evaluate safety and efficacy of vaccine 
administered alone or in sequence with cyclophosphamide. Secondary objectives include 
time to disease progression (TTP) and median overall survival (OS). The following has been 
reported following to date: 
 
  The administration of the whole cell vaccine either alone or in sequence with 
cyclophosphamide is safe and tolerated by subjects with advanced pancreatic cancer, 
the majority of which had received ≥ 2 prior chemotherapy regimens. The median 
number of vaccines administered was 2 in Cohort A and 3 in Cohort B. Treatment 
related adverse events reported in > 5% of subjects included local vaccine injection 
site reactions (100%), fever (14%), rigors (10%) and rash (6%). Grade 3/4 treatment 
related events identified in only one JHU subject and included leukocytosis, 
dehydration, and fatigue. 
  Serum GM-CSF levels peaked at 48 hours post vaccination consistent with published 
results in the adjuvant setting and was seen following repeated vaccination, 
suggesting that vaccine cells are not rapidly cleared by an allogeneic response with 
repeat administration. 
  Stable disease was noted in 16.7 % of subjects in Cohort A and 40% of subjects in 
Cohort B. Median survival in Cohort A and Cohort B were 2.3 months and 4.7 months 
respectively in a subject population that had received ≥ 2 prior chemotherapies in 
12/20 subjects for Cohort B and in 30/50 subjects overall. 
 
The study represents the first report that the combination of chemotherapy using 
immunomodulatory doses integrated with a GM-CSF vaccine in subjects with advanced 
pancreatic cancer is safe and feasible to administer.  
 
A randomized three-arm neoadjuvant and adjuvant feasibility and toxicity study of a GM-
CSF secreting allogeneic pancreatic cancer vaccine administered either alone or in 
combination with either a single intravenous dose or daily metronomic oral doses of 
cyclophosphamide for the treatment of patients with surgically resected adenocarcinoma of 
the pancreas.  
 
We are currently conducting a neo-adjuvant and adjuvant vaccine study comparing 2 
methods of Cyclophosphamide administration given with vaccine versus vaccine alone.  
At present, this study is recruiting 39 research participants, who are randomized into 
three arms. All participants are receiving the first vaccination of 5 x 108 cells of an equal 
mixture of two allogeneic GM-CSF secreting pancreatic vaccine cell lines (Panc 10.05 and 
Panc 6.03) two weeks before a pancreaticoduodenectomy, a second vaccination between 
6 and 10 weeks following the pancreaticoduodenectomy (4 weeks prior to adjuvant 
chemoradiation), and then four additional vaccinations once every 28-days beginning 1-
2 months following completion of chemoradiation. A total of six prime vaccinations are 
administrated. For participants in Arm B and Arm C, each vaccination is combined with 
a single low-dose cyclophosphamide or repetitive twice-daily metronomic doses of 
cyclophosphamide, respectively. The vaccine dose is the same dose found to be safe and 
to induce immune responses in the above described phase I and II studies.  Since 
approval in July 2008, we have enrolled and treated 46 patients (between 7/30/08 and 
08/31/11).  No serious adverse events were observed in these patients as a result of 
vaccine therapy with or without cyclophosphamide. Similar to prior vaccine studies, all 


14 
 
subjects experienced grade I/II local reactions at the vaccine site. Systemic reactions 
rarely occurred and were self-limiting. Systemic lymphopenia, which is anticipated to 
result from the cyclophosphamide treatment, occurred in two patients and was resolved 
within one week and prior to the surgery. No patients’ surgery was delayed because of 
the neoadjuvant treatment.  No additional adverse events were observed with repeated 
dosing of cyclophosphamide prior to each vaccine.   Thus, the preliminary results 
suggest that the PDA vaccine and/or immune modulating doses of cyclophosphamide is 
safe and feasible to give prior to surgical resection of PDA and in a repeated dosing 
schedule. 
 
1.1.5 Rationale for replacing standard chemoradiation with fractionated 
stereotactic body radiation therapy (SBRT) in the adjuvant setting.   
 
Standard chemoradiation (CRT) requires 5-6 weeks of therapy and often attenuated doses 
of chemotherapy when compared to adjuvant regimens that use full doses of 
chemotherapy (CONKO, RTOG 9704)(9).  Standard CRT causes more toxicity (acute and 
chronic) when compared to chemotherapy alone and less compliance of subsequent 
maintenance chemotherapy(15).  Therefore, many investigators have either eliminated 
radiation from adjuvant therapy (CONKO/ESPAC-3) or delayed giving radiation until 
adjuvant full-dose chemotherapy has been completed(10).  Although eliminating or 
delaying radiation therapy may decrease the risk of metastatic disease, it may also 
increase the risk of local recurrence, which can cause extensive morbidity (pain and 
obstruction) and result in death(16).  In our phase I/II adjuvant vaccine trials, we also 
found that adjuvant CRT with or without mitomycin-C caused immunosuppression and 
a decrease in the vaccine-mediated immune response.  Therefore we propose utilization 
of fractionated stereotactic radiation therapy to the tumor bed plus a small margin (1 cm) 
followed by FOLFIRINOX chemotherapy as an alternative to standard CRT.  The most 
common site of a localized recurrence is the tumor bed or superior mesenteric artery 
(SMA) margin.  Therefore, we recommend treating only the SMA region (plus a small 
margin) in this study. 
 
 
1.1.6 Rationale and safety data for stereotactic body radiation therapy 
 
Koong et al. previously used the CyberknifeTM stereotactic radiosurgery system to 
demonstrate that a single dose of 25 Gy stereotactic body radiotherapy (SBRT) was 
feasible to administer in patients with locally advanced pancreatic cancer(17). 
Furthermore, this dose of SBRT resulted in near 100% progression free survival and 
effectively palliated symptoms related to the local growth of pancreatic tumors. Based 
upon this study, they also completed a phase II study assessing the efficacy of combining 
a standard five-week course of chemoradiotherapy followed by a stereotactic radiosurgery 
boost to the primary tumor in patients with locally advanced pancreatic cancer(18).  In 
this cohort of 19 patients, 100% of tumors were without local progression.  However, all 
patients eventually developed metastases with a median time to progression of 5.5 weeks.  
 
More recently, another phase II study treated locally advanced pancreatic cancer patients 
with gemcitabine followed by 25 Gy of SBRT delivered with Cyberknife and maintenance 
gemcitabine chemotherapy.  In this study, the excellent progression free survival was 
confirmed from previous studies (81%).  The median overall survival was 11.4 months, 
median time to progression was 9.7 months and the 1-year survival was 50%(19).  There 
were no significant acute GI toxicities, however, of the 15 patients alive >6 months after 
SBRT, 7 (47%) experienced Grade 2 or greater GI toxicity, with 2 (13%) of the 15 
experiencing Grade 3 or greater GI toxicity. 
 


15 
 
Trilogy  and Synergy are commercially available (Varian Medical Systems, Palo Alto 
CA and Elekta AB, Stockholm, Sweden, respectively) linear accelerators specifically 
designed for image guided radiation therapy (IGRT). These machines combine a 
conventional high-energy linear accelerator with a kV imager capable of volumetric, cone 
beam CT (CBCT). Because of these innovations, it is possible to deliver highly accurate, 
stereotactic radiation treatments. Trilogy and Synergy eliminate a large proportion of 
the uncertainties in tumor location. 
 
A recent protocol evaluated full dose gemcitabine before and after single fraction SBRT 
delivered with the Trilogy linear accelerator(20).  Preliminary results indicate that the 
local progression free survival was comparable to what was previously observed (90%) 
with CyberKnife treatment.  All acute toxicity was grade 2 or less, however a minority of 
patients developed late duodenal ulcers (15%), including 1 perforation (5%) with a single 
fraction of SBRT.   
 
The mortality rate for pancreatic cancer approaches 100%. Current therapies provide only 
partial palliation of symptoms and slight prolongation of survival. Better treatment is 
clearly needed.  Stereotactic radiation therapy may more effectively ablate pancreatic 
tumor cells when compared to conventional radiation therapy, and translate into 
improved patient survival with decreased side effects. To date, Stanford has treated more 
than 150 patients with SBRT and this treatment has resulted in local control rates of 
>90% with acceptable acute GI toxicity. We predict that SBRT will not adversely impact 
patients’ quality of life, however this has not been thoroughly studied in the adjuvant 
setting. The majority of patients with locally advanced pancreatic cancer treated with 
SBRT had a clinical benefit as assessed by decreased pain, decreased fatigue, and 
increased weight. A single fraction of SBRT (25 Gy x 1) has resulted in excellent tumor 
control.  However, close to 50% of these patients developed late duodenal toxicity within 
one year primarily because of its proximity to the pancreas.  At this time there is no clear 
consensus regarding an optimal SBRT fractionation schedule for unresectable pancreas 
cancer(20).   
 
In June 2010, we opened a multi-institutional study (Johns Hopkins, Stanford, and 
Memorial Sloan Kettering) where we are treating locally advanced pancreatic cancer 
patients with SBRT for 6.6 Gy x 5 fractions.  In this study we are treating the tumor plus 
a 2 mm margin expansion.  The small margins are possible due to daily imaging, markers 
to guide therapy, and decreasing breathing motion with airway breathing control (ABC).  
This fractionation schedule is based upon personal conversations with Dr. Timmerman 
who has conducted extensive research on SBRT.  Based on his recent study, this 
fractionation schedule is predicted to provide equivalent tumor control probability as 25 
Gy x 1 while resulting in less normal tissue toxicity(21).  To date, we have treated 35 
patients, all with >4 months of follow-up and there have not been any reported grade 3 or 
4 toxicities. 
 
While a majority of studies have evaluated SBRT in the locally advanced setting, one study 
by Hong et al evaluated 5 Gy x 5 in the neoadjuvant setting.  In his study patients 
received SBRT delivered with protons and concurrent 5-FU by treating the tumor and 
adjacent peri-pancreatic lymph nodes.  Thus far, no patients have experienced grade 3/4 
acute or chronic toxicity (38). 
 
There is one study reporting on the role of SBRT in the adjuvant setting(22). In this study, 
24 pancreatic cancer patients with close or positive margins were treated with a single 
fraction of adjuvant SBRT (20-30 Gy/1 fraction) following surgical resection.  The 
median target volume was 11 cc (4.5-30 cc). Eighteen patients were treated with the 
Cyberknife(R) Robotic Radiosurgery System and six patients were treated with Trilogy 
intensity-modulated radiosurgery. The median follow-up for all patients was 12.5 months 


16 
 
(1.4-39.5 months), and among surviving patients it was 16.3 months (2-39.5 months). 
The Freedom from local progression (FFLP) rates at 6 months, 1 and 2 years were 94.7%, 
66%, and 44%, respectively. Overall, FFLP was achieved in seven (87.5%) patients with 
close margins, and 10 (62.5%) with positive margins. After SBRT, 19 patients resumed or 
started a 6-month course of gemcitabine-based chemotherapy at a median interval of 18 
days (range, 9-31 days) post-SBRT. The median OS was 26.7 months and the 1- and 2-
year OS rates were 80.4% and 57.2%, respectively. Of the 24 patients, 12 (50%) developed 
distant metastases of whom two (25%) had close margins and 10 (62.5%) had positive 
margins. Ten patients (41.7%) were free of progression at last follow-up (range, 3-39.5 
months). Three patients (12.5%) had grade 1-2 acute GI toxicities, and two patients (8.3%) 
had grade 1 and 2 late toxicities. No patients experienced grade 3 or 4 toxicity, including 
bowel perforation, secondary to SBRT.  While these rates of recurrence are higher than 
historical controls, it is important to note that this study only included patients with close 
or positive margins.  Based on these results, we propose treating the tumor bed (based 
on surgical clips) plus a 1 cm expansion to a total of 33 Gy in 5 fractions (6.6 Gy/fraction). 
 
1.1.7 Utilization of FOLFIRINOX in the adjuvant setting 
 
The use of FOLFIRINOX (5-FU, leucovorin, Irinotican, and oxaliplatin) in the adjuvant 
setting has not yet been reported in the literature, however several academic centers have 
started integrating FOLFIRINOX as their standard of care and it appears tolerable (Hong, 
Mass General Hospital-personal communication).  Although, FOLFIRINOX has not yet 
been validated in the adjuvant setting, Conroy et al. have demonstrated an impressive 
survival benefit over gemcitabine in a recently reported phase III study.  Given the dismal 
survival of gemcitabine in the adjuvant setting, utilization of FOLFIRINOX in the adjuvant 
setting may result in a similar survival benefit (months) seen in patients with metastatic 
disease.  However, we believe this should be evaluated in a prospective clinical trial.  
Further, it may be difficult to combine FOLFIRINOX with standard chemoradiation (6 
weeks) and therefore may be better tolerated with a short course of SBRT as outlined 
above. 
 
1.1.8  Rationale for the current study 
 
Given the modest results and lack of progress made with conventional cytotoxic 
chemotherapeutics and FDA-approved biologic agents, it is clear that a paradigm shift is 
needed.  Our phase II study of the whole cell vaccine strategy (GVAX) has been completed 
with provocative results. Further analysis suggests that a benefit may be more durable if 
booster doses of the vaccine are given beyond 6 months. There is reason to believe that 
the addition of immunomodulating doses of cyclophosphamide will enhance the efficacy 
of the vaccine.  It is likely that a short course of fractionated stereotactic body radiation 
therapy (SBRT) delivered to the tumor bed plus a small margin will cause less 
immunosuppression than standard adjuvant chemoradiation with equivalent local 
control rates as standard chemoradiation.  Also, by including FOLFIRINOX in the 
adjuvant setting, we expect similar survival improvements to what has been seen in 
patients with metastatic disease.  This study is also an opportunity to further assess 
whether the immune correlates found promising in our previous study are similar when 
chemotherapy (FOLFIRINOX) and radiation (SBRT) are altered. 
 
1.1.9 Study position nationally 
We expect to observe an improved median DFS and OS with this combination of 
fractionated SBRT/FOLFIRINOX integrated with or without GVAX + Cy.  Both the 
FOLFIRINOX and vaccine therapies have been tested in PDA patients with some 
improvement over other therapeutic options. We anticipate the fractionated SBRT will 
result in similar local control to standard therapy while allowing more rapid integration 
of systemic therapies with less immunosuppression.  We are also improving on the 


17 
 
vaccine by adding low dose Cy to each vaccine cycle to deplete Tregs which have been 
shown to hinder vaccine induced immune responses.  This concept of adding the 
pancreatic vaccine to a short course of fractionated SBRT and aggressive adjuvant 
chemotherapy (FOLFIRINOX) represents a natural step forward in adjuvant treatment.  
The role of stereotactic therapy has been adopted as the standard of care for some primary 
tumors including early stage lung cancer.  While a single fraction of SBRT has shown 
promise in unresectable PDA, fractionated SBRT (5 versus 1 treatment) in the adjuvant 
setting may result in similar tumor control with less side effects than standard adjuvant 
CRT.  Results of gemcitabine in combination with other agents in the metastatic setting 
have been negative (5-FU, oxaliplatin, capecitabine, bevacizumab, cetuximab) or modestly 
positive (erlotinib)(25-28). A recent publication reported encouraging results of 
FOLFIRINOX in patients with metastatic disease when compared to gemcitabine alone, 
although a majority of patients had pancreatic tail lesions and patients experienced a 
high rate of grade 3-4 toxicity requiring significant dose reductions and hospitalizations 
stressing the need for this to be evaluated in a prospective adjuvant clinical trial(29).  
This proposed strategy marks a significant departure in paradigm from these other 
strategies and is backed by strong institutional evidence as well as scientific rationale.  
We also expect to be able to estimate the frequency of the toxicities that were initially 
identified in the phase I and II studies and that are vaccine related. Based on these 
studies, we do not expect to detect significant local or systemic toxicities that are different 
in a multi-institutional setting from what we have already observed since we expect that 
the spectrum of toxicities from the SBRT are different from the vaccine and there should 
be no interactions.  The toxicities of low-dose Cy have also been well characterized.  The 
toxicity profile of the combination of low-dose Cy and vaccination can be estimated from 
the above-described phase II study in patients with metastatic PDA and our experience 
in the neo-adjuvant/adjuvant setting.  Because PDA has a very poor prognosis and there 
are few available treatment options, a <20% non-life threatening toxicity rate would be 
considered acceptable in this study (NCI Common Toxicity Criteria grade 3 or less).  
Based on the low toxicity profiles of vaccine and low-dose Cy, administration of 
preoperative vaccine/Cy is not anticipated to change the outcome of this regimen. 
1.2 Inclusion of Women and Minorities 
 
We expect to recruit, enroll, and treat about 18 patients in this study. No patient will be 
excluded from the study on the basis of sex, race, ethnic background, or socio-economic 
status. Based on pancreatic cancer epidemiologic information as well as data from the 
Johns Hopkins Hospital we believe the sex distribution will be approximately 10 males 
and 8 females for a total of 18 patients in this study. The average age will be between 35 
and 75 with a median age of approximately 58-62. 
    
