Clinical trial NCT03403634
Conditions: Metastatic Carcinoma in the Liver Recurrent Colorectal Carcinoma Stage IV Colorectal Cancer AJCC v7 Stage IVA Colorectal Cancer AJCC v7 Stage IVB Colorectal Cancer AJCC v7
Sponsor: Roswell Park Cancer Institute
Start date: 2018-04-19; Completion date: 2021-08-29
Enrollment: 19 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This early phase IIA trial studies how well celecoxib, recombinant interferon alfa-2b, and rintatolimod work in treating patients with colorectal cancer that as spread to the liver. Celecoxib may stop the growth of tumor cells by blocking some of the enzymes needed for cell growth. Recombinant interferon alfa-2b is a substance that can improve the body's natural response and may interfere with the growth of tumor cells. Rintatolimod may stimulate the immune system. Giving celecoxib, recombinant interferon alfa-2b, and rintatolimod may work better at treating colorectal cancer that has spread to the liver.

Detailed description:
PRIMARY OBJECTIVES:

I. To determine the impact of a chemokine-modulatory regimen on the immune microenvironment of colorectal liver metastases, specifically the changes in the ratio between cytotoxic T-lymphocyte (CTL) marker (CD8a gene expression) to regulatory T cell (Treg) markers (FoxP3 gene expression).

SECONDARY OBJECTIVES:

I. Estimate the objective response rate of a chemokine-modulatory regimen in metastatic colorectal cancer (per Response Evaluation Criteria in Solid Tumors \[RECIST\] 1.1).

II. Examine the safety and tolerability profile of the combination of recombinant interferon alfa-2b (interferon alpha-2b), rintatolimod, and celecoxib when given as chemokine modulation to colorectal cancer patients prior to surgical resection using the Cancer Therapy Evaluation Program (CTEP) National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE version 4.0).

TERTIARY OBJECTIVES:

* Estimate the median progression free survival of a chemokine-modulatory regimen in metastatic colorectal cancer
* Estimate overall survival in participants with recurrent and/or metastatic unresectable colorectal cancer who received the chemokine-modulatory regimen
* Comparison (using RT-PCR, immunofluorescence \[IF\] and immunohistochemistry \[IHC\] on serial sections) of the metastatic tissue specimen with regard to total numbers of infiltrating T cells, their CD4/CD8 ratios, frequencies of FoxP3 cells, and the expression of chemokine receptors on CD4+ and CD8+ T cells (CXCR3, CCR5, CCR4, CCR6, and CXCR4)
* Evaluate the local expression of effector T cells (Teff)-attracting chemokines (CCR5, CXCL9, CXCL10 and CXCL11) and Treg-favoring chemokines (CCL22 and CXCL12) using IF and RT-PCR.

OUTLINE:

Patients receive celecoxib orally (PO) twice daily (BID), recombinant interferon alfa-2b intravenously (IV) over 20 minutes, and rintatolimod IV QD on days 1, 2,3,8,9,10,15,16 and 17 in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every 3 months for up to 12 months.

Arms: arm 1: Patients receive celecoxib orally PO BID, recombinant interferon alfa-2b IV QD over 20 minutes, and rintatolimod IV QD on days 1, 2, 3, 8, 9, 10, 15, 16 and 17 in the absence of disease progression or unacceptable toxicity.
Interventions: intervention 1: Celecoxib intervention 2: Laboratory Biomarker Analysis intervention 3: Recombinant Interferon Alfa-2b intervention 4: Rintatolimod
Intervention descriptions: intervention 1: Given PO intervention 2: Correlative studies intervention 3: Given IV intervention 4: Given IV

Protocol documents:
Prot_SAP_000.pdf: 
PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 1 of 63
PROTOCOL TITLE:
Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients with 
Colorectal Cancer Metastatic to the Liver
PROTOCOL NUMBER:
I 52917          NCT#03403634
PRINCIPAL INVESTIGATOR:
Sarbajit Mukherjee, MD
Roswell Park Cancer Institute
Elm and Carlton Street
Buffalo, New York 14263
716-845-4005
Sarbajit.Mukherjee@RoswellPark.org
VERSION NUMBER: 1 DATE: 7/19/17
Amendment #1: 11/20/17
Amendment #2: 12/07/17
Amendment #3: 02/14/18
Amendment #4: 04/13/18
Amendment #5: 12/10/18
Amendment #6: 04/02/19
Amendment #7: Administrative (PI Change): 091919 
Amendment #8: 01/14/2020
Amendment #9: 03/16/2020
Amendment #10: 07/09/2020
Amendment #11: 10/29/2020
Confidentiality Statement
Any and all information presented in this document shall be treated as confidential and 
shall remain the exclusive property of the party(ies) mentioned above. The use of such 
confidential information must be restricted to the recipient for the agreed purpose and 
must not be disclosed, published, or otherwise communicated to any unauthorized 
persons, for any reason, in any form whatsoever without the prior written consent of the 
party(ies) above.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 2 of 63
ABBREVIATIONS
µg
microgram
µL
microliter
5-FU
5-fluorouracil 
ACE
angiotensin-converting-enzyme 
AE
adverse events
α
alpha
αDC
alpha Dendritic Cell
ALT
Alanine transaminase 
ANA
antinuclear antibodies 
ANC
absolute neutrophil count
AST
Aspartate transaminase 
β
beta
BUN
blood urea nitrogen 
CBER
Center for Biologics Evaluation and Research
cc
cubic centimeter
CD3
cluster of differentiation 3
CDER
Center for Drug Evaluation and Research
CEA
carcinoembryonic antigen 
°C
degrees Celsius
CKM
chemokine modulatory
Cl
chloride
cm
centimeter
CO2
carbon dioxide
COX2
Cyclooxygenase-2
CRC
colorectal cancer
CRCLM
CRC liver metastasis
CRCM
metastatic colorectal cancer
CRS
Clinical Risk Score
CT
computed tomography 
CTCAE
Common Terminology Criteria for Adverse Events 
dL
deciliter
DLT
Dose Limiting Toxicity
DSMC
Data Safety Monitoring Committee
(ds)RNA
Double-stranded RNA
ECOG
Eastern Cooperative Oncology Group
EKG
Electrocardiography
°F
degrees Fahrenheit
FDA
F
g
gram

gamma
GI
gastrointestinal
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 3 of 63
GMP
good Manufacturing Practices
HCG
Human Chorionic Gonadotropin
HDI
High Dose Interferon
HPRT
hypoxanthine phosphoribosyl transferase
ICH
immunohistochemistry
IFN
interferon
IL-2
interleukin-2
im
intramuscular
IND
Investigational New Drug
IRB
Institutional Review Board
ISH
in situ hybridization
IU
International Units
IV
intravenous
kg
kilogram
LPS
lipopolysaccharide
m2
meters squared
mg
milligram
min
minute
mL
milliliter
MRI
Magnetic Resonance 
mRNA
Messenger RNA 
NCI
National Cancer Institute
ng
nanogram
NSAID
non-steroidal anti-inflammatory drug
PET
Positron emission tomography 
PGE2
prostaglandin E2
po
RPCI
by oral route of administration
Roswell Park Cancer Institute
RP2D
recommended Phase 2 dose
SAE
severe adverse events
SGOT
Serum Glutamic Oxaloacetic Transaminase 
SGPT
Serum Glutamic Pyruvate Transaminase
SOC
standard of care
ssRNA
single-stranded RNA 
Teff
effector T cells
TLR
toll-like receptor
Treg
regulatory T cells
U
unit
ULN
upper limit of normal
UPCI
University of Pittsburgh Cancer Institute
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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Table of Contents
1
Objectives ................................................................................................................................5
2
Background..............................................................................................................................5
3
Inclusion and Exclusion Criteria ...........................................................................................10
4
Local and Study-Wide Number of Subjects ..........................................................................12
5
Local and Study-Wide Recruitment Methods .......................................................................12
6
Multi-Site Research ...............................................................................................................12
7
Study Timelines.....................................................................................................................12
8
Study Endpoints.....................................................................................................................12
9
Design....................................................................................................................................13
10
Treatment...............................................................................................................................14
11
Procedures Involved ..............................................................................................................20
12
Withdrawal of Subjects..........................................................................................................23
13
Risks to Subjects....................................................................................................................24
14
Potential Benefits to Subjects ................................................................................................26
15
Data and Specimen Banking..................................................................................................26
16
Measurement of Effect ..........................................................................................................26
17
Safety Evaluation...................................................................................................................27
18
Data Management and Confidentiality..................................................................................31
19
Statistical Plan .......................................................................................................................32
20
Provisions to Monitor the Data to Ensure the Safety of Subjects..........................................36
21
Vulnerable Populations..........................................................................................................36
22
Community-Based Participatory Research............................................................................36
23
Sharing of Results with Subjects ...........................................................................................36
24
Setting....................................................................................................................................36
25
Provisions to Protect the Privacy Interests of Subjects .........................................................36
26
Resources Available ..............................................................................................................36
27
Prior Approvals......................................................................................................................36
28
Compensation for Research-Related Injury...........................................................................36
29
Economic Burden to Subjects................................................................................................36
30
Consent Process.....................................................................................................................37
31
Process to Document Consent in Writing..............................................................................37
32
Drugs or Devices ...................................................................................................................37
33
REFERENCES ......................................................................................................................42
34
APPENDICES/ SUPPLEMENTS.........................................................................................46
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 5 of 63
1
OBJECTIVES
1.1
Study Objectives
1.1.1
Primary Objectives

To determine the impact of a chemokine-modulatory regimen on the immune 
microenvironment of colorectal liver metastases, specifically the changes in the ratio 
between CTL marker (CD8a gene expression) to Treg markers (FoxP3 gene expression)
1.1.2
Secondary Objectives

Estimate the objective response rate of a chemokine-modulatory regimen in metastatic 
colorectal cancer (per RECIST 1.1)

Examine the safety and tolerability profile of the combination of Interferon Alpha-2b, 
rintatolimod, and celecoxib when given as chemokine modulation to colorectal cancer 
patients prior to surgical resection using the CTEP NCI Common Terminology Criteria for 
Adverse Events (CTCAE Version 4.0).
1.1.3
Exploratory Objectives

Estimate the median progression free survival of a chemokine-modulatory regimen in 
metastatic colorectal cancer.

Estimate overall survival in participants with recurrent and/or metastatic unresectable 
colorectal cancer who received the chemokine-modulatory regimen

To conduct correlative science studies including:
o
Comparison (using RT-PCR, Immunofluorescence [IF] and immunohistochemistry 
[IHC] on serial sections) of the metastatic tissue specimen with regard to total 
numbers of infiltrating T cells, their CD4/CD8 ratios, frequencies of FoxP3 cells, 
and the expression of chemokine receptors on CD4+ and CD8+ T cells (CXCR3, 
CCR5, CCR4, CCR6, and CXCR4).
o
Evaluate the local expression of Teff-attracting chemokines (CCR5, CXCL9, 
CXCL10 and CXCL11) and Treg-favoring chemokines (CCL22 and CXCL12) 
using IF and RT-PCR.
2
BACKGROUND
2.1
Metastatic Colorectal Cancer
Cancer of the colon and rectum (colorectal cancer, CRC) is the third leading site of cancer 
diagnosed annually in the United States and the most common form of gastrointestinal malignancy. 
It accounts for approximately 150,000 new cases annually. Hepatic metastases as the sole or 
dominant site of life-limiting disease occur in approximately 20-50% of all patients. Median 
survival for patients with untreated hepatic metastases ranges from 4-12 months [1]. Complete 
surgical resection of isolated hepatic metastases has been demonstrated in numerous series to result 
in 5-year overall survival up to 58% in some series [2]. However, most patients are not candidates 
for resection and systemic therapy remains the mainstay of treatment. Systemic chemotherapy with 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 6 of 63
5-FU based regimens is associated with modest improvements in survival as compared with 
supportive care alone (8-14 months) [3]. The addition of oxaliplatin or irinotecan can increase 
survival up to 24 months. The addition of further biologic agents, including bevacizumab and 
cetuximab, further improves median survival to approximately 30 months [4]. However, gains in 
outcomes have petered off with the most recently approved agents. In the last 5 years, while three 
new drugs have been approved, 2 of 3 confer a median survival benefit of less than two months 
[5, 6]. Novel therapies and approaches are needed to alter the treatment paradigm in this disease. 
On the basis on compelling activity in MSI-H (micro-satellite instability-high)/MMR (mismatch 
repair) deficient cancer, PD-1 targeting therapy has recently been approved in MSI-H tumors and 
offers new hope for these patients [7]. However, MSI-H tumors represent just 3% of all stage IV 
colorectal cancers [8]. For the other 97%, great need remains. Therapies that might alter the tumor 
microenvironment and expand the therapeutic spectrum of immune checkpoint inhibitors would 
be practice changing.
2.2
Critical Role of the Chemokine-Driven T Cell Migration in Colorectal and Other 
Cancers
The numbers of effector T cells (Teff) in CRC tissues have been shown to be an independent 
prognostic marker in CRC, with their high numbers predicting a delayed time to tumor recurrence 
[9-12]. In contrast, regulatory T cells (Treg) in CRC patients are associated with poor tumor 
responses [13-16]. Chemokines and their respective receptors are critical for T cell migration and 
homing into tissues during homeostasis and inflammation [17-22]. Several studies have shown 
that chemokines are equally important for migration and homing in cancer tissues. For example, 
the chemokine receptors CXCR3 and CCR5 are critical for T cell entry into tumors, a process 
which is guided by intra-tumoral expression of their respective chemokines. High levels of the 
chemokine ligands for CCR5 (CCL5/RANTES) and CXCR3 (CXCL9/MIG, CXCL10/IP10, 
CXCL11/I-TAC) in tumor tissue have been associated with infiltration of CD8 T cells in CRC 
[23], malignant melanoma [24] and gastric cancer [25]. High CXCR3+ T cells in the peripheral 
circulation for example have been associated with increased survival of stage III melanoma 
patients [26]. In contrast, high levels of CCL22 (ligand for CCR4) expression by dendritic cells 
(DC) or macrophages in ovarian ascites leads to recruitment of regulatory T cells; a pattern 
associated with decreased patient survival [27]. 
As shown by the above studies, selective enrichment of T cells with specific chemokine receptors 
in patients with cancer may impact tumor response and patient survival. But most tumors do not 
have T cell infiltration or express the right chemokines for effector T cell (Teff) entry. Colon tumors 
frequently show elevated CCL22 levels induced by a Prostaglandin E2 (PGE2) rich tumor 
microenvironment [28, 29] permitting the influx of regulatory T cells (Treg) rather than Teff . This 
leads to a highly biased and unfavorable Treg/Teff ratio in tumors. 
This study attempts to correct the above mentioned chemokine bias in the colorectal tumor 
microenvironment and analyze whether such modulation can help Teff, entry while simultaneously 
preventing Tregs influx into tumors.
2.3
Past experience with IFNα, Rintatolimod and Celecoxib
Interferon–alpha (Intron® A) is currently FDA approved for the adjuvant treatment of stage III 
melanoma. It has been examined by multiple investigators as an immune modulator in the setting 
of vaccine therapy with demonstrated safety [30]. It has been extensively evaluated in the setting 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 7 of 63
of metastatic CRC (as single agent or in combination with chemotherapy or IL-2), but was shown 
to be largely ineffective [31-48] at daily doses ranging from 3-20 million units/m2, administered 
subcutaneously or intravenously. In the treatment of melanoma, a small study by Astsaturov and 
colleagues [49] administered IFNb in previously vaccinated melanoma patients, and was 
shown to convert immunization into objective clinical responses, suggesting its ability to amplify 
the effectiveness of local T cells infiltration and/or function at the tumor site. Vaishampayan et al 
examined IFNα-2b 5 million units subcutaneously three times a week following vaccination with 
a melanoma vaccine (Melacine) [50]. Treatment at this dose was well tolerated. Similarly Mitchell 
at al recently completed a large trial examining IFNα-2b, 5 million units subcutaneously three 
times a week for one year [51]. Di Pucchi and Pilla similarly examined the combination of a 
melanoma peptide vaccine with IFNα-2b, 3 million units subcutaneously three times a week, with 
little to no toxicity. 
We propose to include a short course of high dose Interferon Alpha-2b (20 million units/m2, IV, 
daily for 3 days), a dose similar or lower than the previously evaluated dose in melanoma patients 
[52-54]. In this group of patients, in accordance with previous reports, we expect to consistently 
observe flu-like symptoms but no regimen limiting toxicities, particularly taking into account the 
short duration of this administration.
Celecoxib has been extensively studied in long term clinical trials in patients predisposed to the 
development of colorectal cancer [55, 56]. However, there is to our knowledge, no clinical data 
examining its use as a short term immune modulator in the setting of neoadjuvant therapy. Several 
studies in murine models have suggested improved efficacy of anti-tumor vaccination with Cox-2 
inhibition [57-59]. Recent literature suggests increased risk of adverse cardiovascular events 
associated with the administration of some selective Cox-2 inhibitors [60-62].The literature 
regarding the precise risk with celecoxib remains controversial, with reported cardiovascular side 
effects observed mainly in long-term users. It has been suggested that lower doses and shorter 
lengths of administration may decrease the risk of adverse cardiovascular events. This trial will 
involve a short course of celecoxib, consisting of 200 mg twice a day for 3 days during 
administration of the chemokine modulation.
Rintatolimod (Selective toll-like receptor-3 [TLR3] Ligand; analog of poly IC with reduced 
toxicity for i. v. use). 
Rintatolimod is a TLR3 specific Poly IC analog in which the cytidylic acid chain has uridylic acid 
substitutions at a molar ratio of 12:1. Chemokine modulation in temporal association with type I 
interferon administration is observed with this agent.
Rintatolimod has been studied extensively in multiple clinical settings including cancer, chronic 
viral infection, vaccination protocols, and in chronic treatment of chronic fatigue syndrome.
Rintatolimod (Ampligen®) has been generally well tolerated with only a low incidence of clinical 
toxicity. Clinical experience with Rintatolimod now totals over 800 patients with more than 200 
patients receiving Rintatolimod for up to one (1) year, over 50 patients up to two (2) years, and 
more than 20 patients over two (2) years.
The proposed dosage of 200 mg IV is the starting dose used in chronic treatment of Chronic 
Fatigue Syndrome (CFS). That dose is escalated to 400 mg IV twice weekly for the CFS indication; 
however for use as a chemokine modulator, pharmacologic peak serum levels are achieved at 200 
mg; thus, 200 mg daily for 3 days will be incorporated for the immune modulation regimen.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 8 of 63
Preclinical evidence demonstrates the synergy between IFNα and Rintatolimod in inducing the 
production of the effector T cell-attracting chemokines.
2.4
Clinial experience with Rintatolimod (Ampligen®) in combination with Interferon 
Alpha-2b and Celecoxib.
NCT01545141 (UPCI 10-131) was a phase I study which evaluated the combination of 
rintatolimod, interferon-Alpha 2b, and Celecoxib administered for one course over 5 days, prior 
to tumor resection. The phase I study was completed, with escalation to the maximal planned dose, 
without the emergence of undue toxicity. A 5 day regimen consisting of rintatolimod 200 mg IV 
daily, Interferon Alpha-2b (20 million units/ m2) IV daily and celecoxib 200 mg po bid was deemed 
tolerable and suitable for further investigation. 
In addition to the demonstrated safety, preliminary evidence of biologic efficacy was observed. 
Individuals who were treated with CKM prior to resection, demonstrated an improvement in 
intratumoral CD8/FOXP3 ratios as well as CXCL10/CCL22 ratios when compared to 
nonrandomized controls, treated with standard care at the University of Pittsburgh. The design 
(neo-adjuvant treatment) and numbers of patients treated do not permit any meaningful estimate 
of clinical outcomes or radiographic response at this time. 