The Johns Hopkins Hospital is located in East Baltimore, a historically medically 
underserved area of the city. Part of the mission of the Hospital is to provide medical care 
and access to innovative research to the surrounding community. The Sidney Kimmel 
Comprehensive Cancer Center also serves as a regional referral center for the mid-
Atlantic region. Therefore, we anticipate the study population to reflect the patients that 
Johns Hopkins serves, and target the enrollment of individuals by ethnicity and race as 
indicated in the attached Targeted/Planned Enrollment Table. 
 
Despite the mission of the Hospital to serve the surrounding community, the enrollment 
of African American individuals in clinical trials at the Sidney Kimmel Comprehensive 
Cancer Center remains lower than it should be. Every effort will be made to recruit and 
include underserved individuals and racial minorities in this study. To accomplish this, 
we will take advantage of two programs active at Johns Hopkins. First, we will utilize 
outreach programs developed by the School of Public Health to make the local community 
aware of the opportunity to participate in clinical research. This program reaches out to 
the surrounding African American community through the local churches and religious 


18 
 
network. Second, we will take advantage of the Hopkins/Howard partnership. Howard 
University is a historically black institution that serves the city of Washington DC, and 
has a large community of African Americans as a referral base. There is no racial, ethnic, 
or economically disadvantaged group of individuals that is excluded from study 
participation. 
 
2.0 
Objectives 
  
2.1 Primary Objective 
 
 
To evaluate the toxicity of the whole cell vaccine (GVAX) administered along with 
cyclophosphamide; fractionated SBRT, and FOLFIRINOX. Enrollment is based on 
traditional 3+3 design with grade 3-4 diarrhea and/or neutropenia defined as the dose 
limiting toxicity (DLT) within the first 2 cycles (8 weeks) of FOLFIRINOX. 
 
2.2 Secondary Objective(s) 
 
2.2.1 To estimate the overall survival (OS), disease-free survival (DFS), freedom from local 
progression (FFLP), and distant metastases free survival (DMFS) 
 
2.2.2 To estimate the association of specific in vivo parameters of immune response with 
time to progression in patients with resected pancreas cancer. The specific immune 
parameters include vaccine-induced changes in the number, function, avidity, size 
and diversity of the mesothelin-specific T cell repertoire. 
 
3.0 
On-Study Guidelines 
 
This clinical trial can fulfill its objectives only if patients appropriate for this trial are 
enrolled. All relevant medical and other considerations should be taken into account 
when deciding whether this protocol is appropriate for a particular patient. Physicians 
should consider the risks and benefits of any therapy, and therefore only enroll patients 
for whom this treatment is appropriate.  
 
4.0 
Eligibility Criteria 
 
4.1 
Documentation of Disease:  
4.1.1 Histologic Documentation: Histologic evidence of invasive ductal adenocarcinoma. 
Patients with mixed adenocarcinoma tumors are allowed if the predominant 
component is adenocarcinoma.  Adenocarcinoma (invasive component) arising 
from intraductal pancreatic mucinous neoplasm (IPMN) is permitted.   
4.1.2 Stage: Completely resected with a pancreaticoduodenectomy and an R0 
(microscopically negative margins) or R1 (microscopically positive margins, AJCC 
stage I-IIB, T1-3, N0-1, M0.  
4.1.3 Tumor Site: Pancreas head, neck, and/or uncinate process.  
4.1.4 Block/slides request: It is recommended that patients have paraffin-embedded 
tissue to confirm a diagnosis of adenocarcinoma. 
4.2 
Prior Treatment 
4.2.1 No prior systemic therapy or radiation therapy for pancreatic cancer. 
4.2.2 Enrollment must occur within 10 weeks from surgical resection. 


19 
 
4.2.3 Titanium clips (minimum 1) will be placed to delineate the retroperitoneal/SMA 
margin at the time of surgery for SBRT treatment planning. 
4.2.4 Prior adjuvant or neoadjuvant therapy is (not) allowed. 
4.3 
Patients must not have evidence of recurrent or metastatic disease on post-operative 
re-staging CT scans of the chest/abdomen/pelvis with IV contrast or if IV contrast 
allergic, MRI abdomen/pelvis with contrast and non-contrast chest CT.   
4.4 
No prior abdominal radiation. 
4.5 
Age ≥ 18 years of age. 
4.6 
ECOG Performance Status 0 or 1. 
4.7 
Pregnancy/Nursing Status- Patients must not be pregnant or nursing.  Women of 
childbearing potential must have a negative pregnancy test within 1 week of enrollment 
and agree to birth control.  
4.8  Required Initial Laboratory Values: 
Platelets 
≥ 100,000/mm3 
Absolute neutrophil count 
≥ 1,000/mm3 
Total bilirubin 
≤ 1.5 x ULN 
Alkaline phosphatase  
≤ 2.5 x ULN 
ALT 
≤ 2.5 x ULN 
AST 
≤ 2.5 x ULN 
Serum Creatinine 
≤ 1.5 x ULN 
CA 19-9 
≤ 180, drawn at least 4 weeks out from surgery 
 
4.9 
Exclusion criteria 
4.9.1  
Patients in whom histologic diagnosis is not consistent with ductal 
adenocarcinoma such as pure squamous cell, colloid, islet cell, serous or 
mucinous cystadenoma or cystadenocarcinoma, carcinoid, small or large cell 
carcinoma, intraductal oncocytic papillary neoplasms (IOPN) osteoclast-like 
giant cell tumors, acinar cell carcinoma, pancreatoblastoma, solid 
pseudopapillary tumors, undifferentiated  small cell carcinoma, non-
epithelial tumors (sarcoma, GI stromal tumor, lymphoma). In addition, 
patients with mixed adenocarcinoma tumors will not be included if the 
predominant invasive component of the tumor is not ductal adenocarcinoma. 
4.9.2  
Tumors of the pancreatic body/tail. 
4.9.3 
Known history of HIV or active hepatitis B or C infection. 
4.9.4  
Adenocarcinoma originating in the ampulla, distal bile duct, or duodenum. 
4.9.5  
Patients with gross residual tumor (R2 resection) following surgical resection. 
4.9.6  
Patients with recurrent disease. 
4.9.7  
Metastatic disease including peritoneal implants, liver and/or lung 
involvement. 
4.9.8 
Pregnant or lactating women: Women of childbearing potential must have a 
negative pregnancy test within 1 week prior to study treatment. 
(Contraception Warning: Women of childbearing potential and men enrolled 
in the study must agree to practice an effective method of birth control during 
the study and for at least four weeks after their last treatment on protocol.)  
4.9.9 
Presence of existing second malignancies except for non-melanoma skin 
cancer or a history of second malignancies in the past five years. 


20 
 
4.9.10 
Uncontrolled medical conditions that could potentially increase the risk of 
toxicities or complications of the vaccine, especially heart disease.  If the 
patient has a history of heart disease, they should be evaluated by a 
cardiologist prior to enrollment. 
4.9.11 
Active infections. 
4.9.12 
Active autoimmune diseases or history of autoimmune disease requiring 
chronic medical treatment with systemic immunosuppressants including: 
inflammatory bowel disease, systemic vasculitis, scleroderma, psoriasis, 
multiple sclerosis, hemolytic anemia or immune thrombocytopenia, 
rheumatoid arthritis, SLE, and Sjogren’s syndrome, sarcoidosis. Asthma or 
COPD that does not require systemic corticosteroids or routine use of inhaled 
steroids is acceptable. 
4.9.13  Chemotherapy, radiation therapy or biologic therapy within 28 days prior to 
administration of vaccine. 
4.9.14  Participation in an investigational new drug trial within one month prior to 
administration of vaccine. 
4.9.15  Systemic steroids within 28 days prior to receiving the whole cell vaccine. 
4.9.16  Major active medical or psychosocial problems that could be exacerbated by 
this treatment.  
4.9.17 
Inability to begin protocol treatment within 70 days (10 weeks) after surgery 
or the development of postoperative complications which require ongoing 
medical care past week eleven that would significantly delay time to adjuvant 
therapy.  Patients should be consuming oral nutrition and maintaining 
weight, have no ongoing requirement for biliary stenting, nor have 
persistence of a significant wound infection. 
4.9.18   Known or suspected hypersensitivity to GM-CSF, pentastarch, hetastarch, 
corn, DMSO, fetal bovine serum, or trypsin (porcine origin)  
4.9.19 
Age >76  
4.9.20 
History of cardiac ischemia or cardiovascular disease, the patient must first 
be cleared by their cardiologist. 
 
5.0 
Enrollment Requirements 
  
5.1 
Informed Consent: the patient must be aware of the neoplastic nature of his/her 
disease and consent must be provided after being informed of the procedure to 
be followed, the experimental nature of the therapy, alternatives, potential 
benefits, side-effects, risks, and discomforts. Human protection committee 
approval of this protocol and a consent form is required. 
 
5.2 
HIPAA requirements 
 
6.0 
DATA SUBMISSION AND MODALITY REVIEW 
 
6.1 Surgical Protocol Quality Assurance Requirements  
 
While all patients will have had surgery as required by eligibility, surgery is not part of 
the treatment protocol. Therefore, there will not be specific surgical quality assurance 
required.  However, operative notes will be required and must describe a pancreatic 
surgery performed with intent of removing all gross disease and clips must be placed 
outlining the superior mesenteric artery margin.  
 
6.2  Pathologic Protocol Quality Assurance Requirements  
 
For each patient, the pathological quality assurance form (Oncospace database) must be 
completed.  This will document gross tumor size, AJCC T-stage, differentiation, presence 


21 
 
of lymphovascular invasion (LVI) and perineural invasion (PNI), number of lymph nodes 
assessed, number of lymph nodes involved with tumor, and margin status of the 
uncinate, retroperitoneal, pancreatic transection, and biliary transection margin 
(positive, close defined as < 1 mm, negative defined as > 1 mm, or not assessed). 
 
6.3 Radiation Quality Assurance Requirements  
 6.3.1 QA Documentation 
Prior to the start of radiation therapy, the following information will be recorded: 
6.3.2 Treatment Planning System Output 
 Digitally reconstructed radiographs (DRR) or simulation films for each treatment field 
and orthogonal (anterior/posterior and lateral) images for isocenter localization for each 
group of concurrently treated beams. 
 Isodose distributions (in absolute dose) for the composite SBRT treatment plan in the 
axial, sagittal and coronal planes at the center of the treatment or planning target 
volume. The planning target volume, isocenter and the normalization method (if 
normalized isodoses are sent) must be clearly indicated. 
 Dose volume histograms (DVH) for the composite treatment plan for all target volumes 
and required organs at risk.  
 Treatment planning system summary report that includes the monitor unit 
calculations, beam parameters, calculation algorithm, and volume of interest dose 
statistics. 
 


22 
 
7.0  
Required Data  
 
7.1 Screening visit 
 
All screening evaluations must be completed within 28 days prior to study 
enrollment. 
 
Pre-Study Testing Intervals 
To be completed within 28 days before study drug administration: 
 
Complete history, including review of medications. 
 
Physical examination, including height, weight, vital signs (blood pressure, 
temperature, pulse, respiratory rate), ECOG performance status. 
 
All laboratory blood tests, including pregnancy test. 
 
CT scan chest, abdomen, pelvis with IV contrast or if IV contrast allergic, MRI 
abdomen/pelvis with contrast and non-contrast chest CT.  Pathology report and 
operative report available for review by the Principal Investigator. 
 
To be collected before the first vaccination: 
 
All specimens for correlative studies need to be collected as in Section 7.1.1 below 
and banked for analysis of the secondary immune endpoints.   This includes 
blood samples for HLA testing, monitoring of antigen-specific T cell responses and 
antibody responses. 
 


23 
 
Table 1: Pre-Treatment, Cyclophosphamide (Cy)/Vaccine (GVAX) #1 
 
Screening  
(D-28 to D0) 
D0:  
Cy 
D1: 
Vaccine #1 
Tests & Observations 
 
 
 
History 
X 
X 
 
Physical exam 
X 
X1 
 
Vital Signs 
X 
X 
X2 
Height 
X 
 
 
Weight, BSA4 
X 
 
 
Performance Status 
X 
X 
 
Toxicity Assessment 
 
 
X 
Central Pathology Review 
X 
 
 
Operative Report Review 
X 
 
 
Vaccine Site Assessment3 
 
 
X 
 
 
 
 
Treatment (patients 4-
18 only) 
 
 
 
Cyclophosphamide 
 
X4 
 
Vaccine 
 
 
X4 
 
 
 
 
Laboratory Tests 
 
 
 
Clinical hematology5 
X 
X6  
 
Serum chemistry5 
X 
X6  
 
Urinalysis 
X 
 
 
Pregnancy Test7 
X 
 
 
CA 19-9 
X 
 
 
 
 
 
 
Staging & Scans 
 
 
 
CT chest/abdomen/pelvis 
with contrast  (MRI 
abdomen/pelvis with 
contrast and non-contrast 
chest CT if IV contrast 
allergy) 
X 
 
 
 
 
 
 
Correlative Tests 
(For patients who 
consent to correlative 
studies) 
 
 
 
HLA typing (10 ml) 
X  
 
 
Immune Monitoring 
(up to 180 cc) 
X 
 
 
Serum banking  
(up to 20 cc) 
X 
 
 
 
1Problem oriented exam 
2Vital signs will be taken prior to and after the 30 minute observation period. 
3Vaccine site reactions will be assessed and documented until resolution. 
4First 3 patients will not receive Cy/GVAX and do not require BSA measurement at screening. 
5Clinical hematology: CBC with differential, platelet count, ANC, ALC, and AEC;  
serum chemistry: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, ALT, AST, 
alkaline phosphatase, bilirubin, total protein, albumin, and calcium. 
6Laboratory tests can be drawn up to 1 week prior to Cyclophosphamide administration. 
7For women of childbearing potential only, obtained within 7 days. 
 


24 
 
Table 2:  SBRT Treatment  
 
 
SBRT 
Tests & Observations 
 
History 
X1 
Physical exam 
X 1 
Vital Signs 
X 1 
Weight 
X 1 
Performance Status 
X1 
Toxicity Assessment 
X1,2 
 
1Day 1 and 5 of SBRT treatment                   
2Within 7 days of completion of SBRT. Toxicity Assessment obtained by study 
clinician or study nurse contact with the research participant, his/her family, 
or health care providers. 
    


25 
 
Table 3: FOLFIRINOX 
(Per institution guidelines, can be administered locally) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1Problem oriented exam for cycles 2-6 
2Recomended prior to each cycle per institutional guidelines with the final decision based 
on judgment of treating oncologist. 
3See additional recommended schedule for associated toxicities with the final decision 
based on the judgment of the treating oncologist. 
4Clinical hematology: CBC with differential, platelet count, ANC, ALC, and AEC; serum 
chemistry: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, ALT, AST, 
alkaline phosphatase, bilirubin, total protein, albumin, and calcium. 
5Not collected during cycles 4-6 if patient is having FOLFIRINOX treatment locally. 
 
The first 3 patients will be evaluated after their first 2 cycles of FOLFIRINOX at JHU The 
number, type, and degree of toxicities throughout follow-up will be tabulated. Patients in 
the cohort receiving Cy/GVAX may opt to have cycles 4-6 of FOLFIRINOX from their local 
oncologist. Efforts will be made to collect any CA19-9, CT scans, and toxicity data upon 
patient’s return for their post-FFX/pre-Cy/GVAX #2 visit.  See section 15.3 regarding 
special consideration for AE recording and reporting during local FOLFIRINOX treatment. 
 
FOLFIRINOX (24 Weeks) 
Tests & Observations 
 
History5 
Pre dose 1 of each Cycle 
Physical exam1,5 
Pre dose 1 of each Cycle 
Vital Signs5 
Pre dose 1 of each Cycle 
Weight, BSA5 
Pre dose 1 of each Cycle 
Performance Status5 
Pre dose 1 of each Cycle 
Toxicity Assessment5 
Pre dose 1 of each Cycle 
 
 
Laboratory Tests 
 
Clinical hematology 2,3,4,5 
Within 72 hrs of day 1 and day 
15 of each cycle 
Serum chemistry 2, 3, 4,5 
Within 72 hrs of day 1 and day 
15 of each cycle 
PT/INR5 
As needed 
CA 19-9 
Pre FOLFIRINOX, after 3 
cycles, and post FOLFIRINOX 
 
 
Correlateive Tests 
 
Immune Monitoring 
(up to 180 cc) 
Within 7 days of Cycle 1 Day 1 
Serum banking  
(up to 20 cc) 
Within 7 days of Cycle 1 Day 1 
 
 
Staging & Scans 
 
CT chest/abdomen/pelvis 
or MRI abdomen/pelvis 
(either with contrast) 
After 3 cycles (12 weeks) and 
after completion. 


26 
 
Table 4:  Cyclophosphamide (Cy)/Vaccine #2 & Beyond; Longer-Term Follow-Up or 
Off Study 
 
 
Cyclophosphamide & 
Vaccine #2-5 (q 28 days, +/- 
3 days) 
Cyclophosphamide & 
Vaccine 6+ (q 12 months,+/- 
30 days) 
Off Study 
Evaluation6 
 
D0:  
Cy 
D1: 
Vaccine 
D0:  
Cy 
D1: 
Vaccine 
 
Tests & Observations 
 
 
 
 
 
History1 
X 
 
X 
 
X 
Physical exam1 
X 
 
X 
 
X 
Vital Signs 
X 
X2 
X 
X2 
X 
Weight, BSA 
X 
 
X 
 
 
Performance Status1 
X 
 
X 
 
X 
Toxicity Assessment 
X 
X 
X 
X 
X 
Vaccine Site 
Assessment3 
X 
 
X 
 
X 
 
 
 
 
 
 
Treatment 
 
 
 
 
 
Cyclophosphamide 
X 
 
X 
 
 
Vaccine 
 
X 
 
X 
 
 
 
 
 
 
 
Laboratory Tests 
 
 
 
 
 
Clinical hematology1, 4 
X 
 
X 
 
X 
Serum chemistry1, 4 
X 
 
X 
 
X 
CA 19-91 
X 
 
X 
 
X 
 
 
 
 
 
 
Staging & Scans 
 
 
 
 
 
CT 
chest/abdomen/pelvis 
with contrast or MRI 
abdomen/pelvis 
with contrast and 
non-contrast chest 
CT, if IV contrast 
allergy 
X 
(To be done within 
7 days prior to 
Cy/Vaccine #2 and 
5 only i.e., q 3 
months) 
 
X 
 (To be done within 
28 days prior to 
Cy/Vaccine) until 
progression or 
death 
 
Defer to 
treating 
physician 
 
 
 
 
 
 
Correlative Tests 
 
 
 
 
 
Immune Monitoring 
(up to 180 cc) 
X5 
 
X5 
 
X7 
Serum Banking 
(up to 20 cc) 
X5 
 
X5 
 
X7 
1Laboratory tests, history, physical exam, and ECOG can be completed up to 1 week prior to 
Cyclophosphamide administration #2-5, or up to 28 days prior to Cyclophosphamide 
administration #6 and beyond. 
2Vital signs will be taken prior to and after the 30 minutes observation period following each 
vaccine 
3Vaccine site reactions will be assessed and documented until resolution 
4Clinical hematology: CBC with differential, platelet count, ANC, ALC, and AEC; serum 
chemistry: sodium, potassium, chloride, bicarbonate, glucose, BUN, creatinine, ALT, AST, 
alkaline phosphatase, bilirubin, total protein, albumin, and calcium. 
5For vaccine #5 and beyond, immune monitoring and serum banking specimens will be also 
collected on day 28 (+/- 14 days). As of Amendment #9, research bloods are no longer required 
to be collected. 
6Recomended, but not required 
7As of Amendment #9, research bloods are no longer required to be collected. 


27 
 
7.1.1 Research Blood Collection and Submission: 
 
One 10 ml yellow top tube (Catalog # BD-364606) collected prior to administration of the 
first dose of Cyclophosphamide-vaccine is required for HLA-typing.  Up to 180 cc blood 
in 10 ml lavender/purple top tubes (Catalog # BD-366643) or 180cc heparinized syringes 
and up to 20 cc blood in 10 ml serum separator tubes (SST) (Catalog # BD-366430) 
collected at the indicated time points are required for immune monitoring and serum 
banking respectively. As of Amendment #9, research bloods are no longer required to be 
collected. 
 
Procedure for Isolation of Serum 
 
1) 
 Serum separator tubes (SST) should be spun down within 1 hour after blood draw 
for best results.  The blood in the SST should look deep red in color and thick in 
appearance.   
 
2) 
 Blood is to be at room temperature (18ºC - 25ºC); hold the centrifuge at room 
temperature prior to processing.  
 
3) 
 Invert SST 5-10 times immediately prior to spinning. 
 
4) 
 Place SST in the centrifuge and balance the rotor. 
 
5) 
 Spin SST in centrifuge at 2500 rpm for 10 minutes in swinging bucket (SW) or 15 
 minutes in a fixed angle (FA) rotor at room temperature (18ºC - 25ºC).  Make sure 
 that the centrifuge reaches speed and is maintained throughout the entire spin. 
 
6) 
 Carefully remove SST from centrifuge and visually inspect it for proper separation.  
If  separation is not observed, repeat the spin one more time.  Do not repeat more 
than once.   If separation does not occur following the second spin, send it in its 
unseparated form.  
 
7) 
 Place SST in FedEx Clinical Pak and mark date and time it was spun down. 


28 
 
8.0 
Treatment Plan 
Protocol treatment is to begin within 28 days of enrollment.  
Treatment Schematic 
 
 
 The first three patients will not receive Cy/GVAX.  They will only receive 
SBRT/FOLFIRINOX. 
 
Vaccine/Cyclophosphamide 
treatments: 
 
(patients 
4-18) 
Administer cyclophosphamide (Cy) at 200 mg/m2 intravenously over 30 minutes the day 
before each vaccine.  Each vaccination (GVAX) will consist of six total intradermal 
injections of vaccine.  Two injections are administered each in the upper right and left 
thighs, and two injections in the upper non-dominant arm.  Each injection will consist 
of approximately 8.3x107 cells in a 0.7 to 0.73 ml solution. Vaccine must be initiated 
within 6-10 weeks from surgery. 
 
 Adjuvant SBRT will commence 13-17 days after the first vaccine is administered.  
Patients receive 5 days of SBRT (6.6 Gy daily) over a one to two week period to the tumor 
bed (as delineated by surgical clips placed by the surgeon).   
 
 FOLFIRINOX should start at a minimum of 1 week after completion of SBRT. See 
diagram above. FOLFIRINOX is given for 24 weeks, this can be given locally.  Patients 
will be evaluated after the first 2 cycles to determine if there have been any DLTs.  
Vaccine #2 is given 35 days (+/- 7 days) after completion of FOLFIRINOX.  Cy/Vaccines 
#3-5 are given every 28 days +/- 3 days.  If patients are without evidence of recurrence 
they can qualify for additional Cy/vaccine boosts where they will receive each Cy/vaccine 
every 6 months (every 12 months with Amendment #10) +/- 30 days until recurrence, 
toxicity, or death.   
 


29 
 
8.1 Surgery 
 
Pancreaticoduodenectomy must be performed such that clips are placed at the time of surgery.  
The surgical procedure performed will result in either a R0 or R1 resection as determined by the 
operating surgeon.  Information regarding any surgical 
therapy will be recorded including the operation 
performed, 
whether 
vascular 
resection 
and 
reconstruction was required, completeness of the 
resection (R0 vs. R1), duration of the operation, blood 
loss, the length of stay and the need for re-admission 
within 30 days of surgery.  Central pathology review for 
all patients will be conducted by Dr. Ralph Hruban.  
Pancreaticoduodenectomy is the standard of care to 
which vaccine therapy is added.  Titanium clips 
(minimum 
1) 
will 
be 
placed 
to 
delineate 
the 
retroperitoneal/SMA margin at the time of surgery for 
SBRT 
treatment 
planning. 
 
See 
figure 
above 
(Retroperitoneal/SMA margin).  In the event a clip cannot be placed at the SMA margin, a large 
clip and/or stent will be placed at the pancreaticojejenostomy (PJ) anastamosis as a surrogate 
of the tumor bed. In all cases the clinical target volume will be defined using the location of clips, 
the pathology and operative reports, and consultation with the surgical oncologist to ascertain 
the location of possible microscopic disease. If clips and/or stent cannot be identified to delineate 
the tumor bed or PJ, the patient will not be eligible for the study. 
 
8.2 Cyclophosphamide and Vaccine Dose #1 
For patients receiving Cy/GVAX, vaccine must be initiated within 6-10 weeks from surgery. 
8.2.1  Cyclophosphamide (Pre- Vaccine #1)  
 
 All laboratory tests will be drawn as per Table 1 (section 7).  
 
 
 Administer cyclophosphamide at 200 mg/m2 intravenously over 30 minutes 
Cyclophosphamide should be administered on a Monday, Tuesday, Wednesday or 
Thursday. 
 
 
 Parameters for dosing cyclophosphamide:  ANC ≥ 1000/mm3 and platelets ≥ 
100,000/mm3.  If parameters not met:  delay cyclophosphamide/vaccine by 1 
week. 
 
 
 Vital signs including, ECOG PS, weight, blood pressure, heart rate, respiratory 
rate and temperature, are to be recorded. 
 
 
 Blood samples for immune assays should also be drawn as described in 7.1.1. 
 
8.2.2 Vaccination (GVAX) #1 
 
 Each vaccine will be administered the day following cyclophosphamide. 
 
 
 All patients will be seen in the Oncology outpatient center for vaccine 
administration and monitoring.  
 
 
 Patients will be monitored for 30 minutes following vaccination for evidence of 
acute reaction to the injected vaccine cells. Vital signs: Blood pressure, heart rate, 
respiration rate and temperature will be recorded before each vaccination. BP, 
heart rate, respiration rate and temperature will be recorded again after each 
vaccine administration. 
 


30 
 
 
 Administration of vaccine:  Each vaccination will consist of a total of 6 
intradermal injections, two each in the upper right and left thighs, and two in the 
upper non-dominant arm.  Each injection will consist of approximately 8.3x107 
cells in a 0.7 to 0.73 ml solution. The volume of the vaccination dose is 
approximate. A lidocaine based topical anesthetic (may include but is not limited 
to EMLA or ELA-MAX) cream will be applied to each injection site at least one 
hour prior to vaccination to diminish the discomfort associated with the 
intradermal injections. Omit lidocaine if allergic. See Appendix I for further 
details. 
 
8.3 SBRT administration 
 
 
The first 3 patients will initiate SBRT 6-10 weeks post-surgery.  
 
The remaining 15 patients will begin SBRT between 13-17 days following Vaccine 
#1.  
 
SBRT will be initiated (Monday-Friday) and delivered for one week (preferred), 
although if necessary SBRT can be given over two weeks with at least 2 fractions 
per week.  
 
For schedule of activities and required laboratory tests, please see Table 2, section 
7.   
 
8.3.1 Radiation Treatment information:   
 
Clip placement to outline pancreatic tumor bed:  
 
Treatment on this protocol requires placement of titanium clips outlining the tumor 
bed (retroperitoneal/SMA margin) for targeting purposes (see diagram above).  All 
surgeons listed as co-investigators on the trial must agree to place clips at the time 
of surgery, otherwise the patient will not be eligible. They will place 1 clip at the 
superior and inferior area of the SMA margin and one in the center of the 
superior/inferior clips.  
  
8.3.2 Simulation:   
 
1) Patients can undergo simulation >=3 weeks following surgical resection.  Patients 
are placed supine in an Alpha Cradle or equivalent immobilization. 
2) Standard free-breathing CT and/or respiratory-correlated 4-D pancreatic protocol 
CT will be obtained on each patient. The 4D-CT scan will be used for 
characterizing target motion during quiet respiration. For more accurate 
delineation of anatomy an arterial phase pancreatic protocol CT may be obtained 
(optional, typically during expiration breath hold, 1.25 mm slices).  Clip to clip 
fusions between these scans should be utilized whenever possible.  The 
simulation scan should include T4/T5 to L5/S1 (upper abdomen).   
3) IV and oral contrast must be used for simulation, unless contraindicated.  
4) Specialized compression belts (developed at MSKCC) may be utilized for some 
patients.  They come in 4 sizes: S, M, L, and XL.  Each belt has an adjustable 
pressure cuff which can be used to reduce breathing motion.  Fluoroscopy is 
used to assess motion of surgical clips before and after compression.  The goal is 
to reduce motion from typically 11 - 22 mm peak to less than 5 mm.  If the 
fiducial motion cannot be decreased to 5 mm or less, then respiratory gating using 
either the Varian Respiratory Management (RPM) system or the Elekta Active 
Breathing Coordinator (ABC) will be utilized for treatment delivery.  Prior to 
simulation, standard guidelines will be followed. Abdominal compression devices 
are also acceptable. 


31 
 
Patients may be treated either with respiratory gated or breath hold (ABC) 
(treatment using Elekta LINAC based treatment 
 
8.3.3 Treatment planning: 
 
1) An SBRT treatment plan will be developed using Eclipse, Multi-PlanTM, 
Pinnacle  or equivalent treatment planning system based on tumor geometry 
and location at each institution. Institutional standards for radiation quality 
assurance and radiation delivery will be utilized.  
2) Ideally, all patients will receive five fractions of 6.6 Gy delivered over a five day 
period.  Ideally all 5 fractions should be delivered Monday thru Friday, however 
it may be delivered over two weeks as long as the patient receives at least two 
fractions a week.  
3) The clinical treatment volume (CTV) will be based on the surgical clips and pre-
surgical scan.  The final CTV will be defined by the attending radiation oncologist 
after reviewing the diagnostic CT, respiratory-correlated 4D-CT scan, pancreas 
protocol CT, and the FDG-PET/CT scan (pre-surgical if available). The clips will 
be used to outline the CTV.  These scans will be used to define the ITV (internal 
target volume).  The final PTV (planning treatment volume) expansion will consist 
of an additional 1 cm of margin expansion, except if the margin results in 
expansion into the stomach. In these cases, margin expansion is allowed to be 
non-uniform.  The dose will be prescribed to the isodose line that completely 
surrounds the PTV.  It is recommended that 5-12 co-planer fields be used in the 
radiation treatment plan. 
4) Contours of the clips used for target localization will be generated on the 
applicable image sets, to be used for patient setup on treatment (cone beam CT).  
Radiation dose to the adjacent normal tissue will be minimized.  
 
Normal tissues will be limited as follows:   
- Liver (excluding tumor):  50% should be limited to <12 Gy 
- Kidney:  Combined volume for both should have 75% <12 Gy 
- Stomach:  V15<9cc and V20<3cc.  50% should be limited to <12 Gy (no more 
than 1 cc of stomach can receive >33 Gy) 
- Spinal Cord max: no more than 1cc can receive >8 Gy 
  
5)  No more than 1cc of the PTV can receive >130% of the prescription 
dose (4920 cGy).   
6)  Greater than 90% of the PTV should receive 100% of the prescription 
dose (3300 cGy).   
If above constraints cannot be made then 100% of the GTV must receive at least 
25 Gy (an allowed minor deviation and will be documented). If this constraint 
cannot be met, the patient should be removed from the protocol.  
 
Radiation dose to the adjacent normal tissue will be minimized. 
Based on an analysis of duodenal/bowel toxicity representing pooled data from 3 
previous prospective studies, the following dose constraints must be met: 
7) All patients must start treatment within 4 weeks of the simulation scan. 
 
8.3.4   Treatment Delivery (LINAC based): 
 
1) Initial patient positioning will be based on volumetric kV (cone-beam CT) imaging 
with shifts to bony anatomy as appropriate.   
2) Orthogonal kV/MV or kV/kV projection imaging will be used to verify the location 
of the clips prior to delivery of first treatment beam.  A secondary shift based on 
the location of clips may be utilized, as indicated by the position of the clips.  For 


32 
 
free-breathing treatments, kV fluoroscopic images should be obtained to confirm 
the anticipated position of these clips during the entire respiratory cycle. 
3) Active monitoring of treatment delivery accuracy will be accomplished using kV 
and/or MV projection imaging, either immediately before or during all (or a subset 
of) treatment fields. 
4) Patient-specific dosimetric QA will be performed as per standard practice at each 
participating institution. 
 
 
Following SBRT, all patients will be monitored clinically and with serial imaging (CT 
scans and PET/CT if possible and as needed). Please refer to Tables 2 and 3 for a 
schedule of the medical history and physical examinations, complete blood count 
(CBC), comprehensive chemistry panel, tumor marker studies, and blood sample 
collection for research efforts to develop novel serum biomarkers.  
 
8.4 FOLFIRINOX 24 weeks 
 
8.4.1  FOLFIRINOX administration (After Vaccine #1)  
  Patients will begin FOLFIRINOX 7-28 days post SBRT 
 Patients in the second cohort (receiving Cy/GVAX) may opt to have cycles 4-6 
of FOLFIRINOX locally, with the treating physician responsible for monitoring 
toxicities and determining any dose reductions. Efforts will be made to obtain 
CT scans, CA19-9 labs, and toxicities collected during this time. For AE 
reporting during local treatment, please see section 15.3. 
 For schedule of activities and blood draws, please see Table 3. For parameters 
for FOLFIRINOX dosing, please see Table 5.  
 