In addition to the evaluation of rintatolimod, interferon Alpha-2b and Celecoxib administered i. v. 
for one course over 5 days, as a stand-alone treatment,  the same combinations (but different 
administration regimens) are being evaluated  as a part of combinatorial regimens in additional 
patients with peritoneal carcinomatosis (NCT02151448 / UPCI 12-110) and recurrent ovarian 
cancer (NCT02432378 / UPCI 11-128). Clinical trial NCT02151448 (over 50 patients evaluated 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 9 of 63
so far) involve multiple cycles of DC vaccines followed by 4 day long cycles of IFN-a/celecoxib 
regimen, with rintatolimod administered on days 2 and 4 of each cycle). Clinical trial 
NCT02432378 (5 patients evaluated so far) involve multiple cycles of intraperitoneal (i.p.) 
chemotherapy followed (with 1 day delay) with single i.p. doses of rintatolimod (with increasing 
i.p. doses of IFN and a standard dose of celecoxib (orally).
No DLTs have been observed in either of these trials.
2.5
Rationale and significance
As detailed above, a previously-demonstrated correlation between the density of CRC-infiltrating 
effector T cells and long-term outcomes [11, 12] has been established. In our preclinical ex vivo 
studies performed using explants of resected metastatic CRC, the combination of IFNα with 
nonselective or COX2-selective inhibitors of prostaglandin synthesis resulted in elevated 
production of the effector T cell-attracting chemokines CXCL10 and CCL5. This was associated 
with concomitant suppression of the intratumoral expression of CCL22, a Treg-attracting 
chemokine [63, 64]. However, in a subset of patients, the optimal results, particularly with regard 
to CCL5 induction, required additional stimulation by a third agent, a TLR3 Ligand. 
NCT01545141 demonstrated the safety of the CKM regimen administered over 5 days, without 
the emergence of new adverse effects or with compromise of surgical outcomes. However, the 
brief course, limited patient numbers, and lack of pre-treatment biopsies did not allow for an 
objective estimate of clinical efficacy nor did it allow for a robust evaluation of the impact of this 
CKM regimen on the tumor microenvironment. If solid evidence of a beneficial biologic effect on 
colorectal were demonstrated, this would strongly support further investigation, as a self-standing 
treatment in adjuvant settings or in combination with checkpoint blockade, vaccination or adoptive 
T cell transfer, which all depend on the presence of T cells in tumor microenvironments (or the 
ability of T cells to enter tumors).
We seek to establish the immunologic impact of an abridged 3 day course of a chemokine regimen, 
consisting of Interferon Alpha-2b, celecoxib, and rintatolimod, administered in repeated sessions 
over 3 weeks. A 3 day regimen will be used preferentially over the 5 day regimen due to concerns 
of chronic toxicity with multiple cycles and also for ease of implementation and participant 
scheduling. We further seek to evaluate clinical activity and to confirm the observed safety profile 
with repeated dosing. We hypothesize that the proposed chemokine modulation treatment in 
recurrent/metastatic CRC patients may increase the density of tumor infiltrating lymphocytes 
(TILS) and provide anti-cancer benefit.
Treatment with serial liver biopsies will allow us the comparative analysis of the effect of 
chemokine modulation on the local recruitment of effector-type T cells and the de-recruitment of 
Treg within affected tumor tissues; helping us to determine the “preferred” chemokine-modulating 
regimen for subsequent extended studies. Such prospective studies will focus on using 
combinations of chemokine modulation and cancer vaccines or immune checkpoint inhibitors in 
patients with CRC. We have, for example, recently observed that αDC1, a new type of DC vaccine 
[65, 66] is particularly effective in inducing the effector pathway of T cells differentiation. This 
was manifested by the induction of tumor-killing function and the induction of effector-type 
chemokine receptors (CXCR3 and CCR5) [65, 67]. Combining the αDC1vaccine to a safe, 
tolerable and efficacious CKM regimen may hold promise for patients with poor prognostic CRC. 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 10 of 63
Pre-clinical data similarly demonstrates significant benefit with the addition of anti-PD-1 therapy 
to a CKM regimen, making this another natural combination.
3
INCLUSION AND EXCLUSION CRITERIA
3.1
Inclusion Criteria:
To be included in this study, participants must meet the following criteria:
1. Recurrent and/or metastatic unresectable colorectal cancer with hepatic metastases. 
2. Hepatic metastases present which are amenable to biopsy.
3. Prior treatment with, contra-indication to or refusal of a fluoropyrimidine, irinotecan, 
oxaliplatin and an anti-EGFR targeted therapy (if RAS wt), as well as a PD-1 or PD-L1 
targeted drug if MSI-H/dMMR.
4. No chemotherapy, radiotherapy, major surgery, or biologic therapy within 3 weeks of 
protocol treatment.
5. An ECOG performance status of 0, 1, or 2. Refer to Appendix C.
6. Have measurable disease per RECIST 1.1 criteria present.
7. Ability to swallow and retain oral medications.
8. Participants of child-bearing potential must agree to use adequate contraceptive methods 
(e.g., hormonal or barrier method of birth control; abstinence) prior to study entry. Should a 
woman become pregnant or suspect she is pregnant while she or her partner is participating 
in this study, she should inform her treating physician immediately.
9. Age equal to 18 years or older.
10. Must have normal organ and marrow function as defined below:
o
Platelet ≥ 75,000/µL
o
Hemoglobin ≥ 9 g/dL
o
Hematocrit ≥ 27%
o
Absolute Neutrophil Count (ANC) ≥ 1500/µL
o
Creatinine < institutional upper limit of normal (ULN)
OR
o
Creatinine clearance ≥ 50 mL/min for patients with creatinine levels greater than 
ULN (refer to Appendix I for Cockcroft-Gault Equation)
o
Total bilirubin ≤ 1.5 X institutional ULN or for patients with known Gilbert’s 
Syndrome total bilirubin ≤ 3 x ULN
o
AST (SGOT) and ALT(SGPT) ≤ 2.5 X institutional ULN
o
Plasma amylase and lipase ≤1.5 X institutional ULN.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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11. Participant or legal representative must understand the investigational nature of this study 
and sign an Independent Ethics Committee/Institutional Review Board approved written 
informed consent form prior to receiving any study related procedure.
Please refer to Appendix D for the Investigator Study Eligibility Verification Form: Inclusion 
Criteria.
3.2
Exclusion criteria
Participants will be excluded from the study for the following:
1. Patients currently treated with systemic immunosuppressive agents, including steroids, are 
ineligible until 3 weeks after removal from immunosuppressive treatment.
2. Patients with active autoimmune disease requiring ongoing immunosuppressive therapy or, 
history of transplantation.
3. Patients who are pregnant or nursing. Women of childbearing potential (WOCBP) will have 
to undergo a urine pregnancy test as part of screening.
4. Untreated CNS metastases.
5. Cardiac risk factors including: 
o
Patients experiencing cardiac event(s) (acute coronary syndrome, myocardial 
infarction, or ischemia) within 3 months of signing consent
o
Patients with a New York Heart Association classification of III or IV (Appendix A)
6. History of upper gastrointestinal ulceration, upper gastrointestinal bleeding, or upper 
gastrointestinal perforation within the past 3 years. Patients with ulceration, bleeding or 
perforation in the lower bowel are not excluded.
7. Prior allergic reaction or hypersensitivity to celecoxib, NSAIDs, or any study agents which 
would prevent completion of protocol-therapy.
8. Patients are ineligible if they plan on regular use of NSAIDs at any dose more than 2 times 
per week (on average) or aspirin at more than 325 mg at least three times per week, on 
average. Low-dose aspirin not exceeding 100 mg/day is permitted. Patients who agree to stop 
regular NSAIDs or higher dose aspirin are eligible and no wash out period is required.
9. Received an investigational agent within 30 days prior to enrollment.
10. Unwilling or unable to follow protocol requirements.
11. Patients with known serious mood disorders.
12. Any additional condition which in the Investigator’s opinion deems the participant an 
unsuitable candidate to receive the study drugs
Please refer to Appendix E for the Investigator Study Eligibility Verification Form: Exclusion 
Criteria.
3.3
Inclusion of Women and Minorities
Both men and women and members of all races and ethnic groups are eligible for this study.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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4
LOCAL AND STUDY-WIDE NUMBER OF SUBJECTS
Estimated number of RPCI subjects: The number of subjects required for this study is 
approximately 15 (12 evaluable for the primary endpoint), but will depend upon the number of 
additional accruals required to replace subjects who fail to meet the criteria for efficacy evaluation. 
Accordingly, the subject accruals cannot be known ahead of time but can only be estimated. All 
participants will be enrolled from RPCI. There will be no network site participation.
4.1
Target Accrual
Approximately 15 patients (12 evaluable for the primary endpoint) will be needed to estimate the 
biologic impact of this regimen and establish a preliminary estimate of efficacy. Total accrual time 
is expected to take approximately 48 months.
5
LOCAL AND STUDY-WIDE RECRUITMENT METHODS
5.1
Recruitment
Potential participants will be identified and recruited during scheduled visits to the RPCI 
Gastrointestinal (GI) Center. Non-investigator RPCI physicians and community physicians may 
also refer potential subjects to the investigator for evaluation. There will be no “cold calling”. 
Informed consent will be obtained on all subjects by the investigator/co-investigator prior to all 
study specific procedure (including screening procedures). No subject will be entered into this 
clinical trial without having a signed written consent form.
6
MULTI-SITE RESEARCH
N/A
7
STUDY TIMELINES
15 participants from RPCI will be enrolled to the study over approximately 48 months. Patients 
will be followed for PFS and survival for at least an additional 12 months.
8
STUDY ENDPOINTS
8.1
Primary Endpoint

Immunologic efficacy will be assessed by the increase in the total number of tumor-
infiltrating CD8+ T cells in the CRC lesions (measured as the ratio between the CD8 
mRNA message and the expression of the housekeeping gene HPRT which will be 
provided by the study statistician in a SAS compatible excel formatted electronic file), and 
comparing the total number of tumor-infiltrating CD8+ T cells in pre-treatment vs post-
treatment biopsies.
8.2
Secondary Endpoints

Objective response rate by RECIST v1.1

Overall safety profile characterized by type, frequency, severity (according to CTCAE 
Version 4.0), timing, seriousness and relationship to study treatment
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 13 of 63
8.3
 Exploratory Endpoints

Median progression free survival by RECIST v1.1

Median overall survival
9
DESIGN
9.1
Study Design
The intratumoral efficacy of the combination of Interferon Alpha-2b, rintatolimod, and celecoxib 
will be evaluated by administering fixed doses of each drug. Subjects will receive 3 weeks of the 
Chemokine Modulation (CKM) regimen, administered on days 1, 2, 3, 8, 9, 10, 15, 16, and 17 of 
protocol treatment, according to the safe established dosing levels (see Table 1). During this time, 
subjects will be monitored continuously for safety, based on Bayesian analysis.
Table 1
Dosing
Components of the chemokine modulation regimen
Interferon Alpha-2b (20 
million units/M2) IV over 20 
minutes once a day for 3 
consecutive days, repeated 
weekly over 3 weeks (days 
1,2,3,8,9,10,15,16,17). 
Rintatolimod (200 mg)
IV once a day for 3 
consecutive days, repeated 
weekly over 3 weeks (days 
1,2,3,8,9,10,15,16,17). 
Initial administration should 
begin at a slow rate of 
infusion (approximately 20 
cc/ hour). Increase rate to 
40cc/hour after 30 minutes.
Celecoxib (200 mg, orally, 
twice a day) for 3 consecutive 
days, repeated weekly over 3 
weeks (days 
1,2,3,8,9,10,15,16,17).  Doses 
should be given 
approximately 12 hours apart.
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Date 102920
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9.2
Treatment Phase
A total of three weeks  of therapy will be planned. Serial liver biopsies will be obtained, with the 
first performed prior to initiating therapy and the second performed on Day 20 (± 2 days).  
Following completion of the 3 consecutive weeks of treatment, the study treatment period will 
conclude. In order to secondarily assess clinical benefit, repeat CT imaging will be assessed at day 
46 (± 3 days). If a patient completes therapy and a decision is made to pursue a further alternate 
treatment, the subject will come off study; however, in this circumstance, assessment of the next 
clinical staging study will be requested for determination of RECIST parameters.
Enrollment
Week 1
Week 2
 Week 3
Biopsy
Biopsy Day 24 ± 4 days
EOT
F/U
CT scan
Schema
9.3
Follow-up Phase
Patients will be seen for an end of treatment visit to review adverse events, clinical outcome of 
therapy. If stable disease/response is demonstrated during repeat CT imaging, patients will 
continue in follow-up with CT imaging every 8 weeks until progression, clinical deterioration or 
withdrawal from the study. If in the clinical judgement of the treating team, it is in the best interest 
of the patient to pursue another therapeutic option, the patient will come off study and CT imaging 
will be obtained only as per SOC/protocol. 12 months of survival follow-up will be pursued by 
chart audit or if necessary phone contact. If the patient comes off study during the follow-up period 
to start a new treatment, the new treatment information will be captured in the database.
10 TREATMENT
10.1
Dosing and Administration
10.1.1 Chemokine modulating regimen
For dosing, refer to Table 1. The chemokine modulating regimen will be administered on an 
outpatient basis at Roswell Park Cancer Institute over 3 consecutive days, every week x 3 weeks 
(Days 1, 2, 3, 8, 9, 10, 15, 16, 17) in the following order:

Pretreatment: 500 mL Normal saline IV over 60 minutes

Pre-meds: Acetaminophen (Tylenol) 650 mg by mouth x 1 dose; Prochlorperazine 
(Compazine) 10 mg by mouth x 1 dose – administered 30 minutes (±5 minutes) after 
starting pre-treatment hydration
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
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Date 102920
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
Celecoxib: 200 mg orally, administered along with pre-meds

Interferon Alpha-2b : (20 million units/M2) IV over 20 minutes 

Rintatolimod: 200 mg IV, initial administration should begin at a slow rate of infusion 
(approximately 20 cc/ hour) and increase to 40 cc/ hour after 30 minutes. Tubing should 
be flushed with 30 to 50 mL of normal saline solution upon completion. Administration 
will be followed by 1 hour of observation and vital signs at 30 and 60 minutes post infusion 
(± 5 minutes)

Celecoxib: 200 mg orally to be taken by the patient at home approximately 12 hours 
following the initial dose.
Pretreatment and pre-meds listed above are recommendations and may be modified based upon 
institutional SOC requirements and at the discretion of the investigator. Treatment is intended for 
an outpatient setting. However, at the investigator’s/physician’s discretion, the participant may 
receive treatment as an inpatient, if deemed necessary.
Each 3 day treatment will be initiated after interval history and physical examination is performed 
and once the relevant laboratory studies have been confirmed to be within clinically acceptable 
ranges, specifically: ANC ≥ 1000/mm3, total bilirubin ≤ 1.5 x ULN or ≤ 3 x ULN (for patients 
with Gilbert’s Syndrome), AST and ALT < 3 x ULN (or < 150% of values at baseline). Treatment 
may be delayed up to 3 weeks to allow for resolution of any intercurrent illness or for logistical 
reasons. Delays beyond 3 weeks will require discussion with the study PI to review appropriateness 
of continuing therapy on study. 
10.2
Dose Modification
The following dose modification rules will be used with respect to potential toxicity. Toxicity will 
be assessed according to the NCI Common Terminology Criteria for Adverse Events Version 5.0 
(CTCAE v5.0).  
Therapy will be immediately discontinued for any grade IV treatment-related toxicity that becomes 
apparent. The exception to this is for grade 4 neutropenia of < 7 days duration. Study treatment 
will be reinitiated for any grade treatment-related III toxicity pending the reversal of such toxicity 
after withholding treatment (i.e. the toxicity resolves to the subject’s baseline level). In the event 
of any adverse effect, appropriate medical treatment will be instituted and study treatment will be 
discontinued if the above toxicity remains.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 16 of 63
Table2. Treatment Related Toxicity Management
Treatment-
related AEs
Toxicity 
grade or 
conditions 
(CTCAE5.0)
Action taken for 
Interferon 
Alpha-2b
Action taken 
for 
Rintatolimod
Action taken for 
Celecoxib
Additional 
actions
Chills/Fever
Grade 3
None
None
None
Consider 
additional 
acetaminophen 
dosing, supportive 
care
Pancreatitis
Grade 3
Hold
Decreased future 
doses by 50%
   Hold
Hold
Supportive 
measures as 
clinically 
indicated
AST / ALT 
elevation or 
Increased 
bilirubin
Grade 3
Hold until 
improved to 
grade 1; 
Decrease future 
doses by 50%
Hold
Hold
Advise evaluation 
for other possible 
etiologies; 
consider imaging
Vomiting
Grade 3
Hold until 
resolved to grade 
1; Decrease 
future doses by 
50% 
Hold
Hold
Neuropathy
Grade 2 or 
greater
Hold until 
decreased to 
patient’s 
baseline; 
Decrease future 
doses by 50%
None
None
Depression or 
other clinically 
relevant mood 
disorder
Grade 3
Permanently 
discontinue; 
appropriate 
supportive 
care/intervention
None
None
Neutropenia
Grade 3 or 
greater
Hold until ANC 
> 1000; Decrease 
future doses by 
50%
Hold
Hold
Hemorrhage
Grade 2 or 
greater
None
None
Permanently 
discontinue
Myocardial 
infarction or 
other arterial 
thrombotic event
Grade 2 or 
greater
None
None
Permanently 
discontinue
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Date 102920
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Treatment-
related AEs
Toxicity 
grade or 
conditions 
(CTCAE5.0)
Action taken for 
Interferon 
Alpha-2b
Action taken 
for 
Rintatolimod
Action taken for 
Celecoxib
Additional 
actions
Intolerable 
Grade 2 or 
Grade 3
Hold therapy 
until resolved; 
reduce future 
doses by 50%
Hold therapy 
until resolved; 
reduce future 
doses by 50%
Hold therapy until 
resolved 
All other 
clinically 
significant AEs1
Grade 4
Permanently 
Discontinue
Permanently 
Discontinue
Permanently 
Discontinue
1.
Holding of any therapies here for intolerable grade 2 or grade 3 toxicities will be at the 
discretion of the investigator based upon the nature of the AE and whether one drug 
can be clearly implicated or not; in the case that one drug can be clearly implicated, 
only that drug should be dose reduced in the future; in the case that the causative agent 
is unclear, it is recommended that interferon and rintatolimod are reduced as directed
10.2.1 Celecoxib Non-Hematologic Toxicities
Considered to be possibly, probably, or definitely related to Celecoxib (Interferon Alpha-2b and 
rintatolimod will be continued). See Table 2. Celecoxib will be discontinued for any attributable 
grade ≥2 toxicity, except for nausea, vomiting, or a similar readily manageable condition.
10.2.2 Interferon Alpha-2b  and/or rintatolimod Non-hematologic toxicities
Considered to be possibly, probably, or definitely related to Interferon Alpha-2b and rintatolimod:

Interferon Alpha-2b :
For grade 3 toxicity:
o
1st episode: dose will be held and restarted at the next study visit at a dose 
reduction of 50%. The dose can be re-escalated if toxicity is reduced to ≤ 
grade 1 or baseline.
o
2nd episode: Treatment will be discontinued
For grade 4 toxicity (except neutropenia of < 7 days duration):
o
Treatment will be discontinued

Rintatolimod:
For grade 3 toxicity:
o
1st episode: dose will be held and restarted at the next study visit at a dose 
reduction of 33%.The dose can be re-escalated if toxicity is reduced to ≤ grade 
1 or baseline
o
2nd episode: dose will be held and (if toxicity is resolved to ≤ grade 1 or 
baseline) restarted at the next study visit at a dose reduction of 33%. The dose 
cannot be re-escalated
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For grade 4 toxicity:
o
Treatment will be discontinued
10.2.3 Toxicity Management
The toxicity of high dose interferon (20million units/m²/d) has been established by Kirkwood et al 
in a number of trials. Most notable was the E1684 trial [68] where HDI (20 million units/m²/d) 
was administered daily for 5 days x 4weeks. In that trial (n=143), grade 3 toxicities were 67%, 
grade 4 toxicities were 9% (mainly constitutional and neurologic), and there were 2 treatment 
related mortalities (grade 5) due to hepatoxicity. The proportion of Grade 3 and 4 toxicities in that 
trial were 48.2% for constitutional toxicities (defined as ‘worst grade of any constitutional toxicity, 
including fever, chills, flu-like symptoms, fatigue, malaise, and diaphoresis), and 66% for non-
constitutional toxicities (23.8% for myelosuppression, 13.9% for hepatotoxicity, 28% for 
neurological toxicity).
While the combination of HDI and rintatolimod may lead to synergistic additive side effects, we 
will monitor subject toxicities for unexpected increases in constitutional symptoms, 
myelosuppression, hepatotoxicity, and neurological toxicity. Moreover, the presence of celecoxib 
may improve the side effect profile. Rather than a separate phase of the study to characterize safety, 
we will use continual Bayesian monitoring of SAEs with a stopping rule that permits suspension 
of the trial by the investigator for review by the Data Safety and Monitoring Committee (DSMC).  
We will focus on monitoring for grade 3 or greater treatment related hematologic toxicities, and 
grade 4 or greater treatment related non-hematologic toxicities. A non-informative prior 
distribution of SAEs will be utilized to develop the safety stopping rules (details in Section 19.4).