  FOLFIRINOX Administration: 
Treatment will be administered on an outpatient   basis.  Reported adverse 
events and potential risks for FOLFIRINOX are described in Section 9.5.  
Appropriate dose modifications for FOLFIRINOX are described in Section 9.4.  
No investigational or commercial agents or therapies other than those described 
below may be administered with the intent to treat the patient's malignancy. 
Qualified personnel who are familiar with procedures that minimize undue 
exposure to them and to the environment should undertake the preparation, 
handling, and safe disposal of chemotherapeutic agents in a self-contained, 
protective environment.  Discard unused portions of injectable chemotherapeutic 
agents supplied as single-dose preparations within eight hours of vial entry to 
minimize the risk of bacterial contamination. The total administered dose of 
chemotherapy may be rounded up or down within a range of 5% of the actual 
calculated dose. 
 
 


33 
 
Table 5: FOLFIRINOX REGIMEN DESCRIPTION 
 
Agent 
Premedications; 
Precautions 
 
Dose 
 
Route 
 
Schedule 
(-1/+3 days) 
Cycle 
Length  
Oxaliplatin 
Avoid exposure to 
cold (food, liquids, 
air) for 24 hr after 
each dose. 
85 mg/m2 in  
500 cc D5W 
IV over 
approximately 
2 hours 
Days 1 and 15, 
every 28 days  
One 
cycle is 
approx. 
28 days 
Irinotecan 
Atropine should 
be immediately 
available for anti-
cholinergic 
reactions 
180 mg/m2 
in 500cc 
D5W 
IV over 
approximately 
90 minutes  
Days 1 and 15, 
Every 28 days  
Leucovorin 
 
400 mg/ m2 
in 250cc NS 
IV over 
approximately
2 hours 
Day 1and 15, 
Every 28 days  
5-FU 
infusion 
 
2,400 mg/m2 IV over  
approximately 
46 hours 
Days 1 and 15, 
Every 28 days 
Peg-
Filgrastim 
May experience 
bone pain 
6 mg 
SQ  
24-72 hours 
after the end of 
each 
chemotherapy 
dose 
(Every 2 weeks 
or as clinically 
indicated)  
 
8.5 Cyclophosphamide/Vaccine #2-5 and Beyond (following completion of 24 weeks of 
FOLFIRINOX chemotherapy)   
 
***All but the first 3 patients will receive Cy/GVAX. 
 
 8.5.1  Pre-Vaccine Cyclophosphamide  
  Please see Table 4 for schedule of blood draws and other activities.  CBC and CMP 
to be drawn within 1 week of cyclophosphamide dosing. 
 
  Cyclophosphamide to be administered on a Monday, Tuesday, Wednesday or 
Thursday. 
 
  Parameters for dosing cyclophosphamide:  ANC ≥ 1000/mm3 and platelets ≥ 
100,000/mm3.  If parameters not met:  delay cyclophosphamide/vaccine by 1 
week. 
 
  Administer cyclophosphamide at 200 mg/m2 intravenously over 30 min. 
 
  Vital signs including ECOG PS, weight and, blood pressure, heart rate, respiration 
rate, and temperature are to be recorded. 
 
  Blood samples for immune assays should also be drawn as described in 7.1.1. 
 
8.5.2 Vaccine (GVAX) #2-5 
  Vaccines #3-5 will be administered at 28 day intervals (+/- 3 days) following 
vaccine #2.  For vaccine #2, this time frame is also gauged as being approximately 


34 
 
35 days (+/- 7 days) following completion of the final dose of adjuvant FOLFIRINOX.  
 
 
 Please see Table 4, section 7 for schedule of laboratory and other tests.  
 
8.5.3 Vaccine (GVAX) #6 and thereafter until recurrence 
 
  If patient has no evidence of disease, they can qualify for additional cy/vaccine 
boosts (Vaccine #6 +) where Cy/vaccine are delivered every 6 months (+/- 30 days). 
As of Amendment #10, boost vaccinations will be administered annually (+/- 30 
days). Up to 28 days prior to every vaccination, all patients will undergo a re-staging 
scan, CT chest/abdomen/pelvis (or MRI abdomen/pelvis with contrast and non-
contrast chest CT) and CA 19-9, complete blood count and differential, 
comprehensive panel. 
 
 
 Please see Table 4, section 7 for schedule of laboratory and other tests.  
 
 
 Blood samples for immune assays should also be drawn as described in 7.1.1. 
As of Amendment #9, research bloods are no longer required to be collected. 
 
 
8.6 Off Study and Follow-up 
 
8.6.1 Criteria for Removal from Study 
 
Patients will be taken off study if one of the following criteria applies: 
 
Recurrent or metastatic disease  
 
Patient chooses not to receive additional vaccine boosts (Vaccine #6+) or elects to 
withdraw from the study 
 
Intercurrent illness that prevents further administration of treatment 
 
Unacceptable adverse events 
 
Changes in the subject’s condition render the subject unacceptable for further 
treatment in the judgment of the investigator 
 
 
8.6.2 Off Study Visit 
 
The following evaluations are recommended (but not required) at the off study visit: 
 
 
History and Physical exam with vitals and ECOG performance status 
 
Assessment of toxicities (including vaccine site reactions) 
 
Heme-8 with differential, including platelets 
 
Comprehensive panel including electrolytes, BUN, creatinine, AST, ALT, alkaline 
phosphatase, and total bilirubin. 
 
CA19-9 
 
Correlative tests that include up to 180 cc of blood for immune monitoring and 
up to 20 cc of blood for serum banking. As of Amendment #9, research bloods are 
no longer required to be collected. 
 
CT scan abdomen/pelvis and chest. If done within 30 days the CT scans do not 
need to be repeated. (If allergic to CT scan contrast, obtain abdominal/pelvic MRI 
with contrast and non-contrast chest CT) 
 
8.6.3 Follow-Up 
 
If consent is granted, patients who received the pancreatic tumor vaccine will be followed 
annually via a separate protocol entitled, “Long-term follow-up of patients who receive 


35 
 
lethally irradiated allogeneic pancreatic tumor cells transfected with the GM-CSF gene.”  
Consent can be obtained at any point in the protocol. It is recommended that patients 
schedule follow-up visits at the discretion of the patient’s local oncologist and the results 
sent to us if the patient agrees. All attempts will be made to obtain disease-free and overall 
survival data on each patient, including those not receiving vaccine.  
 
8.7 General Concomitant Medication and Supportive Care Guidelines 
 
8.7.1 Radiation Therapy (SBRT)  
  Use of acid-blocking agents such as proton pump inhibitors is required during SBRT 
and is recommended to continue for 6 months following SBRT.  
 
  Anti-emetic pre-medication, if needed, should be administered per institutional 
guidelines. 
 
  Use of high dose antioxidants is not permitted during radiation therapy. 
 
  Use of moisturizing creams and other topically applied medications and ointments 
should not be used within the radiation ports without prior approval from the radiation 
oncologist. 
 
8.7.1.1 Anti-diarrheals and Anti-emetics 
For symptoms of diarrhea and/or abdominal cramping that occur within 2 weeks after 
SBRT, patients will be instructed to begin taking loperamide.  Additional anti-diarrheal 
measures may be used at the discretion of the treating physician.  Patients should be 
instructed to increase fluid intake to help maintain fluid and electrolyte balance during 
episodes of diarrhea. 
 
For symptoms of nausea and vomiting, it is recommended that patients take Compazine 
or Zofran one hour prior to SBRT and on a PRN basis.  These medications will continue 
for 5 days following SBRT.  Patients will be instructed to increase fluid intake.   
 
8.7.1.2 Other Concomitant Medications 
Therapies considered necessary for the patient's well-being may be given at the 
discretion of the investigator.  Other concomitant medications should be avoided 
except for analgesics, chronic treatments for concomitant medical conditions, or agents 
required for life-threatening medical problems. In general, these medications will be 
prescribed by the attending medical oncologist. 
 
8.7.1.3 Supportive Care Guidelines 
In case participants develop nausea/vomiting/diarrhea or myelosuppression, 
supportive medications will be prescribed as per Clinical Center and ASCO guidelines.  
Seizures were seen in some animal toxicology studies, although at doses much higher 
than those anticipated for this study.  Seizures in animals were successfully treated 
with lorazepam. 
 
8.7.1.3.1 Risk Information 
It is difficult at this time to predict with confidence the percentage rate of 
complications from the proposed SBRT treatment. However, it is reasonable to 
extrapolate from the current experience with radiotherapy in and around the 
pancreas. Based upon prior phase I and phase II studies, we anticipate that the 
toxicities associated with this treatment will be acceptable. 
 
Toxicity commonly associated with such treatment includes nausea, vomiting, 
anorexia and weight loss. Severe side effects such as gastrointestinal (GI) obstruction, 


36 
 
perforation, or hemorrhage are uncommon complications, occurring in <5% of 
patients undergoing standard radiation therapy for pancreatic cancer. Although we 
expect a comparable rate of complications with fractionated radiotherapy, it is 
important to note that vomiting, GI obstruction, GI hemorrhage, anorexia and weight 
loss are also commonly associated with pancreatic cancer progression. Clinical and 
radiographic assessments will be performed in an effort to identify these effects, 
ascertain their etiology and provide the most appropriate palliative measures. Hepatic 
and renal toxicity is not anticipated given the expectation of limited incidental 
irradiation of these organs. Complications, if any, will be graded according to the 
CTCAE, National Cancer Institute, version 4.0.   
 
8.7.2 Chemotherapy (FOLFIRINOX)  
 
8.7.2.1 Anti-emetics 
 
Patients should be pre-medicated prior to the FOLFIRINOX treatment with anti-emetics 
per institutional guidelines. 
 
Agents that may be considered include, but are not limited to: promethazine, 
prochlorperazine, metoclopramide, haloperidol, droperidol, lorazepam and 
serotonin-antagonists (e.g. ondansetron, granisetron, dolasetron). 
 
Delayed emesis, should it occur, will be treated for future FOLFIRINOX chemotherapy 
doses with a delayed emesis regimen (e.g. 3 days of metoclopramide + dexamethasone, 
3 days of serotonin antagonist, or use of long-acting serotonin antagonist). 
 
Due to the emetogenic nature of this regimen, aprepiant will be administered with each 
cycle in addition to concomitant anti-emetics at the discretion of the treating physician. 
 
8.7.2.2 Anti-diarrheal 
 
Loperamide:  For symptoms of diarrhea and/or abdominal cramping that occur at any 
time during a treatment cycle patients will be instructed to begin taking loperamide.  
Loperamide should be started at the earliest sign of (1) a poorly formed or loose stool or 
(2) the occurrence of 1 to 2 more bowel movements than usual in 1 day or (3) an increase 
in stool volume or liquidity.  Loperamide should be taken in the following manner: 4 
mg at the first onset of diarrhea, then 2 mg every 2 hours around the clock until 
diarrhea-free for at least 12 hours.  Patients may take loperamide 4 mg every 4 hours 
during the night.  The maximum daily dose of loperamide is 16 mg/day. 
 
Antibiotics: Oral fluoroquinolone treatment may be initiated for ANC<500 or diarrhea 
for >24 hours despite loperamide, at the discretion of the treating physician. 
 
8.7.2.3 Anticoagulants  
 
Prophylactic or therapeutic doses of Coumadin or low-molecular weight heparin are 
permitted. Low-dose aspirin (≤ 325 mg/d): Aspirin may be continued if the patient was 
on this prior to enrollment. 
8.7.2.4 Growth Factors  
 
Peg-filgrastim (Neulasta) will be administered 24-72 hours after the end of each 
chemotherapy dose, approximately every 2 weeks (2x per cycle) or as clinically 
indicated at the discretion of the treating physician. 
 


37 
 
The use of erytropoetin EPO in this protocol is permitted at the discretion of the treating 
physician.  However, these agents are not recommended. 
 
8.7.2.5 Neurotoxicity Management 
 
Ca++/Mg++: Various agents have been used in an attempt to minimize neurotoxicity of 
oxaliplatin (e.g. Mg++, Ca++).  Their routine use requires further confirmation of 
efficacy.  They may be used in this study at the discretion of the treating physician. 
 
8.7.2.6 Supportive Care Guidelines 
 
All supportive measures consistent with optimal patient care will be given throughout 
the study. 
 
9.0 
Dose Modifications And Management of Toxicity 
 
All toxicities should be graded according to the Common Terminology Criteria for Adverse Events 
(CTCAE) (version 4). 
 
9.1 Cyclophosphamide Dose Modifications 
 
No dose modifications will be made for cyclophosphamide.  The cyclophosphamide dose 
is fixed at 200 mg/m2 IV, delivered over 30 minutes. Parameters for treatment within 1 
week of planned dose (or 28 days for cy/vaccine doses 6 and beyond):  ANC ≥ 1000/mm3 
and platelets ≥ 100,000/mm3. 
 
9.2 Vaccine Dose Modifications 
  
No dose modifications will be made for the vaccine.  
 
9.3 Dose Modifications for Obese Patients 
 
There is no clearly documented adverse impact of treatment of obese patients when 
dosing is performed according to actual body weight. Therefore, all chemotherapy dosing 
(except cytoxan) is to be determined solely by actual weight without any modification 
unless explicitly described in the protocol. This will eliminate the risk of calculation error 
and the possible introduction of variability in dose administration. Failure to use actual 
body weight in the calculation of drug dosages will be considered a major protocol 
deviation. Physicians who are uncomfortable with calculating doses based on actual body 
weight should recognize that doing otherwise would be a protocol violation.  Please note:  
All chemotherapy agents will be dosed per BSA.   
 
9.4 FOLFIRINOX Dose Modifications 
 
Adapted from Conroy, T et al. FOLFIRINOX versus Gemcitabine for Metastatic 
Pancreatic Cancer. N Engl J Med 2011; 364:1817-1825.  
 
Dosage adjustment guidelines for toxicities with FOLFIRINOX  
If more than one of the dose modifications apply, use the most stringent (i.e., the greatest 
dose reduction).  Dose modifications are cumulative and permanent.  Note that the dose 
of Leucovorin does not change with FOLFIRINOX dose level reductions, but is dependent 
on pharmacy supply. 
 


38 
 
If treatment is held for any of the below toxicities for > 3 weeks, patients should 
discontinue all protocol therapy. Patients are off study if they develop the same grade 4 
toxicity despite a first dose reduction. 
 
Dose levels for FOLFIRINOX 
 
Dose Level 
Oxaliplatin 
(mg/m2) 
Irinotecan 
(mg/m2) 
Leucovorin1 
(mg/m2) 
5-FU Infusion 
(mg/m2) 
0 
85 
180 
400 
2400 
-1 
65 
150 
400 
1920 
-2 
50 
120 
400 
1600 
-3 
40 
100 
400 
1360 
1Dose dependent upon pharmacy supply 
 
9.4.1 Hematologic toxicity 
 
Do not dose reduce until the granulocyte count is ≤ 1.0 x 109/L and the platelet count is 
≤75 x 109/L. Note:  FOLFIRINOX dose modifications for hematologic toxicity are not 
based on CTCAE severity grades. 
 
For ANC < 1,000/mm3: Delay FOLFIRINOX until ANC ≥ 1,000/mm3, then resume 
FOLFIRINOX with one dose level reduction for all subsequent cycles.  
 
For Febrile Neutropenia (defined as ANC < 1,000/mm3 and temperature ≥ 
100.5°F): Delay FOLFIRINOX until resolution of fever and ANC ≥ 1,000/mm3, then 
resume FOLFIRINOX with one dose level reduction for all subsequent cycles.  
 
For Platelets 50,000 – 75,000/mm3: Delay FOLFIRINOX until platelets ≥ 
75,000/mm3, then resume FOLFIRINOX at the same dose level. 
 
Second or More Occurrence of platelets 50,000 - 75,000/mm3: Delay 
FOLFIRINOX until platelets ≥ 75,000/mm3, then resume FOLFIRINOX with one 
dose level reduction for all subsequent cycles.  
 
For Platelets < 50,000/mm3: Delay FOLFIRINOX until recovery to Plts ≥ 
75,000/mm3, then resume FOLFIRINOX with one dose level reduction for all 
subsequent cycles.  
 
 
9.4.2 Gastrointestinal toxicities 
 
Patients must be instructed in the use of loperamide as treatment for diarrhea, and must 
have a supply of this drug upon starting FOLFIRINOX. Patients should not be retreated 
with irinotecan until diarrhea has resolved to < grade 2 with maximal medical 
management within 5 days. Patients should be optimally managed with anti-diarrheal or 
anti-emetic medications before dose modifications are made. 
 