Gastrointestinal Toxicity:
o
Nausea and/or vomiting should be controlled with adequate antiemetic therapy. 
Prophylactic antiemetic therapy can be used at the discretion of the 
investigator/sub-investigator. Subjects are encouraged to take plenty of oral fluids.
o
Diarrhea should be managed with appropriate antidiarrheal therapy. Subjects 
should be encouraged to take plenty of oral fluids. If symptoms do not decrease to 
grade 1 or less with adequate antidiarrheal therapy, all protocol drugs should be 
held until resolved to < grade 1.

Pain
o
For fever or mild local pain, acetaminophen will be utilized at the discretion of the 
investigator/sub-investigator or designee.

Hypersensitivity Reactions
Caution: Subjects who had a mild to moderate hypersensitivity reaction have been successfully 
re-challenged, but careful attention to prophylaxis and bedside monitoring of vital signs is 
recommended. Hypersensitivity reactions to Interferon Alpha-2b  and/or rintatolimod will be 
managed as follows:
o
Mild symptoms (e.g., mild flushing, rash, pruritus): Complete infusion. Supervise 
at bedside. No treatment required.
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Date 102920
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o
Moderate symptoms (e.g., moderate rash, flushing, mild dyspnea, chest 
discomfort): Stop infusion. Give intravenous diphenhydramine 25 mg and 
intravenous dexamethasone 10 mg. Resume infusion after recovery of symptoms 
at a low rate, then, if no further symptoms, at full dose rate until infusion is 
complete. If symptoms recur, stop infusion. The subject should receive no 
additional Interferon Alpha-2b or rintatolimod for that week’s three-day treatment, 
but may be retreated after discussion with the investigator. Record toxicity.
o
Severe life threatening symptoms (e.g., hypotension requiring pressor therapy, 
angioedema, respiratory distress requiring bronchodilation therapy, generalized 
urticaria): Stop infusion. Give intravenous diphenhydramine and dexamethasone as 
above. Add epinephrine or bronchodilators if indicated. If wheezing is present, that 
is not responsive to bronchodilators, epinephrine is recommended. Subject should 
be removed from further protocol therapy. Report as serious adverse event.
10.3
General Concomitant Medication and Supportive Care
Additional chemo-, immune-, and radiotherapies are not permitted during the active treatment 
period of this trial. Palliative radiotherapy may be permitted for symptomatic control of pain from 
bone metastases following discussion with the Principal Investigator, provided that the 
radiotherapy does not affect target lesions. 
10.4
Duration of study treatment
A total of 3 weeks of treatment is planned. A repeat liver biopsy will be performed at Day 24 (± 
4 days) after completion of protocol therapy and the study biopsy; the patient will then proceed 
onto the follow-up period. 
The participant may stop treatment earlier than planned in the event that the following occurs:

Disease progression

Unacceptable toxicity

Withdrawal from study

Intercurrent illness that prevents further administration of treatment

Participant non-compliance with study requirements
10.5
Compliance
Interferon Alpha-2b, Rintatolimod and the morning dose of Celecoxib will be administered in the 
Clinical Research Center (or other clinical area) and documented by the nurse on the Medication 
Administration Record. The evening dose of Celecoxib will be self-administered at home and 
documented by the participant on the patient diary. The participant will be asked to bring the diary 
with him/her to each clinical visit. Refer to Appendix H
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Date 102920
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11 PROCEDURES INVOLVED
11.1
Description of Procedures 
The study-specific assessments are detailed in this section and outlined in Appendix F (Study 
Calendar). Baseline and/or Screening assessments must be performed within 14 days prior to the 
first dose of investigational product unless otherwise noted. Any results falling outside of the 
reference ranges may be repeated at the discretion of the investigator. All on-study visit procedures 
are allowed a window of ± 1 day unless otherwise noted.
Unless otherwise defined in the written protocol text, all procedures/assessments will be conducted 
in accordance with RPCI Clinical Research Services Standard Operating Procedures. 
Informed consent MUST be completed prior to receiving any study related procedures.
11.1.1 Screening (performed between days -14 through day -1 unless otherwise specified)

Recording of concomitant medications

Medical and Surgical History

Complete Physical Exam including height and weight

Vital Signs

ECOG Performance Status Assessment

Hematology

Chemistry

CEA Level

ANA testing

Serum HCG pregnancy testing (within 7 days of Day 1 in women of child-bearing potential 
only)

CT and/or MRI (within 28 days of start of treatment)

EKG

Liver Biopsy
11.1.2 Evaluations Performed on day 1 of each treatment week (day 1, 8, 15):

Recording of concomitant medications

Recording of Adverse Events

Targeted Physical Exam including weight

Vital Signs (temperature, blood pressure, pulse rate and respiratory rate) will be performed 
pre- treatment and at 30 and 60 minutes post rintatolimod 

(± 5 minutes).

ECOG Performance Status Assessment

Hematology

Chemistry

Chemokine Modulating regimen

Blood (60cc) for correlative studies on Day 1 and Day 15 only (within 1 hour after end of 
infusion treatment)
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11.1.3 Evaluations Performed on days 2 and 3 of each treatment week(days 2,3, 9, 10, 16, 
17):

Recording of concomitant medications

Recording of Adverse Events

Vital Signs (temperature, blood pressure, pulse rate and respiratory rate) will be performed 
pre-treatment and at 30 and 60 minutes post rintatolimod (± 5 minutes).

Chemokine Modulating regimen

Blood (60cc) for correlative studies on Day 3 only (within 1 hour after end of infusion 
treatment)
11.1.4 Evaluations Performed on Day 20 (+/- 2 days):

Recording of Adverse Events

Liver Biopsy
11.1.5 End of Treatment Visit on Day 29 (+/- 10 days):

Recording of concomitant medications

Recording of Adverse Events

Targeted Physical Exam including weight

Vital Signs

ECOG Performance Status

Hematology

Chemistry
NOTE: In the event patient cannot tolerate treatment with all 9 days of treatment, then 
Blood 60cc for correlative will be collected at time that the patient recovers from toxicities 
(ideally within 1 week of the last infusion). Liver biopsy will also be collected provided 
there is not an overriding safety concern for the patient.
11.1.6 Follow-up (patients will be followed for 12 months after EOT visit)

Survival status (phone contact/chart review is acceptable)

CT scan and/or MRI: to be performed at day 46 (± 3 days). If reassessment scan shows 
stable disease/response, patients will continue in follow-up with CT imaging every 8 weeks 
until progression, clinical deterioration or withdrawal from study. If in the clinical 
judgment of the treating team, it is in the best interest of the patient to pursue another 
therapeutic option, the patient will come off study and CT imaging will be obtained only 
as SOC/protocol. In this instance, review of the subsequent disease assessment study will 
be requested for determination of RECIST parameters.
11.2
Correlative studies (blood samples)
Five (10 mL) green-top heparinized tubes of blood will be collected via venipuncture for 
biomarker analysis at multiple time points. These will be collected as outlined in section 11.1. All 
tubes will be sent to the RPCI Hematologic Procurement Shared Resource Laboratory.
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Hematologic Procurement Shared Resource
Attn: I 52917 Specimens
Basic Science Building 5th Floor Room 528
Elm & Carlton Streets
Buffalo, New York 14263
716-845-7656
In addition 1 (10 mL) green-top heparinized tube will be sent to Dr. Kalinski’s Lab in Cancer 
Cell Center Room 502F to the attention of Melissa Grimm, PhD contact phone 716-845-7353 or 
cell 716-353-5384. This will be for preliminary analyses, which may include the pre- and post-
treatment cytokine levels and immune cell subsets, via RT-PCR, flow cytometry assays, or 
alternative laboratory methods.
NOTE: All six tubes will be sent to RPCI Hematologic Procurement Shared Resource 
Laboratory first for sample tracking. The Procurement Shared Resource will then forward 1 
(10mL0 green-top to Dr. Kalinski’s Lab
Plasma samples are to be processed at 4°C using a refrigerated centrifuge at approximately 3000 
rpm for about 10 minutes with the plasma being aliquoted into 2 cryovials per time-point. The 
samples will immediately be frozen at - 70ºC or below until analyzed. PBMC’s will then be 
obtained by Ficoll gradient as per the lab’s standard procedure. Two of the tubes will be pooled 
and the PBMC’s will be frozen in Gibco Cell culture freezing media and will be stored in LN2 
until time of analysis. The remaining tube of PBMC’s will be frozen in RNA later and will be 
stored in -70 degrees or below until analyzed. The screw cap polypropylene cryogenic tubes will 
be labeled with the clinical study number, participant’s MR number, participant’s study number, 
protocol time point, protocol day, date and time of draw.
As a component of exploratory aims, blood may be analyzed to assess pre- and post- treatment 
cytokine levels and immune cell subsets, via ELISA, RT-PCR and flow cytometry assays.
Note: All investigator or analyzing research laboratories housing research samples need to 
maintain current Temperature Logs and study-specific Sample Tracking and Shipping Logs. 
The Principal Investigator/Laboratory Manager must ensure that the stated lab(s) have a process 
in place to document the receipt/processing/storage/shipping of study-related samples/specimens. 
This is required for both observational and interventional clinical studies collecting clinical 
samples.
11.3
Pathology
Fresh Biopsy Samples
At each liver biopsy collection time point, 6 total cores will be obtained, including at least 5 tumor 
cores and 1 additional core of surrounding liver tissue (to enhance the stringency of our assays). 4 
cores of tumor and 1 core of surrounding liver tissue will be placed in Dulbecco’s Phosphate-
Buffered saline, and 1 core of tumor will be placed in formalin, and processed to FFPE block per 
institute standard.
Pre- and post-treatment cores should be obtained from the same lesion. If non-necrotic lesions 
are present at baseline, they should be prioritized for biopsy, with the necrotic lesions being 
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avoided per the interventional radiologists’ discretion. Any biopsy core which appears as 
necrotic should be discarded.
Label the samples with study-specific subject ID number, clinical study number, protocol time 
point and, protocol day. Phosphate-Buffered saline, will be supplied by Dr. Kalinski's lab and 
sample will be kept at ambient temperature. Samples in Dulbecco’s Phosphate-Buffered Saline 
will be sent to Dr. Pawel Kalinski’s lab upon completion of processing (preferably ASAP within 
2 hours of collection, but within 4 hours of collection is allowed). Once the remaining core has 
been processed to FFPE block, it will be delivered to OmniSeq