For Grade 2 Diarrhea (despite optimal medical management): 
First Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1 or baseline, 
then resume FOLFIRINOX at the same dose level. 
Second or More Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1 or 
baseline, then resume FOLFIRINOX with one dose level reduction for all 
subsequent cycles. 


39 
 
 
For Grade 3 Diarrhea (despite optimal medical management): 
First Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1 or baseline, 
then resume 5-FU and oxaliplatin at the same dose level and irinotecan with one 
dose level reduction for all subsequent cycles. 
Second or More Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1 or 
baseline, then resume FOLFIRINOX with one dose level reduction for all 
subsequent cycles.  
For Grade 4 diarrhea (despite optimal medical management):  
Delay FOLFIRINOX until recovery to grade ≤ 1 or baseline then resume FOLFIRINOX 
with one dose level reduction for all subsequent cycles.  
Nausea/Vomiting The following dose modifications are based on toxicity experienced 
during a cycle.  
 
For Grade 3 Nausea/Vomiting (despite optimal medical management): 
First Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1 or baseline, 
then resume 5-FU at the same dose level and oxaliplatin and irinotecan with one 
dose level reduction for all subsequent cycles. 
Second or More Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1 or 
baseline, then resume FOLFIRINOX with one dose level reduction for all 
subsequent cycles. 
For Grade 4 Nausea/Vomiting (despite optimal medical management): 
Delay FOLFIRINOX until recovery to grade ≤ 1 or baseline, then resume FOLFIRINOX 
with one dose level reduction for all subsequent cycles.  
Mucositis The following dose modifications are based on toxicity experienced at any 
time during a cycle. 
 
Grade 3 Mucositis: 
First Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1, then resume 
irinotecan and oxaliplatin at the same dose level and 5-FU with one dose level 
reduction for all subsequent cycles. 
For Second or More Occurrence: Delay FOLFIRINOX until recovery to grade ≤ 1, 
then resume FOLFIRINOX with one dose level reduction for all subsequent cycles.  
Grade 4 Mucositis: Delay FOLFIRINOX until recovery to grade ≤ 1, then resume 
FOLFIRINOX with one dose level reduction for all subsequent cycles.  
9.4.3 Peripheral Sensory Neuropathy  
 
For paresthesia/dysethesia interfering with function and persisting between 
treatments: Decrease oxaliplatin by one dose level for all subsequent cycles. 
 
For painful paresthesia/dysesthesia or symptoms that interfere with function and 
ADL, but improve (no longer painful or no longer interfering with ADL) between 
treatments: Decrease oxaliplatin by one dose level for all subsequent cycles. 
 


40 
 
For painful paresthesia/dysesthesia or symptoms that interfere with function and 
ADL that persists between treatments: Discontinue oxaliplatin. 
 
For persistent disabling or life-threatening paresthesia/dysesthesia: Discontinue 
oxaliplatin. 
 
For pharyngo-laryngeal dysesthesia: Increase the duration of oxaliplatin infusion to 3 
hours for subsequent cycles. 
 
9.4.4 Venous Thromboembolic Events 
 
For Grade 2 or 3 venous thromboembolic event: Continue FOLFIRINOX at the same 
dose level. Do not use warfarin for therapeutic anticoagulation; use of low molecular 
weight heparin is allowed. 
 
Grade 4 venous thromboembolic event: Discontinue FOLFIRINOX. 
 
9.4.5 Cardiac toxicity 
 
In case of angina pectoris or of myocardial infarction, 5FU has to be stopped. 
 
9.4.6 Increase of bilirubin 
 
In case of elevation of bilirubin, it is suggested to exclude an obstruction of the biliary 
stent or progressive disease and to postpone chemotherapy.  
 
For Grade 2 Increased Bilirubin: Skip irinotecan until bilirubin improves to ≤ grade 1. 
For hyperbilirubinemia considered at least possibly related to irinotecan, resume 
irinotecan with one dose level reduction for all subsequent cycles. 
 
For hyperbilirubinemia considered unrelated to irinotecan, resume irinotecan at 
the previous dose level. 
 
For Grade 3 or 4 Increased Blood Bilirubin: Delay FOLFIRINOX until bilirubin 
improves to ≤ grade 1. If bilirubin is thought to be due to a chemotherapy drug, then 
resume that drug at the next lower dose level and the other drugs at the same dose level 
when total bilirubin improves to ≤ grade 1. 
 
For hyperbilirubinemia considered unrelated to treatment (all drugs), resume 
FOLFIRINOX at the previous dose levels. 
 
9.4.7 Allergic Reactions 
 
For grade 2 allergic reactions: Interrupt infusion(s). Manage reaction according to 
institutional policy. Restart the infusion(s) when symptoms resolve to ≤ grade 1 and 
pretreat before all subsequent doses. 
 
For grade 3 or grade 4 allergic reactions: Discontinue infusion. Manage reaction 
according to institutional policy. Discontinue FOLFIRINOX. 
 
9.4.8 Other toxicities 
 
Any other toxicity > grade 2, except anemia and alopecia, can justify a reduction of dose 
if medically indicated.  
 


41 
 
For all other grade 3 non-hematologic toxicities considered at least possibly related 
to FOLFIRINOX: Skip the responsible drug(s) until toxicity improves to ≤ grade 1, then 
resume the responsible drug(s) with one dose level reduction for all subsequent cycles. 
 
For grade 4 non-hematologic toxicities considered at least possibly related to 
FOLFIRINOX: Discontinue the responsible drug(s). 
 
9.5 FOLFIRINOX Toxicities  
 
9.5.1 Oxaliplatin [Eloxatin] Toxicity 
 
The most commonly observed oxaliplatin toxicities include neurotoxicity, GI toxicity, and 
myelosuppression.  Three neurotoxicity syndromes have been seen:   
 
 
Acute sensory neuropathy develops within hours to 2 days after oxaliplatin 
administration.  Symptoms include paresthesias, dysesthesias, and hypothesia 
of the hands, feet and perioral regions.  Jaw spasm, abnormal tongue sensation, 
dyarthria, eye pain and a sensation of chest pressure have also been noted.  
Acute sensory neuropathy symptoms may be exacerbated by exposure to cold 
temperature or cold objects.  Symptoms are reversible, usually resolving within 
14 days and commonly recurring with further dosing.  This syndrome has been 
observed in about 56% of patients receiving oxaliplatin with 5-FU and leucovorin. 
 
 
Acute pharyngolaryngeal dysesthesia is reported to occur in 1-2% of patients.  
This syndrome is characterized by a subjective sensation of difficulty breathing or 
swallowing without laryngospasm or bronchospasm or objective evidence of 
hypoxia.  Avoidance of cold drinks, food and air is suggested in order to minimize 
pharyngolaryngeal dysesthesia.  Antianxiety agents (e.g. lorazepam) may be used 
to treat pharyngolaryngeal dysesthesias once oxygen saturation has been 
documented to be normal. 
 
 
Peripheral neuropathy persisting > 14 days is characterized by paresthesias, 
dysesthesias, and hypothesia.  Abnormalities in proprioception may also be seen.  
Symptoms of persistent neuropathy may improve upon discontinuation of 
oxaliplatin. 
 
 
Various agents have been used in an attempt to minimize neurotoxicity of 
oxaliplatin (e.g. carbamazepine, Mg++, Ca++).  Their routine use requires further 
confirmation of efficacy.  They may be used in this study at the discretion of the 
treating physician. 
 
 
Gastrointestinal toxicities include nausea, vomiting (oxaliplatin is considered to 
be moderately emetogenic) and diarrhea. 
 
 
Neutropenia is reported in 73% of patients receiving oxaliplatin with 5-FU and 
leucovorin (44% grade 3 or 4). Grade 3 or 4 thrombocytopenia is reported to occur 
in 4% of patients receiving the combination. 
 
 
Allergic reactions, similar to those seen with other platinum compounds, have 
also been observed in patients treated with oxaliplatin.  Reactions range from 
rash to anaphylaxis 
 
 
Rarely, oxaliplatin has been associated with pulmonary fibrosis, which may be 
fatal.  Oxaliplatin should be discontinued in the presence of unexplained 
pulmonary symptoms (e.g. nonproductive cough, dyspnea) or pulmonary 


42 
 
infiltrates until interstitial lung disease or pulmonary fibrosis have been ruled out. 
 
 
Recent reports of oxaliplatin extravasation suggest that tissue necrosis may result 
and that oxaliplatin should be considered a vesicant.  No standard treatment 
exists for oxaliplatin extravasation although heat and sodium thiosulfate have 
both been suggested. 
 
 
Veno-occlusive disease (VOD) of the liver is a rare complication associated with 
oxaliplatin and 5-FU.  Clinical manifestations of VOD include hepatomegaly, 
ascites, and jaundice.  Histologically, VOD is characterized by diffuse damage in 
the centrilobular zone of the liver.  Sequelae of VOD include hepatomegaly, 
splenomegaly, portal hypertension, and esophageal varices. A recent analysis of 
resected liver metastases in 153 patients indicated histological findings consistent 
with VOD in 6/27 patients who received 5-FU alone, 4/17 patients who received 
5-FU and irinotecan, 20/27 patients who received 5-FU and oxaliplatin, and 
14/16 who received 5-FU, oxaliplatin and irinotecan.  The remaining 66 patients 
had not received chemotherapy prior to resection.  There were no such findings 
in these patients. 
 
For more information on toxicities associated with oxaliplatin, please see the package 
insert (Appendix III). 
 
9.5.2  5-Fluorouracil (5-FU: fluorouracil: Adrucil®) Toxicity 
 
Nausea, diarrhea, vomiting (mild);   
 
Stomatitis (5-8 days after treatment initiation);  
 
Myelosuppression; granulocytopenia (9-14 days); thrombocytopenia (7-14 days);  
 
Alopecia; loss of nails;  hyperpigmentation; 
 
Photosensitivity;  maculopapular rash; palmar-plantar erythrodysethesias: (42-
82% receiving continuous infusion);  
 
CNS effects:  cerebral ataxia (rare);  
 
Cardiotoxicity:  MI, angina: asymptomatic S-T changes 68%; 
 
Ocular effects: excessive lacrimation and less commonly, tear duct stenosis. 
 
Drug Interactions 
Leucovorin enhances the cytotoxicity of 5-FU by forming a more stable tertiary complex 
with thymidylate synthase.  Concomitant administration of 5-FU with warfarin has 
been reported to result in increased INR/prolonged prothrombin time.  Patients 
receiving both drugs should be followed with weekly INRs. 
 
Please refer to the package insert for complete product information (Appendix IV). 
 
9.5.3  Leucovorin Calcium (Folinic Acid; calcium folinate; citrovorum factor; N 5-
formyltetrahydrofolate; 5-formyl-FH4; folinic acid) Toxicity 
 
The only adverse reactions associated with leucovorin are allergic reactions.  These 
are extremely uncommon. 
 
Please refer to the package insert for complete product information (Appendix V). 
 
9.5.4  Irinotecan (CPT-11, Camptosar) Toxicity  
 
Virtually all phase I and II studies of irinotecan have reported neutropenia and/or late 
diarrhea (diarrhea occurring more than 24 hours after the irinotecan administration 
as the dose limiting toxicities (depending on the schedule).  


43 
 
 
Bone 
marrow 
suppression: 
[U.S. 
Boxed 
Warning]: 
May 
cause 
severe 
myelosuppression. Deaths due to sepsis following severe myelosuppression have 
been reported. Routine administration of a colony-stimulating factor is generally 
not necessary, but may be considered for patients experiencing significant 
neutropenia. 
 
Colitis: Colitis, complicated by ulceration, bleeding, ileus, and infection has been 
reported. 
 
Diarrhea: [U.S. Boxed Warning]: Severe diarrhea may be dose-limiting and 
potentially fatal; two severe (life-threatening) forms of diarrhea may occur. Early 
diarrhea occurs during or within 24 hours of receiving irinotecan and is 
characterized by cholinergic symptoms (e.g., increased salivation, diaphoresis, 
abdominal cramping); it is usually responsive to atropine. Late diarrhea occurs 
more than 24 hours after treatment which may lead to dehydration, electrolyte 
imbalance, or sepsis; it should be promptly treated with loperamide. Patients with 
diarrhea should be carefully monitored and treated promptly. 
 
Hypersensitivity reactions: Severe hypersensitivity reactions have occurred.  
 
Renal toxicity: Renal impairment and acute renal failure have been reported, 
possibly due to dehydration secondary to diarrhea. 
Disease-related concerns: 
 
Bowel obstruction: Patients with bowel obstruction should not be treated with 
irinotecan until resolution of obstruction.  
 
Hepatic impairment: Use with caution in patients with hepatic impairment. 
 
Hyperbilirubinemia: Patients with even modest elevations in total serum bilirubin 
levels (1-2 mg/dL) have a significantly greater likelihood of experiencing first-
course grade 3 or 4 neutropenia than those with bilirubin levels that were <1 
mg/dL. Patients with abnormal glucuronidation of bilirubin, such as those with 
Gilbert's syndrome, may also be at greater risk of myelosuppression when 
receiving therapy with irinotecan. Use caution when treating patients with known 
hepatic dysfunction or hyperbilirubinemia; dosage adjustments should be 
considered. 
Other less severe toxicities include: 
 
Nausea and vomiting; 
 
Anorexia, abdominal cramping; 
 
Alopecia, asthenia; 
 
Lymphocytopenia, anemia; 
 
Dehydration has occurred as a consequence of diarrhea, particularly when 
associated with severe vomiting. 
 
Cholinergic reactions:  Patients may have an acute syndrome of lacrimation, 
diaphoresis, abdominal cramping, and diarrhea (early diarrhea) during or shortly 
after irinotecan administration; this syndrome is thought to be cholinergically 
mediated, and may be treated and subsequently prevented with atropine.  
 
Pulmonary toxicity, manifested as shortness of breath, non-productive cough and 
transient infiltrates on chest x-ray have been reported.  
 
Mucositis or colitis (sometimes with gastrointestinal bleeding);  
 
Occasionally, 
abnormalities 
of 
serum 
creatinine, 
hepatic 
enzymes, 
or 
thrombocytopenia have been observed.  
 
Please refer to the package insert for complete product information (Appendix VI). 
 


44 
 
10.0 
Companion Studies  
 
There will be one correlative substudy and all patients are encouraged to participate.  
 
10.1 Correlative Science  
 
As described in 1.1, the John’s Hopkin’s group has completed three single institution clinical 
whole cell vaccine studies. Initially, the vaccine was tested in the adjuvant setting in a 14 
patient phase I dose-escalation study(13).  Results from that study showed that 3 of 8 
subjects receiving the 2 highest doses of vaccine developed increased post-vaccination DTH-
responses to autologous tumor.  A functional genomic approach was developed that 
employed banked lymphocytes isolated from treated patients to screen differentially 
expressed pancreatic adenocarcinoma (PDA) antigens.  This approach identified mesothelin 
as a novel PDA-associated T cell antigen.  Using public domain computer algorithms, two 
mesothelin-derived epitopes each were identified that bound HLA-A0101, A0201, A0301 and 
A2402 (these four alleles covered all treated patients).  Enhanced post-vaccination CD8+ T 
cell responses to these epitopes were exclusively detected in the 3 patients demonstrating 
positive DTH responses.  Importantly, these were the only patients on that study who 
demonstrated prolonged disease-free survival (>12 years).  Thus, the induction of 
mesothelin-specific immunity appeared to be associated with disease-free survival (DFS)(13). 
 
 More recently, the whole cell vaccine was tested in a follow-up 60 patient adjuvant study 
testing the highest dose found to be bioactive in the phase I trial(12).  Similar to the phase I 
study design(13), patients on this phase II study received an initial vaccination 8 weeks after 
pancreaticoduodenectomy, followed by chemoradiation, and then up to 4 more 
immunizations with the vaccine.  Peripheral blood lymphocytes (PBL) from two patients 
demonstrating prolonged DFS were used to identify additional mesothelin epitopes by 
screening 15mer peptides overlapping by 10 amino acids covering the entire mesothelin 
protein sequence.  The PBL used for epitope discovery were isolated from an HLA-A0201+ 
and HLA-A0101+ patient at 10 and 22.5 months following treatment completion respectively.  
Both patients were disease free for more than 2 years at the time of blood draw.  Peptide 
library screening resulted in the identification of 4 new HLA-A0201-binding and 6 new HLA-
A0101-binding mesothelin epitopes.  CD8+ T cell responses to the expanded set of 
mesothelin peptides were evaluated in 43 of the 60 treated patients whom expressed HLA-A1 
and/or HLA-A2 (12).  IFN-alpha ELISPOT analysis demonstrated that enhanced mesothelin-
specific T cell responses were not observed following the 1st vaccination in patients with 
rapidly recurring disease. In addition, in patients remaining disease-free, the maintenance of 
enhanced mesothelin-specific responses throughout the course of treatment correlated with 
longer DFS.  Furthermore, an expansion in the mesothelin-specific T cell repertoire following 
boosting vaccinations was observed almost exclusively in patients who demonstrated longer 
DFS.  These data suggest that the induction, maintenance and expansion of the mesothelin-
specific T cell repertoire may distinguish clinical responders from non-responders.   
 
In the 3rd clinical study, the whole cell vaccine was tested in 50 patients with stage IV 
pancreas ductal adenocarcinoma refractory to Gemcitibine)(11).  Patients enrolled in this 
study were divided into 2 cohorts.  All patients received up to 6 whole cell vaccine treatments 
given every 3 weeks.  However, 30 patients (cohort A) received vaccine alone and 20 patients 
(cohort B) received Cyclophosphamide (Cy) one day prior to each vaccination.  Cy was 
combined with the vaccine because preclinical studies had shown that when given 1 day 
prior to vaccination, low doses of Cy can enhance vaccine-mediated immune 
induction(30)(30).  This effect was mediated at least in part through the depletion of 
CD4+/CD25+ regulatory T cells (Tregs).  Median survival in Cohort A and Cohort B were 2.3 
months and 4.7 months respectively comparing favorably with what is reported for first and 
second line therapy in this patient population.  IFN ELISPOT assays were used to measure 
CD8+ T cell responses in the treated HLA-A1+, HLA-A2+ and HLA-A3+ patients.  These studies 


45 
 
demonstrated a trend toward prolonged progression-free survival in those patients who 
demonstrated persistent mesothelin-specific T cell response.  Furthermore, HLA tetramer 
dilution analyses performed on a subset of treated HLA-A2+ patients demonstrated that post-
immunotherapy increases in the avidity of mesothelin-specific T cells were associated with 
prolonged survival(11).   
 
More recently, the avidity of mesothelin-specific T cell responses in patients treated on the 
previously described 60 patient phase II adjuvant study have been assessed.  Dilutional 
tetramer analysis was performed on PBL isolated prior to the first vaccination and following 
the first and final vaccinations from HLA-A2+ subjects to assess the avidity of T cells specific 
for each of the 6 HLA-A0201-binding mesothelin epitopes.  T cell avidity for each mesothelin 
peptide was plotted against DFS.  Figure 1 shows the relationship between the avidity of 
MesoA2(530-538)-specific T cells and DFS.  For each of the 6 mesothelin peptides evaluated, a 
trend toward improved DFS was observed in patients demonstrating higher avidity 
mesothelin-specific T cells.  In addition, this trend was observed at each time point.  
However, although higher avidity mesothelin-specific T cells were sometimes present in pre-
vaccination PBL, mesothelin-specific IFN responses were frequently not detected until after 
the first vaccination.  Furthermore, in some patients, multiple boosts were required before 
both high avidity T cells and IFN responses could be detected.  These data suggest that 
higher avidity pre-committed T cells are sometimes present pre-treatment in resected PDA 
patients and can be activated with vaccination.   These data also suggest that these patients 
have up to a 10 fold increase in avidity compared to patients with metastatic disease that 
correlates with avidities measured in mice that clear tumors following vaccination with a GM-
CSF-secreting vaccine.  In addition, the distribution of avidities measured for each peptide 
was used to define cutoffs for distinguishing high from low avidity mesothelin-specific T cells.  
For this preliminary analysis, DFS>20 months vs. DFS<20 months was chosen as a binary 
clinical outcome parameter.  Figure 2 shows the number of mesothelin peptides for which 
high avidity T cells were detected for each patient evaluated.  Interestingly, a larger 
repertoire of high avidity mesothelin-specific T cells was associated with improved DFS.   
 
Collectively, the results from these 3 clinical studies have identified mesothelin as a relevant 
PDA T cell antigen and suggest that the induction and maintenance of mesothelin-specific 
immune responses is associated with prolonged survival.  Furthermore, these studies 
suggest that two new T cell parameters, avidity and the expansion of the mesothelin-specific 
T cell repertoire, are key parameters for predicting prolonged disease-free survival.  This new 
study will further assess the value of these T cell parameters in predicting DFS in patients at 
multiple institutions. 
 
Figure 1. Meso A2(530-538)-specific T cell Avidity vs DFS.   


46 
 
Figure 1.  Dilutional MesoA2(530-538) 
tetramer analysis was performed on PBL 
isolated a) prior to vaccination, b) 14 days 
following the 1st vaccination or c) 28 days 
following the final vaccination from HLA-
A2+ patients.  MesoA2(530-538)-specific T 
cell avidity measured for each patient is 
shown plotted against DFS.  Linear 
regressions were performed and the trend 
lines are shown. Blue data points were 
used when MesoA2(530-538)-specific IFN 
responses were also detected.  Red data 
points were used when IFN responses 
were not detected.  Dilutions were 
performed using 1 M tetramer stock 
solutions.  Data is an example shown for 
all HLA-A2 patients for one HLA-A2 
epitope.   Summarized data for all HLA-
A2 patients and for all 6 HLA-A2 epitopes 
is shown in Figure 2. 
 
Figure 2.  Longer Disease-Free Survival is Associated with Larger High Avidity 
Mesothelin-Specific CD8+ T Cell Repertoires.  
 
Figure 2. Dilutional tetramer analysis 
was performed for each of the 6 HLA-
A2-binding mesothelin epitopes on 
PBL isolated  prior to vaccination 
(Pre Vac), 14 days following the 1st 
vaccination (Vac 1 Day 14) or 28 days 
following the final vaccination (Post 
Tx) 
from 
HLA-A2+ 
patients.  
Dilutions were performed using 1 M 
tetramer stock solutions.  Patients 
were divided into 2 groups: those who 
recurred within 20 months (< 20 mo) 
and those who remained disease-free 
for greater than 20 months (> 20 mo). 
Avidity dilution profiles were used to 
define cutoffs between high and low 
avidity T cells for each peptide.  
Shown are the numbers of peptides 
for which high avidity T cells were 
detected for each patient evaluated.  High avidity repertoires were compared between groups 
using two-tailed Wilcoxon sign-rank tests and the calculated p-values are shown. 
10.1.1  Objectives 
Two key objectives for the correlative study are: 
 
 To estimate the association of immune correlates to time to disease progression 
in patients with resected pancreatic cancer who receive the whole cell vaccine as 
part of their adjuvant therapy.  The specific immune parameters include vaccine-
induced changes in the number, function, avidity, size and diversity of the 
mesothelin-specific T cell repertoire.   
 
>20 mo <20 mo 
>20 mo <20 mo 
>20 mo <20 mo 
0
2
4
6
0.053
0.035
Pre Vac           Vac 1 Day 14         Post  Tx
0.033
# high avidity peptides/ patient


47 
 
10.1.2 Methods 
The time points for collection of research bloods and the processing of samples are 
identified in the study calendar and described in detail in 7.0 
Mesothelin-specific T cell analyses.  We will assess mesothelin-specific T cell 
responses using an ELISPOT assay and dilutional HLA tetramer staining and flow 
cytometry analysis that are well established and have been successfully used to analyze 
immune responses in the prior phase I and II studies.  Immune parameters to be studied 
include:  the induction and maintenance of mesothelin-specific, cytokine secreting CD8+ 
T cell responses, the evaluation of the size and diversity of the mesothelin-specific CD8+ 
T cell repertoire against an expanded set of mesothelin T cell epitopes, and the 
assessment of the changes in avidity of the T cell repertoire with repeated vaccinations.    
 
PBL.  Lymphocytes will be obtained from peripheral blood before each immunotherapy 
treatment.  Pre and post-treatment PBL will be isolated by Ficoll-Hypaque density 
gradient centrifugation.  Isolated PBL will be stored frozen at -135C in 90% AIM-V 
serum-free media containing 10% DMSO until the day of analysis.  All specimens will be 
banked with a unique study identification number without any patient identifiers.   
 
ELISPOT assay.  HLA typing of all participants is performed at the Johns Hopkins 
Immunodiagnostics CORE facility.  Mesothelin epitopes have so far been identified for 
HLA-A1, A2, A3 and A24.  These four HLA alleles covered 82.3 percent of patients treated 
in the previously mentioned vaccine studies.  However, it may be necessary to identify 
additional mesothelin MHC class I binding peptides if additional alleles are identified and 
needed to cover all subjects enrolled into this study.  IFN ELISPOT assays will be 
performed to measure the frequency of cytokine-secreting T cells specific for each relevant 
(on the basis of HLA-restriction) mesothelin epitope using freshly thawed and enriched 
patient CD8+ PBL as previously described(31).  All peptides will be synthesized by the 
Johns Hopkins Peptide Core facility and will be purified to greater than 95% purity.  T2 
cells are TAP-deficient, human B and T lymphoblast hybrid cells, and therefore fail to 
transport newly processed HLA class I binding epitopes from the cytosol into the 
endoplasmic reticulum where these epitopes would normally bind to nascent HLA 
molecules and stabilize them for expression on the cell surface.  T2 cells naturally 
express HLA-A2, but T2 cell lines have also been engineered to express additional HLA 
alleles, including HLA-A1, A3, A24, A11, A25, A26, A31 and A66.  T2 cells expressing 
the appropriately matched HLA molecules will be pulsed with peptides (2 g/ml) and used 
as APCs in the ELISPOT assays.  Developed plates will be counted using an automated 
image system ELISPOT reader.  The CEF pool of epitopes derived from CMV, EBV, and 
Influenza which is obtained from the NIH AIDS Consortium and reliably results in positive 
T cell responses in pancreatic cancer patients, will be used as a positive control.  HIV 
(32) renal cell carcinoma (33) or melanoma epitopes (34) are used as negative controls.  
Background reactivity, measured against the negative control peptides, will be subtracted 
from experimental values.  All time points will be assayed in a minimum of three 
replicates.   Individual patient responses will be reported as the mean number of 
peptide-specific CD8+ T cells per 1x106 total CD8+ T cells, whereas group responses will 
be reported as medians. 
 
Mesothelin-specific T cell repertoire analysis.   The induction of T cell responses to 
multiple mesothelin epitopes will be evaluated using the ELISPOT assay as described 
above.  The induction of T cell responses to each individual epitope will be defined as a 
2-fold or greater increase in the number of mesothelin epitope-specific CD8+ T cells in 
post-vaccinated PBL as compared with that in PBL isolated prior to the first vaccination.  
For PBL at each post-vaccinated time point, the mesothelin-specific T cell repertoire is 
defined by the number of different mesothelin epitopes for which an induced response is 


48 
 
measured.   The size of the T cell repertoire is thus the total number or percentage of 
epitopes for which an induction is measured.   
 
Mesothelin-specific T cell avidity analysis.  Dilutional tetramer staining will be 
performed on unmanipulated PBL isolated prior to and following immunotherapy as 
previously described(11).  HLA class I tetramers are manufactured by Beckman Coulter 
under quality controlled conditions.  Based on prior unpublished studies assessing T 
cell avidity in resected patients who received the GM-CSF-secreting vaccine, staining will 
be performed at tetramer dilutions ranging from 1:10 to 1:500 starting with 1 M tetramer 
stock solutions.  Flow cytometry will be used to determine the greatest dilution at which 
tetramer staining is lost.  Higher avidity is associated with detectable staining at lower 
tetramer concentrations. Background staining will be assessed using tetramers prepared 
with irrelevant peptides.  This analysis will be limited to the subset of patients for which 
tetramers are available.  Tetramers are currently available for each of the 6 HLA-A0201-
binding mesothelin epitopes and under development for the 8 HLA-A0101 epitopes. 
 
11.0 
Drug Formulation, Availability, And Preparation 
 
Qualified personnel who are familiar with procedures that minimize undue exposure to 
themselves and to the environment should undertake the preparation, handling, and safe 
disposal of chemotherapeutic agents in a self-contained, protective environment. 
 
Discard unused portions of injectable chemotherapeutic agents that do not contain a 
bacteriostatic agent or are prepared with unpreserved diluents (i.e., Sterile Water for Injection 
USP or 0.9% Sodium Chloride for Injection USP) within eight hours of vial entry to minimize the 
risk of bacterial contamination. 
 
The total administered dose of chemotherapy may be rounded up or down within a range of 5% 
of the actual calculated dose.  BSA will be calculated at baseline and prior to each cycle.   
 
11.1 Cyclophosphamide 
 
Other names 
Cytoxan.  Neosar.  The chemical name for cyclophosphamide is 2-[bis(2-
chloroethyl)amino]tetrahydro-2H-1,3,2-oxazaphosphorine 2-oxide monohydrate.  
 
Classification 
Alkylating agent. Antineoplastic, immunosuppressant. 
 
Mode of action 
Cyclophosphamide is classed as an alkylating agent of the nitrogen mustard type. An 
activated form of cyclophosphamide, phosphoramide mustard, alkylates or binds with many 
intracellular molecular structures, including nucleic acids. Its cytotoxic action is primarily 
due to cross-linking of strands of DNA and RNA, as well as to inhibition of protein synthesis.  
Metabolism is primarily hepatic via CYP450.  Excretion is in the urine (5-25% unchanged).  
Half-life 3- 12 hours. 
 
Storage and stability 
Cyclophosphamide for Injection, USP is a sterile white powder containing cyclophosphamide 
monohydrate. Cyclophosphamide is a synthetic antineoplastic drug chemically related to the 
nitrogen mustards. Cyclophosphamide is a white crystalline powder with the molecular 
formula C7H15CI2N2O2P•H2O and a molecular weight of 279.1. Cyclophosphamide is 
soluble in water, saline, or ethanol and has the following structural formula: 
 
Dose Specifics 


49 
 
When used as the only oncolytic drug therapy, the initial course of cyclophosphamide for 
patients with no hematologic deficiency usually consists of 40 to 50 mg/kg given 
intravenously in divided doses over a period of 2 to 5 days. Other intravenous regimens 
include 10 to 15 mg/kg given every 7 to 10 days or 3 to 5 mg/kg twice weekly.  Oral 
cyclophosphamide dosing is usually in the range of 1 to 5 mg/kg/day for both initial and 
maintenance dosing.  Many other regimens of intravenous and oral cyclophosphamide have 
been reported.  
 
Preparation 
Cyclophosphamide should be prepared for parenteral use by infusion by adding Sterile Water 
for Injection, USP. Cyclophosphamide, constituted in water, is hypotonic and should not be 
injected directly. Add the diluent to the vial and shake it vigorously to dissolve. If the powder 
fails to dissolve immediately and completely, it is advisable to allow the vial to stand for a few 
minutes.  Store intact vials of powder at room temperature of 15°C to 30°C (59°F to 86°F). 
Reconstituted solutions are stable for 24 hours at room temperature and 6 days under 
refrigeration 2°C to 8°C (36°F to 46°F). Further dilutions in D5W or NS are stable for 24 hours 
at room temperature (25°C) and 6 days at refrigeration. 
 
Administration 
IV infusions may be administered over 1-24 hours. Doses of up to 2 gm may be administered 
over 20- 30 mins.  To minimize bladder toxicity, increase fluid intake before and after 
cyclophosphamide administration.  High dose cyclophosphamide should be accompanied by 
vigorous hydration and MESNA. 
 
Compatibilities 
Stable in D5LR, D5NS, D5W, LR, 1/2NS, or normal saline. 
 
Drug interactions 
The rate of metabolism and the leukopenic activity of cyclophosphamide are increased by 
chronic administration of high doses of phenobarbital. Cyclophosphamide treatment, which 
causes a marked and persistent inhibition of cholinesterase activity, potentiates the effect of 
succinylcholine 
chloride. 
Interactions 
with 
allopurinol, 
cardiac 
glycosides, 
CYP 
inducers/inhibitors. 
 
Availability 
Cyclophosphamide for Injection, USP contains cyclophosphamide monohydrate and is 
supplied in vials for single dose use of 500 mg, 1.0 g or 2.0 g size.  Tablet forms, 25 mg or 
50 mg. 
 
Side Effects 
Carcinogenesis, Mutagenesis, Fertility Impairment:  Second malignancies have developed in 
some patients treated with cyclophosphamide used alone or in association with other 
antineoplastic drugs.  Cyclophosphamide can cause fetal harm when administered to a 
pregnant woman.  Cyclophosphamide interferes with oogenesis and spermatogenesis. It may 
cause sterility in both sexes. Development of sterility appears to depend on the dose of 
cyclophosphamide, duration of therapy, and the state of gonadal function at the time of 
treatment. Amenorrhea associated with decreased estrogen and increased gonadotropin 
secretion can occur.  
 