The changes in the ratio between CTL marker (CD8a gene expression) to Treg markers 
(FoxP3 gene expression), using RT-PCT will be considered as a primary endpoint of 
efficacy.  
Additional correlative studies may be performed on the same material:

Comparison (using RT-PCR, Immunofluorescence [IF] and immunohistochemistry [IHC] 
on serial sections) of the metastatic tissue specimen with regard to total numbers of 
infiltrating T cells, their CD4/CD8 ratios, frequencies of FoxP3 cells, and the expression 
of chemokine receptors on CD4+ and CD8+ T cells (CXCR3, CCR5, CCR4, CCR6, and 
CXCR4).

Evaluate the local expression of Teff-attracting chemokines (CCR5, CXCL9, CXCL10 and 
CXCL11) and Treg-favoring chemokines (CCL22 and CXCL12) using IF and RT-PCR.

Additional tissue evaluations, including OmniSeq Immune Report card, NanoString or 
similar, may be performed, depending on the availability of funding.
12 WITHDRAWAL OF SUBJECTS
12.1
Treatment Discontinuation
Upon treatment discontinuation all end of treatment evaluations and tests will be conducted. All 
participants who discontinue due to an AE must be followed until the event resolves or stabilizes. 
Appropriate medical care should be provided until signs and symptoms have abated, stabilized, or 
until abnormal laboratory findings have returned to acceptable or pre-study limits. The final status 
of the AE will be reported in the participant’s medical records and the appropriate eCRF.
Reasons for treatment discontinuation should be classified as follows:

Death

Progressive disease

Toxicity; treatment related or unrelated

Investigator judgment
o
The Investigator may discontinue a participant if, in his/her judgment, it is in the 
best interest of the participant to do so.

Noncompliance

Participant voluntary withdrawal
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o
A participant may withdraw from the study at any time, for any reason. If a 
participant discontinues treatment, an attempt should be made to obtain information 
regarding the reason for withdrawal.

Sponsor decision. 
13 RISKS TO SUBJECTS
13.1
Celecoxib
Prolonged use of celecoxib may cause dyspepsia, headaches (including migraines) and borderline 
elevated liver function tests (which could indicate liver damage). Recently, information from three 
long-term studies of celecoxib has become available. In the first study, a cancer prevention study, 
an increased risk of heart attacks, strokes, and/or deaths resulting from heart or blood vessel disease 
was reported among people taking celecoxib. Approximately 1 in 100 subjects enrolled in this 
study receiving the placebo treatment had one of these serious events. In contrast, between 2 and 
3 in 100 subjects taking celecoxib (between 400 and 800 mg daily) had one of these serious events. 
Another clinical cancer prevention study found no increased risks in subjects taking celecoxib 400 
mg daily. The third study, an Alzheimer's disease prevention study, did not find increased risks 
with celecoxib. Dosing has been suspended in all three of these studies based on the findings of 
the first cancer prevention study. As a result, the FDA is now evaluating the possibility that 
celecoxib increases the risk of heart attack, stroke, and or death resulting from heart or blood vessel 
disease. Known infrequent side effects of celecoxib include nausea and/or vomiting, diarrhea, 
flatulence, abdominal and stomach pain, bleeding ulcer, upper respiratory tract infection, 
pharyngitis, rhinitis, sinusitis, peripheral edema, back pain, dizziness, insomnia, and skin rash. 
Rare risks include sudden death (unexpected or instant death that occurs within minutes or hours 
from any cause other than violence), vasculitis, hepatitis, liver failure, kidney failure, blood 
dyscrasia, hypoglycemia, hyponatremia, viral meningitis, severe allergic reaction, visual changes, 
and transient ischemic attack. Warnings/Precautions: Stomach problems may be more likely to 
occur if patients drink alcoholic beverages while taking this medicine. Taking two or more of the 
nonsteroidal anti-inflammatory drugs together on a regular basis may increase the chance of 
unwanted effects. Also, taking acetaminophen, aspirin or other salicylates, or ketorolac (e.g., 
Toradol) regularly, while taking a nonsteroidal anti-inflammatory drug, may increase the chance 
of unwanted effects. The risk will depend on how much of each medicine is taken every day and 
how long the medicines are taken together. Therefore, patients should not take acetaminophen or 
aspirin or other salicylates or ketorolac (e.g., Toradol). Clinical studies with celecoxib have 
identified potentially significant interactions with fluconazole and lithium. Experience with 
nonsteroidal anti-inflammatory drugs (NSAIDs) suggests the potential for interactions with 
furosemide and ACE inhibitors. Celecoxib is contraindicated in patients with known 
hypersensitivity to celecoxib. Celecoxib should not be given to patients who have demonstrated 
allergic-type reactions to sulfonamides. Celecoxib should not be given to patients who have 
experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs. 
Severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients.
For more risk information reference the Investigator’s Brochure or package insert.
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13.2
Interferon Alpha-2b
Interferon Alpha-2b may cause fever, chills and flu-like symptoms; loss of appetite; nausea; 
vomiting, diarrhea and abdominal pain; fatigue; lowered white blood count may increase risk of 
infection; lowered platelets may lead to an increase in bruising or bleeding; hair loss. Other risks 
which may be common in cases of prolonged administration of Interferon Alpha-2b include 
drowsiness; temporary confusion; anxiety, amnesia, irritability, confusion, delusions and 
depression which can be severe; numbness and/or tingling in the hands and/or feet, skin rashes and 
inflammation of the pancreas. Inflammation of the pancreas is swelling or irritation of the pancreas 
which may result in tenderness or pain in the stomach and/or back. When the pancreas is inflamed, 
the body is not able to absorb all the nutrients it needs.
For more risk information reference the Investigator’s Brochure or package insert.
13.3
Rintatolimod
Clinical experience with rintatolimod totals over 800 patients with more than 400 patients 
receiving Rintatolimod for at least six (6) months, greater than 200 patients for one (1) year, over 
50 patients up to two (2) years, and with 20 or more patients over two (2) years at doses as high as 
1200 mg i. v. twice weekly. No evidence of dose-limiting organ toxicity, including hematologic, 
liver, or renal toxicity, has been observed.
Adverse events related to infusion such as mild flu-like symptoms, transient headache, fever, 
myalgia, arthralgia, and fatigue/malaise which were seen, usually occur during the initial weeks of 
treatment and tend to subside on repeated administration. These side events were seen in Chronic 
Fatigue Syndrome patients, cancer patients, chronic hepatitis B infected patients and individuals 
infected with HIV at doses of 200 and 400 mg and higher. Patients that experience these minor 
side effects can continue on Rintatolimod and as noted, these signs and symptoms typically subside 
after several weeks of continued treatment. Specific symptoms of note include a flushing reaction, 
characterized by at least one occurrence of erythema of the face, neck and chest, which has been 
observed in approximately 10% of patients treated in various studies. Usually the flushing is both 
mild and transient and disappears with repeated dosing. Occasionally, it can be accompanied by a 
tightness of the chest, tachycardia, anxiety, shortness of breath, subjective reports of "feeling hot", 
diaphoresis and nausea. The reaction is usually infusion-rate dependent and can generally be 
controlled by slowing the infusion rate. An antihistamine (diphenhydramine hydrochloride) can 
be helpful in controlling and reducing the response in the occasional patient for whom the symptom 
persists. Other less frequently occurring adverse effects include nausea, diarrhea, itching, urticaria, 
bronchospasm, transient hypotension, photophobia, rash, bradycardia and transient visual 
disturbances. A severe unexpected local reaction to extravasation of rintatolimod (Ampligen®, 
Poly I:Poly C12U) at the infusion site in the dorsum of the left hand was reported in a Chronic 
Fatigue Syndrome patient with chilblains. Several patients experienced liver enzyme level 
elevations while receiving Rintatolimod associated with chronic dosing over many weeks.
Rintatolimod has been dosed in combination with alpha interferon in investigator initiated studies 
under investigator IND applications during the period between December 1985 and April 1994. A 
total of 24 patients received combination treatments. Clinical conditions included renal cell 
carcinoma, chronic myelogenous leukemia, melanoma, and ovarian cancer. Rintatolimod was 
given as an IV infusion at a dose of 300 mg twice weekly. The starting dose was sometimes as low 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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as 1-10 mg. The interferons were administered at a dose of 3 million Units daily, with some doses 
of 0.75 million units at the low side and up to 6 million units at the higher side.
The therapy with rintatolimod in combination with alpha interferon was generally well tolerated 
without evidence of dose-limiting or cumulative toxicities. The most frequent adverse reactions 
were considered minor in severity and duration. Most of them were flu-like symptoms such as 
chills, cold feeling, fatigue, decreased appetite, fever, muscular aches. Also shortness of breath has 
been seen as well as hypotension, nausea, anemia, dyspnea, numbness, itching and blurred vision. 
These adverse events were judged possibly related to the condition of the patients, but also possibly 
related to the administration of rintatolimod or interferon. In some cases worsening of the patient’s 
condition has been seen due to tumor progression, but in general favorable clinical patterns were 
observed in these patients with advanced disease. Such combinations were not intended to be 
immune modulating and were evaluated in the context of clinical cancer care.
For more risk information reference the Investigator’s Brochure or package insert.
14 POTENTIAL BENEFITS TO SUBJECTS
Patients enrolled in this study have either been treated with standard therapies which 
provide substantial beneficial or are ineligible for or refusing such therapies. This 
treatment has potential to provide anti-tumor benefit (regression/stabilization). The 
probability of such a benefit is unknown.
15 DATA AND SPECIMEN BANKING
After processing, all samples for correlative analysis (blood and tissue) will be sent to Dr. 
Kalinski’s laboratory for storage and analysis (CCC, C-502). Samples will be used for planned 
study assays as well as for future analysis for other, yet to be identified biomarkers that may be 
related to clinical outcome. Any clinical data that is associated with the samples will be stored on 
a secured server in the Department of Medicine, will be accessible only by the PI, co-investigators 
and PI-designated data manager and, will be password protected. All computer entry and 
networking programs will be done using PIDs only.
Note: All investigator or analyzing research laboratories housing research samples need to 
maintain current Temperature Logs and study-specific Sample Tracking and Shipping Logs. The 
Principal Investigator/Laboratory Manager must ensure that the stated lab(s) have a process in 
place to document the receipt/processing/storage/shipping of study-related samples/specimens. 
This is required for both observational and interventional clinical studies collecting clinical 
samples.
16 MEASUREMENT OF EFFECT
16.1
Solid Tumors
Response and progression will be evaluated in this study using the new international criteria 
proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline 
(version 1.1) [Eur J Ca 45:228-247, 2009]. Changes in the largest diameter (unidimensional 
measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph 
nodes are used in the RECIST criteria.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
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Date 102920
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For the purposes of this study, patients should be re-evaluated for response on Day 46 (± 3 days). 
In addition to a baseline scan, confirmatory scans should also be obtained 8 weeks (not less than 
4) weeks following initial documentation of objective response.
Please refer to Appendix G for a summary of tumor response assessment according to RECIST 
1.1 criteria.
17 SAFETY EVALUATION
17.1
Adverse Events
17.1.1 Definition
An adverse event or adverse experience (AE) is any untoward medical occurrence associated with 
the use of a drug in humans, whether or not considered drug related. Therefore, an AE can be ANY 
unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of a medicinal (investigational) product, whether or not 
considered related to the medicinal (investigational) product (attribution of ‘unrelated’, ‘unlikely’, 
‘possible’, ‘probable’, or ‘definite’).
An AE is considered “unexpected” if it is not listed in the investigator brochure or is not listed at 
the specificity or severity that has been observed; or if an investigator brochure is not required or 
available, is not consistent with the risk information described in the general investigational plan 
in other study-related documents.