GI: Nausea, vomiting, diarrhea, stomatitis. 
 
Endocrine/Metabolic: Hyponatraemia, SIADH, transient succinylcholinesterase deficiency. 
 
Cutaneous:  Rash, alopecia. 
 


50 
 
Pulmonary/ENT: Interstitial pneumonitis. Nasal congestion when IV doses administered too 
rapidly.  Occasionally, runny eyes, sinus congestion and sneezing. 
 
Cardiac:  A few instances of cardiac dysfunction have been reported following use of 
recommended doses of cyclophosphamide. Acute cardiac toxicity has been reported with 
doses as low as 2.4 g/m2 to as high as 26 g/m2. Rarely high doses of cyclophosphamide, 
severe, and sometimes fatal, congestive heart failure has occurred after the first 
cyclophosphamide dose (haemorrhagic myocarditis). Cyclophosphamide has been reported 
to potentiate doxorubicin-induced cardiotoxicity. 
Hematologic: Anemia, neutropenia, thrombocytopenia. 
 
Infections:  Treatment with cyclophosphamide may cause significant suppression of 
immune responses. Serious, sometimes fatal, infections may develop in severely 
immunosuppressed patients.  
 
Renal/GU:  Hemorrhagic cystitis may develop in patients treated with cyclophosphamide. 
Fibrosis of the urinary bladder, sometimes extensive, also may develop with or without 
accompanying cystitis. Such bladder injury is thought to be due to cyclophosphamide 
metabolites excreted in the urine. Forced fluid intake helps to assure an ample output of 
urine, necessitates frequent voiding, and reduces the time the drug remains in the bladder. 
Hematuria usually resolves in a few days after cyclophosphamide treatment is stopped, but 
it may persist.  
 
Nursing implications 
Similar in name to several cytotoxics, e.g., cisplatin, cytarabine, Cytosar, Cytotec. 
 
11.2 Whole Cell Vaccine 
 
Other names 
Lethally Irradiated Allogeneic Granulocyte-Macrophage Colony-Stimulating Factor Secreting 
Tumor Vaccine, GVAX. 
 
Classification 
Whole cell vaccine.  Immunotherapy. 
 
Manufacture and Supply 
The whole cell vaccine is prepared and supplied by Cell Processing and Gene Therapy Facility 
(CPGT) at Johns Hopkins University. 
 
 
  
 
 
 
  
 
Mode of Action 
Immunologic. 
 
Storage and Stability 
Each whole cell vaccine vial is shipped frozen and stored frozen in vapor phase liquid nitrogen 
in the injectable formulation. 
 
At the time of vaccination, the vials are removed from the appropriate storage conditions 
and quickly thawed in a 37°C water bath. The thawed vials are transferred from the 


51 
 
water bath to wet ice until the vaccine is drawn from the vial with a 16 gauge needle into 1 
cc luer lock syringes and then changed to 22 gauge luer lock needles for subject’s 
administration.  The syringes are then released to the appropriate medical personnel for 
intradermal injection and are kept on ice until the vaccine is administered. All injections 
must be given within 3 hours of thaw.  The 3 hours start when the vials are placed in the 
water bath for thaw. 
 
Dose Specifics 
Each vaccine will consist of 6 intradermal injections.  Each injection consists of 
approximately 8.3 x107 cells in 0.7 to 0.73 ml solution. 
 
Administration 
Intradermal injection. Each vaccination will consist of a total of six intradermal injections, 
two each in the upper right and left thighs, and two in the upper non-dominant arm.  A 
wheal should be created. See Appendix I for further details. 
 
Incompatibilities 
No information available. 
 
Side Effects 
Dermatologic:  Erythema, induration, pain/soreness, at vaccine site, lasting for up to a 
week.  Pruritus, blister formation, hyperpigmentation, rash. 
 
Hematologic:  Eosinophilia, leukocytosis. 
 
Other:  Flu-like symptoms, fatigue, fever, chills, myalgias.  
 
Immunologic:  Autoimmunity (theoretic). 
 
Disposal 
The vaccine is considered a biosafety hazard.  All used vials and all material that comes in 
contact with the vaccine should be disposed of in a biosafety hazard container (e.g., Sharp's 
container or red bag) and then treated as medical waste in accordance with institution 
practice. Each institution should abide by federal, state and local waste disposal regulations.  
Material from the vaccine vials should not be poured or pipetted into a drain for disposal to 
sanitary sewer systems. 
 
Nursing Implications 
Each vaccine consists of a total of 6 intradermal injections.  Two each in the upper right and 
left thighs and two in the upper non-dominant arm.  Lidocaine-based topic anesthetic 
(EMLA or Lidocaine) will be applied to each injection site at least 1 hour prior to vaccination 
and covered with an occlusive dressing.  Do not shave the sites prior to applying the 
numbing cream.  Omit Lidocaine if subject is allergic. For upper extremity injection, use the 
upper portion of the arm. For lower extremity injection, use the upper portion of the thigh. 
Injections can be placed randomly, but at least 2 inches apart. If the patient is unable to 
receive an injection in the arms or legs, an acceptable alternative injection site is the 
abdomen. Do not place injections into skin that is ulcerated or infected. Topical steroids and 
topical antihistamines should be avoided. Each dose will be administered on an outpatient 
basis. Patients must remain in the clinic for observation for at least 30 minutes following the 
vaccination. See Appendix I for further details. 
 
 
12.0 
Ancillary Therapy 
 


52 
 
12.1 Patients should receive full supportive care, including transfusions of blood and blood 
products, erythropoetin (unless otherwise specified in the protocol), antibiotics, 
antiemetics, etc., when appropriate. 
12.2 Treatment with hormones or other chemotherapeutic agents may not be administered 
except for steroids given for adrenal failure; hormones administered for non-disease-
related conditions (e.g., insulin for diabetes); and intermittent use of dexamethasone 
as an antiemetic in solid tumor protocols. Megesterl acetate (Megace) is permitted to 
support anorexia.  
 
13.0 
CRITERIA FOR RESPONSE, PROGRESSION AND RELAPSE (SOLID TUMORS) 
 
For the purposes of this study, patients should be reevaluated per study calendar and per 
standard of care as described in section 7.0 after completion of adjuvant therapy until taken off 
study. 
 
Most patients will be expected to have only minimal residual microscopic disease if they remain 
to be eligible for this study following the surgery. Therefore, there will be no disease to measure 
at baseline. Patients will be monitored for disease-free and overall survival. The results from the 
current trial will be compared to the results of the prior phase II adjuvant study conducted at 
Johns Hopkins Hospital, conducted with a similar treatment protocol.  
 
Patients will undergo standard of care evaluations consisting of abdominal, chest, and pelvis CT 
scans at regular intervals to evaluate for local recurrence and distant metastases. In addition, 
any patient presenting with symptoms will undergo evaluation for metastases. Recurrent disease 
is defined as evidence of either definitive local or metastatic recurrence by CT scan.  The serum 
tumor marker CA 19-9 lacks a sufficient sensitivity and specificity to serve as reliable indicators 
of response/recurrence.  The CA 19-9 levels will be followed to evaluate whether large and 
persistent changes might correlate with either in vitro immune responses or with time to clinical 
recurrence. 
 
13.1 Definition of Progression 
 
Distant progressive disease is defined as the unequivocal appearance of any lesions.  
This includes liver metastases, pulmonary metastases, bone metastases, brain 
metastases and mesenteric/abdominal nodal progression outside the radiation CTV.  
Malignant ascites will also be scored as distant progression if cytologic evaluation of 
cytology fluid yields malignant cells. 
 
Locoregional progression is defined as progressive change from baseline post-operative 
CT in the context of rising CA19-9, increasing symptoms such as pain or biliary 
obstruction of the hepaticojejunostomy, or biopsy confirmation. 
 
13.2 Evaluation of Immune Responses 
 
See section 10 of protocol. 
 
14.0 
Statistical Considerations 
 
Statistical Analysis Plan 
 
The primary endpoint is safety.  The toxicity profile of FOLFIRINOX (F) in the metastatic setting 
and standard radiation therapy (RT) in the adjuvant setting has been well established.  
Approximately 20% of patients experience diarrhea, 50% experience non-recoverable 
neutropenia, and 10% experience thrombocytopenia.  We are interested in exploring the 
combination of FOLFIRINOX with stereotactic body radiation therapy (SBRT) plus GVAX.  


53 
 
Toxicity rates of grade 3-4 diarrhea, grade 3-4 neutropenia, and grade 3-4 thrombocytopenia 
would be considered unacceptable (dose limiting toxicity-DLT) if they were 40%, 60%, and 40% 
respectively.   Although GVAX is not expected to contribute to these two types of toxicity, we 
will enroll patients into two cohorts so that only one factor in the therapy is modified at each 
step. The first cohort will receive FOLFIRINOX plus SBRT in place of standard radiation therapy.  
The second cohort will receive the same combination plus GVAX.   
 
A decision rule similar to the traditional 3+3 design will be used to determine whether or not it 
is safe to continue on to the next cohort.  An initial 3 patients will be treated with F+SBRT.  If 
no toxicities are observed within the first 2 cycles of FOLFIRINOX administration (8 weeks) then 
the next group of patients will be treated with F+SBRT+GVAX.  If 2-3 patients are observed with 
uncontrolled grade 3-4 diarrhea, 2-3 patients are observed with grade 3-4 thrombocytopenia, or 
if 3 patients are observed with grade 3-4 neutropenia within the first 2 cycles of FOLFIRINOX 
administration (8 weeks) then the trial will be halted.  Otherwise (i.e. if 1 patient is observed 
with grade 3-4 diarrhea, 1 patient is observed with thrombocytopenia, or 1-2 patients are 
observed with neutropenia), then an additional 3 patients will be treated with F+SBRT.  If 0-1/6 
patients experience grade 3-4 diarrhea, 0-1/6 patients experience grade 3-4 thrombocytopenia, 
and 0-3/6 experience  grade 3-4 neutropenia, then the next group of patients will receive 
F+SBRT+GVAX.  Treatment groups for which < 40% experience grade 3-4 diarrhea (i.e. < 2/6), 
< 40% experience grade 3-4 thrombocytopenia ( i.e. <2/6), and < 60% experience grade 3-4 
neutropenia (i.e. < 4/6) will be considered tolerable.  An expansion cohort of 6 patients will be 
treated with F+SBRT+GVAX, if tolerable, in order to refine estimates of toxicity and initial efficacy 
for a total sample size of 15-18 patients. 
 
-Any grade 3-4 toxicity within the context of the decision rule described above will be dose 
limiting with the exception of 1) nausea, vomiting or diarrhea that improves to ≤ grade 2 with 
maximal medical management within 5 days; 2) neutropenia that resolves within 5 days; or 3) 
thrombocytopenia that resolves within 7 days.   
 
-Patients who get DLT-qualifying diarrhea but do not adhere to appropriate medical management 
will be considered inevaluable for DLTs and will be replaced. 
 
The number, type and degree of toxicities will be tabulated.  In particular, the toxicities for each 
round of vaccination will be followed and the proportion of individuals who have a DLT within 
the first 28 days of vaccination will be estimated with exact 95% confidence intervals.  Poisson 
modeling with robust confidence intervals will be used to estimate the rate per individual as well 
as the rate per vaccine dose. 
 
Secondary objectives:  Due to the small sample size, the analysis of secondary outcomes will 
be primarily exploratory in nature.  Overall survival (OS) is defined as the time from surgery 
until death.  Disease free survival (DFS) is defined as the time from surgery until disease 
progression or death.  All enrolled individuals will the included in the analysis.  Individuals who 
are lost to follow-up will be included in the analysis and censored at the date of the last visit for 
DFS and date of the last contact for OS.  For time-to-event outcomes (OS and DFS), Kaplan-
Meier estimates of the survival function will be used to graphically compare treatments as well 
as subgroups of interest.  Log-rank tests and Cox proportional hazards models will be used to 
statistically compare the two treatment arms as well as subgroups of interest.   
 
Continuous variables will be summarized with means and standard deviations or medians with 
ranges, as appropriate. Dichotomous and categorical variables will be summarized using 
proportions with exact 95% confidence intervals and counts respectively.  Linear regression and 
logistic regression models will be used to compare treatment arms for continuous and binary 
variables, respectively.  In the case of repeated measurements, generalize estimating equations 
will be used to account for the correlation between measurements within an individual.   
 


54 
 
Additional analyses will be conducted to examine the immune response parameters for patients 
in the vaccine arm.  Analyses will be assessed for each dose and related to clinical outcomes. 
The primary focus will be upon the 3 immune response parameters identified previously but 
additional exploratory analyses will be completed to identify novel parameters.  These 
summaries will be computed for each patient both pre- and post- administration of each 
vaccination. Plots will be used to show the changes in immune response over time both for each 
individual and summarized for the study as a whole. For each vaccination, comparisons in the 
pre- and 28 day post-vaccine responses will be made using paired t-tests (or Wilxcoxon signed 
rank tests if appropriate) for continuous measurements. McNemar’s test will be used to identify 
significant changes in the percentage of individuals with a dichotomous characteristic pre- and 
post-vaccine.  Associations between immune parameters will be explored graphically (e.g. 
scatterplots, boxplots) and numerically (e.g. correlations, Kappas, McNemar’s tests).  The 
relationships between the immune parameters and clinical outcomes will be assessed using 
univariate and multivariate modeling. In the case of a binary clinical outcome (e.g. toxicity, 
DFS>20 months vs. DFS< 20 months years), logistic regression will be used. In the case of a 
time-to-event clinical outcome (e.g. OS), Cox proportional hazards models will be used. 
 
15.0 
Adverse and Problem Event Reporting 
 
15.1 Recording of an adverse event 
 
The principal investigator is responsible for evaluating all adverse events, obtaining 
supporting documents, and determining that documentation of the event is adequate. The 
Investigator should attempt, if possible, to establish a diagnosis based on the patient's signs 
and symptoms. When a diagnosis for the reported signs or symptoms is known, the 
Investigator should report the diagnosis, not the symptoms, as the adverse event. The 
principal investigator is responsible for determining the severity and relationship of the 
adverse event to the investigational drug. The principal investigator may delegate these duties 
to sub-investigators and must assure that these sub-investigators are qualified to perform 
these duties under the supervision of the principal investigator. 
 
The Investigator or designee must completely and promptly record each adverse event using 
the eCRF, regardless of relationship to study drug as determined by the Investigator. All 
adverse events will be recorded in the subject’s Case Report Form and in the study data base. 
The detailed description of the event will include appropriately graded severity of the adverse 
event and its relationship to the study drug. 
 
Severity will be categorized by toxicity grade according to the NCI Common Terminology 
Criteria 
for 
Adverse 
Events 
version 
4.0 
available 
at 
http://ctep.cancer.gov/reporting/ctc.html  
 
Adverse events not listed in the NCI Common Terminology Criteria for Adverse Events will be 
evaluated using the following criteria: 
 Grade 1, Mild: Awareness of symptom, but easily tolerated; usually transient requiring no 
special treatment; does not interfere with usual status or activities 
 Grade 2, Moderate: May be ameliorated by simple therapeutic measures; may interfere with 
usual activities 
 Grade 3, Severe: Incapacitating, inability to perform usual activities 
 Grade 4, Life-threatening/Disabling: Subject was at risk of death or significant disability 
at the time of the event 
 Grade 5, Death related to AE  
 
Relationship of the adverse event to the investigational drug will be determined by the 
principal investigator, and will be categorized as: 


55 
 
 Not Related: The adverse event is clearly related to other factors such as the subject’s 
clinical state, environmental factors, or other modes of therapy or concomitant drugs 
administered to the subject. 
 Not likely: There is a temporal relationship to investigational product administration, but 
there is not a reasonable causal relationship between the investigational product and the AE.  
 Possible: The adverse event follows a reasonable temporal sequence from administration 
of the study drug, and/or follows a known response pattern to the study drug, but could 
readily have been produced by the subject’s clinical state, environmental factors, or other 
modes of therapy or concomitant drugs administered to the subject. 
 Probable: The adverse event follows a reasonable temporal sequence from administration 
of the study drug and follows a known response pattern to the study drug, and cannot readily 
have been produced by the subject’s clinical state, environmental factors, or other modes of 
therapy or concomitant drugs administered to the subject. 
  Definite: There is a reasonable causal relationship between the investigational product 
and the AE. The event responds to withdrawal of investigational product (dechallenge), and 
recurs with rechallenge when clinically feasible. 
 
Clinically significant laboratory abnormalities present at the Baseline visit will be recorded 
as pre-treatment signs and symptoms. After study treatment administration, all grade 3 and 
4 clinical laboratory results that represent an increase in severity from baseline will be 
reported as adverse events. A grade 1 or 2 clinical laboratory abnormality should be reported 
as an adverse event only if it is considered clinically significant by the investigator. Laboratory 
abnormalities will not be recorded as adverse events unless considered clinically significant 
by the Investigator, and clinically significant laboratory abnormalities will not be recorded as 
serious AEs unless the event meets the definition of serious. 
 
In the event of death, the cause of death should be recorded as the adverse event. An attempt 
will be made to obtain a copy of the death certificate. Because the long-term effects of gene 
therapy are not known, the National Institutes of Health (NIH) would like an autopsy, in the 
event of death. If an autopsy is performed, a copy of the autopsy report should be obtained. 
 
15.2 Reporting guidelines 
 
We will use the current JHM IRB, Institutional Bio-safety Committee (IBC), NIH Recombinant 
DNA Advisory Committee (RAC), FDA guidelines and SAE Reporting Criteria, and Safety 
Reporting Requirements for IND Holders for reporting relevant problems, events, adverse 
events, and adverse drug reactions that occur after starting experimental treatment. 
 
ALL serious adverse events that occur after starting experimental treatment, regardless of 
causality, should be reported to ALL of the following: 
1. IND Sponsor 
2. Institution IRB 
3. Institution IBC 
 
Timelines for reporting SAE’s 
A. IND Sponsor (Dr. Jaffee)- within 24 hours 
 
B. IRB- within 3 days if the SAE is related to the study drug. If the SAE is not 
considered related to the study drug within 10 days.  
 
Johns Hopkins Medicine IRB 
 
 


56 
 
 
 
 
C. IBC- within 15 days 
 
D. FDA- As per section 16.2 
 
E. RAC- As per section 16.2 
 
Follow up on SAE reports should also be sent to all the above agencies within two weeks of 
receipt of information at the site. 
 
15.2.1 Safety Reporting Requirements for IND Holders 
 
For Investigator Sponsored IND Studies, there are some additional reporting 
requirements for the FDA in accordance with the guidance set forth in 21 CFR 312.32. 
Sponsor-investigators of studies conducted under an IND must comply with the following 
safety reporting requirements:  
15.2.1.1 Expedited IND Safety Reports: 
 
7 Calendar-Day Telephone or Fax Report:   
The Sponsor-Investigator is required to notify the FDA and RAC of any fatal or life-
threatening adverse event that is unexpected and assessed by the investigator to 
be possibly related to the vaccine.  An unexpected adverse event is one that is not 
already described in the Investigator Brochure.  Such reports are to be telephoned 
or faxed to the FDA within 7 calendar days of first learning of the event.  The RAC 
will be notified by e-mail within 7 calendar days of first learning of the event. Each 
telephone call or fax transmission (see fax number below) should be directed to the 
FDA new drug review division in the Center for Drug Evaluation and Research or in 
the product review division for the Center for Biologics Evaluation and Research, 
whichever is responsible for the review of the IND. 
 
15 Calendar-Day Written Report:   
The Sponsor-Investigator is also required to notify the FDA, RAC, and all participating 
investigators, in a written IND Safety Report, of any serious, unexpected AE that is 
considered possibly related to the vaccine.  An unexpected adverse event is one that 
is not already described in the Investigator Brochure. 
 
Written IND Safety Reports should include an Analysis of Similar Events in 
accordance with regulation 21 CFR § 312.32.  All safety reports previously filed with 
the IND concerning similar events should be analyzed.  The new report should 
contain comments on the significance of the new event in light of the previous, similar 
reports.   
 
Written IND safety reports with Analysis of Similar Events are to be submitted to the 
FDA, RAC, and all participating investigators within 15 calendar days of first learning 
of the event. In this study electronic CRF will be used. 
 
FDA fax number for IND Safety Reports: 
301-827-9796 
 
15.2.1.2 IND Annual Reports 
 


57 
 
In accordance with the regulation 21 CFR § 312.32, the Sponsor-Investigator shall 
within 60 days of the anniversary date that the IND went into effect submit a brief 
report of the progress of the investigation.  Please refer to Code of Federal 
Regulations, 21 CFR § 312.32 for a list of the elements required for the annual report.  
All IND annual reports will be submitted to the FDA by the Sponsor-Investigator. 
 
15.3 Special considerations for AEs that occur during local FOLFIRINOX treatment 
 
FOLFIRINOX has significant and well-documented toxicities and is standard of care for 
metastatic pancreatic adenocarcinoma. Sufficient safety data will have been collected during 
the first 3 cycles of FOLFIRINOX to permit local treatment for cycles 4-6.   
 
Therefore, during any period of local FOLFIRINOX treatment, the study will be focused on 
monitoring and reporting: 
1. All grade III and grade IV gastrointestinal adverse events 
2. All toxicities deemed by the study PI as related to SBRT, Cyclophosphamide or GVAX 
3. All SAEs  
 
These events will be recorded as described in Section 15.1 and their severities will still be 
categorized by NCI CTCAE v4.0 criteria.  Relationship of these events to the investigational 
drug will be determined by the principal investigator together with oncology co-investigators 
of the study team. Reporting of these events will follow the same guidelines described in 
Section 15.2 
 
 
 


58 
 
16.0 
Clinical Trial Monitoring 
 
The SKCCC Compliance Monitoring Program will provide external monitoring for JHU-affiliated 
sites in accordance with SKCCC DSMP (Version 6.0, 02/21/2019). The SMC Subcommittee will 
determine the level of patient safety risk and level/frequency of monitoring.  The Principal 
Investigator is responsible for internal monitoring for both safety and data quality. Data 
monitoring of this protocol will occur on a regular basis with the frequency dependent on the 
rate of subject accrual and the progress of the study. On a regular basis the protocol will be 
internally monitored by the principal investigator, and the study’s sponsor, Dr. Elizabeth Jaffee.  
 
16.1 Internal review 
 
The PI will have a regular internal monitoring. 
 
The study will be monitored internally by the Principal Investigator. The internal review 
should occur after the first three patients are enrolled and have completed two cycles of 
therapy. The process should occur every six months thereafter. The PI will review data to 
assure the validity of data, as well as, the safety of the subjects. The PI will also monitor 
the progress of the trial. The PI will review safety reports and clinical trial efficacy 
endpoints and to confirm that the safety outcomes favor continuation of the study. 
  
The PI will be responsible for maintaining the clinical protocol, reporting adverse events, 
assuring that consent is obtained and documented, reporting of unexpected outcomes, 
and reporting the status of the trial in the annual report submitted to the IRB. Content 
of the report will include year-to-date and full trial data on: accrual and eligibility, 
protocol compliance, treatment administration, toxicity and adverse events, response, 
survival, regulatory compliance, compliance with prearranged statistical goals. The 
following will be reviewed: 
 
- Original, signed consent forms to ensure that one is available for each subject.  
 
- Case report forms and source documentation for validity and consistency in the 
completed entries, as well as, accuracy, legibility, signatures and dates.  
 
- Treatment administration records to ensure concurrence between dispensing records 
and CRFs as to subject identity, and dosage of study drug administered.  
 
- Compliance with the protocol will also be checked.  
 
- Pharmacy drug accountability records for accuracy and completeness, and study drug 
storage to ensure proper maintenance and supply levels.  
 
16.2 External review 
 
External data monitoring will be performed by the SKCCC at Johns Hopkins Clinical 
Research Office Quality Assurance Program (CRO QA) in accordance with SKCCC 
guidelines. Data and safety monitoring oversight will be conducted by the SKCCC at 
Johns Hopkins Safety Monitoring Committee (SMC).  Per the SKCCC at Johns Hopkins 
Safety Monitoring Plan, the CRO QA will forward summaries of all monitoring reports to 
the medical expert committee (MEC) and JHU SKCCC Safety Monitoring Committee for 
review.  All reportable anticipated and unanticipated protocol events/problems and 
amendments that are submitted to the IRB will also be reviewed by the JHU SKCCC 
Safety Monitoring Committee Chair (or designee) and QA manager. 
 


59 
 
The MEC will review safety data on at least a semi-annual basis. The MEC will provide a 
written summary of each assessment to the Principal Investigator after each meeting. In 
turn, the study team will forward these summaries to the JHU IRB and JHU SKCCC SMC. 
The operating plan of the MEC will be as follows:   
 
Meetings will be held at least semi-annually, and potentially more frequently if 
needed.  
 
Meetings will be conducted in-person or via video/teleconference, with a 
participant sign-in sheet collected at each meeting.  
 
Approximately one week prior to each MEC meeting, the study team will submit 
the following items to MEC personnel for review and discussion at the meeting:  
o 
A summary of the clinical trial’s progress to date; 
o 
The latest IRB-approved consent document;  
o 
A summary of all AEs, SAEs, deaths, and withdrawals to date 
Note that the MEC reserves the right to halt trial accrual or all study activity if, after 
review, serious safety concerns warrant this action. If the MEC halts study accrual or all 
study activity, then the study team must notify the JHU SKCCC SMC, JHU IRB, FDA, 
and NIH RAC immediately. 
The MEC consists of the following members: 
 Dr Russel Hales (Radiation oncology); 
  
 Dr Chuck Drake (Medical oncology); phone:
 
 Dr 
Christine 
Hahn 
(Medical 
oncology); 
 
 
 


60 
 
17.0 
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64 
 
Appendix I: Vaccine Administration Standard Operating Procedure 
Purpose:  
To describe the standard procedure administering the  pancreatic vaccine 
 
Scope:  
Licensed personnel (Registered Nurse or Nurse Practitioner) 
administering the pancreatic vaccine. 
 
Procedure:  
Supplies 
1. Obtain supplies:  wipes, alcohol pads and band aids 
Patient preparation 
1. Assess patient and hold vaccination for fevers, flu-like symptoms, and any other 
worrisome symptoms. 
2. Apply lidocaine based numbing cream (omit if pt is allergic) to anticipated vaccine 
sites 1-2 hours prior to vaccination and cover with an occlusive transparent 
dressing.  Two sites on the non-dominant upper arm, two sites on the right and left 
upper thighs. (refer to SOP) 
 
Patient Administration 
1. After validating correct patient and correct vaccine (refer to SOP), remove occlusive 
dressings one at a time and remove excess numbing cream with a clean dry wipe. 
2. Cleanse site with alcohol pad and let air dry. 
3. Assess color and consistency of vaccine solution. 
4. Remove all air from syringe barrel. 
5. Administer vaccine syringe, bevel up, intradermally slowly over 30-60 seconds to 
reduce discomfort and create a wheal.   
6. Place band aid over site. 
7. Monitor patient for at least 30 minutes after administration of the vaccine. 
 
 


65 
 
Purpose:  
To describe the standard procedure for validating correct  patient and 
correct vaccine prior to administration. 
 
Scope:  
Licensed personnel (Registered Nurse or Nurse Practitioner) 
 
 administering the vaccine. 
 
 
Procedure:  
1. Obtain order form and patient’s identification card (ie: hospital patient identifier card) 
 
2. Administering RN or NP and vaccine preparation personnel confirm the following 
against the order form: 
a. Patient name 
b. Date of birth/hospital ID card number 
c. Vaccine lot numbers 
d. Thaw time 
e. Quantity of each syringe 
f. 
Expiration time 
 
3. Keep all vaccine syringes on ice until ready to administer. 
 
 
 


66 
 
Purpose:  
To describe the standard procedure for self or study  
personnel application of the lidocaine-based numbing cream. 
 
Scope:      Subjects self applying lidocaine-based numbing cream and study  personnel 
applying cream. 
 
Supplies:    lidocaine-based numbing cream and (6) occlusive dressings 
Procedure: 
1. Obtain numbing cream and (6) occlusive dressings. 
2. Wash hands before applying the lidocaine-based cream. 
3. The lidocaine-based cream should be placed on the non-dominant upper arm and both 
upper thighs in 2 areas. 
4. Clean off arm and thighs sites with soapy water and dry thoroughly. 
5. Open the occlusive transparent dressings (6) and place beside you. 
6. Put a quarter size dollop of the lidocaine-based cream on your non-dominant upper arm 
(below the shoulder in the front of the arm) and cover with the occlusive dressing. 
7. Put another quarter size dollop of the lidocaine-based cream on the same arm about 4 
inches below the other area and just to the side and cover with the occlusive dressing. 
8. Now do the same for both of the thigh sites.  Place a quarter size dollop of the 
lidocaine-based cream on the upper thigh (about 4-5 inches below the underwear line) 
and cover with the occlusive dressing. 
9. Place another dollop of the lidocaine-based cream on your inner thigh site about 5 
inches below the other dressing. 
10. Repeat both #8 and #9 on the other thigh. 
11. There should be a total of 6 sites with the lidocaine-based cream covered with the 
dressings. 
12. Once finished, wash hands with warm soapy water to remove any excess cream. 
13. You may dress, but do not cross legs or place anything on lap since this may have the 
cream leak out from under the dressing. 
 
 
PLEASE AVOID ANY EYE CONTACT WITH THE CREAM.  THIS CREAM IS A LIDOCAINE-BASED 
NUMBING CREAM AND COULD CAUSE EYE IRRITATION.  IF EYE CONTACT IS MADE, WASH EYE 
WITH WARM WATER FOR 10 MINUTES TO FLUSH THE CREAM FROM THE INNER EYE. 


67 
 
Appendix II: Patient Documentation for Vaccination 
 
Pt name:  ______________________________  Date:  ____________ 
 
Vaccine #:  ___                                                                Thaw time:  _________ 
  
Topical anesthetic applied at:  _________ Pt is R or L handed 
 
Right/Left upper arm:   Amount:                              Time:    
(use nondominant arm unless otherwise indicated) 
 
 Proximal site            __________                          ________ 
 
 Distal site              __________          _________ 
 
Right/Left upper thigh:  Amount:             Time:  
 
 Proximal site            __________                          ________ 
 
 Distal site              __________          _________ 
 
Right/Left upper thigh:  Amount:             Time: 
 
 Proximal site            __________                         ________ 
 
 Distal site              __________          _________ 
 
 
Assess previous vaccination reactions: 
 
 Redness:                start:                                           resolved: 
 Tenderness:       start:                                          resolved: 
 Induration:       start:                                         resolved: 
 Pruritis:                start:                                           resolved: 
Other symptoms:  start:          resolved: 
 
Vital signs: 
 
 
 
Medication Changes: 


68 
 
Appendix III: Oxaliplatin Prescribing Information 
 


69 
 
Appendix IV: 5-Fluorouracil Prescribing Information 
 


70 
 
Appendix V: Leucovorin Prescribing Information 
 


71 
 
Appendix VI: Irinotecan Prescribing Information 


72 
 
Appendix VII: Serious Adverse Event Reporting Form 
 
Serious Adverse Event Reporting Form  
 
 
 Please notify Dr. Jaffe and Dr. Laheru within 24 hour  
 
Protocol Title: 
 
 
A Phase II Study Evaluating Allogeneic Pancreatic Tumor Immunotherapy, 
Fractionated Stereotactic Body Radiation Therapy (SBRT) and FOLFIRINOX 
chemotherapy in Patients with Resected Adenocarcinoma of the Pancreas 
 
Protocol 
Number: 
 
Principal Investigator: 
 
 
 
Signature of PI: 
 
 
 
Date: 
 
 
 
Report Date: 
 
Hospital Admission Date: 
Date of Discovery of 
Event: 
Report Type: 
  Initial    
  Follow-up 
  Final Follow-up 
  Death 
  Addendum to: 
 
Section A: Subject Information 
Subject ID: 
Subject Initial: 
 
Subject Gender: 
  Male 
  Female 
 
Section B: Event Information 
Event diagnosis or 
symptoms: 
 
Date of First Dose 
(vaccine): 
 
Action taken with the 
study drug 
(Cyclophosphamide): 
 
 None 
 Interrupted 
 Discontinued 
 
Action taken with 
the study drug 
(vaccine): 
 
  None 
  Interrupted 
  Discontinued 
Date of Last Dose 
(vaccine) prior to 
Event: 
 
Number of Total Doses 
(vaccine): 
 
Event Onset Date: 
 
Event End Date: 
Relationship to: 
Cyclophospham
ide 
Vaccine  
Chemothera
py 
SBRT 
Underlying 
Disease 
Unrelated 
 
 
 
 
 
Probably Unrelated 
 
 
 
 
 
Possible Related 
 
 
 
 
 
Probably Related 
 
 
 
 
 
Definitely Related 
 
 
 
 
 


73 
 
Section C: Brief Description of the Event: 
 
 
 
 
 
 
 
Section D: Relevant Medical History 
 
 
 
 
Section E: Concomitant Drug (Not related to SAE) 
Name of the Drug 
Start Date 
Stop Date 
Route 
Dose 
Frequency 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Section F: Comments 
 
Additional Documents: 
 Please specify