Diagnosis Versus Signs and Symptoms
If known, a diagnosis should be recorded on the CRF rather than individual signs and 
symptoms (e.g., record only liver failure or hepatitis rather than jaundice, asterixis, and 
elevated transaminases). However, if a constellation of signs and/or symptoms cannot be 
clinically characterized as a single diagnosis or syndrome at the time of reporting, each 
individual event should be recorded as an AE or SAE on the CRF. If a diagnosis is subsequently 
established, it should be reported as follow-up information.

Adverse Events Occurring Secondary to Other Events
In general, AEs occurring secondary to other events (e.g., cascade events or clinical sequelae) 
should be identified by their primary cause. For example, if severe diarrhea is known to have 
resulted in dehydration, it is sufficient to record only diarrhea as an AE or SAE on the CRF.
However, clinically significant AEs occurring secondary to an initiating event that are 
separated in time should be recorded as independent events on the CRF. For example, if a 
severe gastrointestinal hemorrhage leads to renal failure, both events should be recorded 
separately on the CRF.

Abnormal Laboratory Values
Only clinically significant laboratory abnormalities that require active management will be 
recorded as AEs or SAEs on the CRF (e.g., abnormalities that require study drug dose 
modification, discontinuation of study treatment, more frequent follow-up assessments, further 
diagnostic investigation, etc.).
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Date 102920
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If the clinically significant laboratory abnormality is a sign of a disease or syndrome 
(e.g., alkaline phosphatase and bilirubin 5 x the upper limit of normal associated with 
cholecystitis), only the diagnosis (e.g., cholecystitis) needs to be recorded on the Adverse 
Event CRF.
If the clinically significant laboratory abnormality is not a sign of a disease or syndrome, the 
abnormality itself should be recorded as an AE or SAE on the CRF. If the laboratory 
abnormality can be characterized by a precise clinical term, the clinical term should be 
recorded as the AE or SAE. For example, an elevated blood potassium level of 7 mEq/L should 
be recorded as “hyperkalemia”
Observations of the same clinically significant laboratory abnormality from visit to visit should 
not be repeatedly recorded as AEs or SAEs on the CRF, unless their severity, seriousness, or 
etiology changes.

Preexisting Medical Conditions (Baseline Conditions)
A preexisting medical condition should be recorded as an AE or SAE only if the frequency, 
severity, or character of the condition worsens during the study. When recording such events 
on an Adverse Event CRF, it is important to convey the concept that the preexisting condition 
has changed by including applicable descriptors (e.g., “more frequent headaches”).
17.2
Grading and Reporting Adverse Events

Grading and Relationship to Drug
The descriptions and grading scales found in the CTEP Version 4 of the NCI Common 
Terminology Criteria for Adverse Events (CTCAE) will be utilized for AE reporting. 
CTEP Version 4 of the CTCAE is identified and located at:
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.
AEs not covered by specific terminology listed should be reported with common medical 
terminology, and documented according to the grading scales provided in the CTCAE 
Version 4.
The relationship of event to study drug will be documented by the Investigator as follows:
Unrelated: The event is clearly related to other factors such as the participant’s clinical 
state, other therapeutic interventions or concomitant drugs administered to the 
participant.
Unlikely: The event is doubtfully related to investigational agent(s). The event was most 
likely related to other factors such as the participant’s clinical state, other therapeutic 
interventions, or concomitant drugs.
Possible: The event follows a reasonable temporal sequence from the time of drug 
administration, but could have been produced by other factors such as the participant’s 
clinical state, other therapeutic interventions or concomitant drugs.
Probable: The event follows a reasonable temporal sequence from the time of drug 
administration, and follows a known response pattern to the study drug. The event 
cannot be reasonably explained by other factors such as the participant’s clinical state, 
therapeutic interventions or concomitant drugs.
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Date 102920
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Definite: The event follows a reasonable temporal sequence from the time of drug 
administration, follows a known response pattern to the study drug, cannot be 
reasonably explained by other factors such as the participant’s condition, therapeutic 
interventions or concomitant drugs; AND occurs immediately following study drug 
administration, improves upon stopping the drug, or reappears on re-exposure.

Reporting Adverse Events: Routine AEs occurring between the start date of intervention 
until 30 days after the last intervention, or until the event has resolved, the study participant 
is lost to follow-up, the start of a new treatment, or until the study investigator assesses the 
event(s) as stable or irreversible, will be reported. New information will be reported after 
it is received.
Table 2
Guidelines for Routine Adverse Event Reporting (Regardless of 
Expectedness)
Attribution
Grade 1
Grade 2
Grade 3
Grade 4
Unrelated
X
X
Unlikely
X
X
Possible
X
X
X
X
Probable
X
X
X
X
Definite
X
X
X
X
17.3
Serious Adverse Events
A serious adverse event (SAE) is any adverse event (experience) that in the opinion of either the 
investigator or sponsor results in ANY of the following:

Death.

A life-threatening adverse event (experience). Any AE that places a participant or 
participants, in the view of the Investigator or sponsor, at immediate risk of death from 
the reaction as it occurred. It does NOT include an AE that, had it occurred in a more 
severe form, might have caused death.

Inpatient hospitalization or prolongation of existing hospitalization (for > 24 hours).

A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions.

A congenital anomaly or birth defect.

Important Medical Event (IME) that, based upon medical judgment, may jeopardize 
the participant and may require medical or surgical intervention to prevent one of the 
outcomes listed above.
Reporting Serious Adverse Events
All new SAEs occurring from the date the participant signs the study consent until 30 days after 
the last intervention or a new treatment is started, whichever comes first, will be reported. The 
RPCI SAE Source Form is to be completed with all available information, including a brief 
narrative describing the SAE and any other relevant information. 
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SAEs occurring after the 30 day follow-up period that the investigator determines to be possibly, 
probably or definitely related to the study intervention should be reported.
SAEs identified as an Unanticipated Problem by the Investigator must be reported. Please refer to 
Section 17.5 for details on reporting Unanticipated Problems.
17.4
Follow-Up for Serious Adverse Events
All related SAEs should be followed to their resolution, until the study participant is lost to 
follow-up, the start of a new treatment, or until the study investigator assesses the event(s) as stable 
or irreversible. New information will be reported when it is received.
17.5
Unanticipated Problems
An Unanticipated Problem (UP) is any incident, experience, or outcome that meets all of the 
following criteria:

Unexpected (in terms of nature, severity, or frequency) given:
o
The research procedures that are described in the study-related documents, 
including study deviations, as well as issues related to compromise of 
participant privacy or confidentiality of data.
o
The characteristics of the participant population being studied.

Related or possibly related to participation in the research (possibly related means there 
is a reasonable possibility that the incident, experience, or outcome may have been 
caused by the procedures involved in the research).

Suggests that the research places participants or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) than was previously 
known or recognized and if in relation to an AE is also deemed Serious per 
Section 17.3.
Reporting Unanticipated Problems:
The Reportable New Information (RNI) Form will be submitted to the CRS Compliance Office 
within 1 business day of becoming aware of the Unanticipated Problem. After review, CRS 
Compliance will submit the RNI to the IRB.
When becoming aware of new information about an Unanticipated Problem, submit the updated 
information to CRS Compliance with an updated Reportable New Information Form. The site 
Investigator or designated research personnel will report all unanticipated problems, whether 
related or unrelated to the investigational agent(s) to the IRB in accordance with their local 
institutional guidelines.
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17.6
FDA Reporting
When RPCI is the IND holder the following describes the FDA reporting requirements by timeline 
for AEs and new safety findings that meet the criteria outlined below:
Within 7 Calendar Days
Any adverse event that meets ALL the following criteria:
Related or possibly related to the use of the study drug;
Unexpected; and
Fatal or life-threatening.
Within 15 Calendar Days
Any adverse event that meets ALL the following criteria:
Related or possibly related to the use of the study drug;
Unexpected; and
Serious but not fatal or life-threatening;
Or, meets ANY of the following criteria:
A previous adverse event that is not initially deemed reportable but is later found to fit the 
criteria for reporting (report within 15 days from when event was deemed reportable).
Any findings from other studies, including epidemiological studies, pooled analysis of multiple 
studies, or other clinical studies conducted with the study drug that suggest a significant 
risk in humans exposed to the drug.
Any findings from animal or in vitro testing that suggest a significant risk for human 
participants including reports of mutagenicity, teratogenicity, or carcinogenicity or reports 
of significant organ toxicity at or near the expected human exposure.
Any clinically important increase in the rate of occurrence of a serious, related or possibly 
related adverse event over that listed in the protocol or investigator brochure.
Sponsors are also required to identify in IND safety reports, all previous reports concerning similar 
adverse events and to analyze the significance of the current event in the light of the previous 
reports.
Reporting Process
The principal investigator or designee will complete and submit a FDA Form 3500A MedWatch 
for any event that meets the above criteria. Forms will be submitted to the CRS Compliance Office 
via email to CRSCompliance@RoswellPark.org.
18 DATA MANAGEMENT AND CONFIDENTIALITY
18.1
Data Collection
Full build studies are managed by RPCI CRS Data Management for analysis by RPCI 
Biostatisticians. All electronic case report form (eCRF) data are captured for these studies.
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Data management activities are performed using a CTMS system that enables the collection, 
cleaning and viewing of clinical trial data. CRS data management designs the study-specific 
database and facilitates development by the Information Technology team. Once the database 
design is approved by the Investigator, Statistician, and Clinical Research Coordinator, the 
database is put into production and data entry can begin. Data can be entered and changed only by 
those with the rights to do so into the eCRFs.
18.2
Maintenance of Study Documents
Essential documents will be retained per RPCI’s policy for 6 years from the study termination 
date. These documents could be retained for a longer period, however, if required by the applicable 
local regulatory requirements or by an agreement with RPCI.
18.3
Revisions to the Protocol
RPCI may make such changes to the protocol as it deems necessary for safety reasons or as may 
be required by the U.S. FDA or other regulatory agencies. Revisions will be submitted to the 
IRB/ERC for written approval before implementation.
18.4
Termination of the Study
It is agreed that, for reasonable cause, either the RPCI Investigators or the Sponsor, may terminate 
this study, provided a written notice is submitted within the time period provided for in the Clinical 
Trial Agreement. In addition, RPCI may terminate the study at any time upon immediate notice if 
it believes termination is necessary for the safety of participants enrolled in the study.
18.5
Confidentiality
Any data, specimens, forms, reports, video recordings, and other records that leave the site will be 
identified only by a participant identification number (Participant ID, PID) to maintain 
confidentiality. All records will be kept in a limited access environment. All computer entry and 
networking programs will be done using PIDs only. Information will not be released without 
written authorization of the participant.
19 STATISTICAL PLAN
19.1
Study Design/Endpoints
This is a Phase 2A study of the chemokine-modulating regimen Celecoxib, IFNα, and rintatolimod. 
The regimen will be evaluated via serial biopsies comparing the quantity of tumor infiltrating 
CD8+ cells prior to therapy with that seen post-therapy. Tumor imaging will be repeated at day 46 
(+/- 3 days) to assess objective response to therapy. Tumor infiltrating CD8+ cells in the biopsied 
tumor will be measured by quantitative RT-PCR and results will be expressed as a ratio to a 
housekeeping gene. 
19.2
Power and Sample Size
Sample Size Determination: We consider a five-fold increase in TIL expression as clinically 
meaningful. In a series of 55 ex-vivo CRC tumor specimens from patients treated surgically for 
recurrent CRC, the log (base 10) transform of the TIL expression yielded an estimated mean = 1.2 
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Date 102920
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and standard deviation = 0.9. A fivefold increase due to chemokine modulation would increase the 
mean from 1.2 to 1.9 (a 0.77 SD shift).
The sample size calculations are based on the primary analysis, where the change in TILs is 
evaluated using a one-sided permutation t-test. With a sample size of n=12 evaluable patients, the 
study design has 90% power to detect a 0.77 standard deviation increase (pre- to post-treatment) 
at a significance level of 0.1. Therefore we have an adequate design to detect a clinically 
meaningful increase in TIL expression.
Analysis Cohorts and Patient Replacement: Patients missing pre-treatment and/or post-treatment 
TILs are consider unevaluable for the primary endpoint, and will be replaced. Patients that receive 
at least one study dose will be included in the safety analysis cohort. Patients that are considered 
‘evaluable’ for the primary endpoint will be included in the primary analysis cohort. All patients 
that receive at least one study dose and are followed for clinical outcomes will be included in the 
secondary analysis cohort.
Demographics: Patient characteristics will be summarized for each analysis cohort using the 
appropriate descriptive statistics – mean, standard deviation, and percentiles for continuous 
variables; and frequencies and relative frequencies for categorical variables.
19.3
Proposed Data Analysis
Primary Analysis: The primary objective is to determine the impact of a chemokine-modulatory 
regimen on the immune microenvironment of colorectal liver metastases. The primary endpoint is 
the change in TILs, as measured by CD8= transcript, which is treated as a continuous variable.
The TILs will be summarized by time-point (pre-/post-treatment) using the mean, median, 
standard deviation; and graphically using dot-plots. A 90% confidence interval for the mean 
change in TILs will be obtained using standard methods. Using a one-sided permutation paired t-
test, the following hypotheses about the change in TILLs will be evaluated:
 versus 
,
𝐻0: 𝜇𝑑≤0
𝐻𝐴: 𝜇𝑑> 0
where 
 is the true change in TILs (post-treatment – pre-treatment).
𝜇𝑑
This analysis will be limited to subjects who are considered evaluable for efficacy. Therefore the 
recommended sample size for efficacy is 12 evaluable subjects.
Secondary Analysis: The secondary objectives are to evaluate the clinical outcome of objective 
response and safety of the proposed therapy. The responses (based on RECIST v1.1 criteria) will 
be treated as binary data and summarized using frequencies and relative frequencies; with the 
objective response rate (ORR) estimated using a 90% confidence interval obtained using Jeffrey’s 
prior method.  The safety analysis is described in Section 9.4.
Exploratory Analyses: The exploratory objectives are to evaluate the clinical outcomes of overall 
survival (OS) and progression-free survival (PFS). The OS and PFS will be treated as bivariate 
time-to-event data and will be summarized using standard Kaplan-Meier methods. OS will be 
defined as the time from the start of treatment until death due to any cause or last follow-up. PFS 
will be defined as the time from the start of treatment until disease progression (defined by RECIST 
1.1) or last-follow-up.
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Interim Analysis: As part of amendment #8, an interim analysis will be utilized to examine whether 
refinement of patient selection (i.e. earlier line) and tumor selection (i.e. selection of lesion and 
number of tumor cores) will improve: 1) the intra-subject variability observed in the first patients 
(likely due to choice of lesion and abundance of necrotic tissue), and efficacy with respect to the 
primary end-point (change in TILs).
The intra-class correlation coefficient (ICC) as an interim evaluation of the intra-subject variability 
associated with TILs. The conditional power for the one-sided paired t-test about the change in 
TILs will be calculated as an interim evaluation of efficacy. 
The research team will meet to discuss these results and determine whether to: 1) continue 
enrollment in this patient cohort at the given dose level; or 2) incorporate a dose escalation scheme. 
If there is reduced intra-patient variability and potential evidence of efficacy (i.e. high ICC and 
conditional power), then the study enrollment will be completed as currently described. Otherwise, 
we may consider increasing the dose of Rintatolimod using an accelerated titration design (detailed 
in a subsequent amendment).
19.4
Safety Monitoring
Safety Evaluation:  A previous Phase I study utilized the same dosing strength (at a different dosing 
schedule: 5 days versus the proposed 3 days), but only gave one cycle; whereas the current study 
purposes 3 consecutive weeks of 3-day treatments. As such, a continuous toxicity monitoring plan 
will be implemented to quickly identify the emergence of any new AEs or SAEs.
Subject safety will be monitored continuously using Bayesian methods with the following decision 
rule: if the posterior probability is .80 or greater that 33% or more of treated subjects experience a 
treatment related  serious adverse event (SAE), then the study will be suspended pending review. 
This posterior probability will be calculated from the study’s accumulating data and a weakly 
informative prior distribution. If π denotes a random variable representing the proportion of 
subjects who will experience a treatment related SAE, we assume π has a beta distribution with 
parameters a = 1 and b = 2.
Selected values of the posterior distribution PP(π ≥ .33 | SAEs and prior) are shown in the table 
below. Also shown are the binomial probabilities of suspending the study for observed count of 
SAE’s.
Table X
Number of Subjects Observed to Have Treatment-Related SAEs and 
Corresponding Posterior and Binomial Probabilities Needed to Suspend the Study
Subjects
Treatment-Related SAEs
PP(π > 33%)*
Pr(X ≥ r|p = .33)
2
2
.892
.109
3
3
.956
.036
4
3
.903
.108
5
3
.832
.205
6
4
.915
.097
7
4
.860
.168
8
5
.927
.085
9
5
.883
.140
10
5
.829
.206
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
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11
6
.901
.117
12
6
.857
.171
13
6
.805
.233
14
7
.880
.143
15
7
.836
.195
*π is the SAE rate. The minimum acceptable upper bound of a treatment-related SAE is 33%. 
PP(π > 33%) is the posterior probability that the SAE rate exceeds this 33% upper bound. This 
posterior probability of an SAE is calculated from the prior distribution, the number of subjects 
treated and the observed number of treatment-related SAEs.
It is anticipated that 15 patients will be enrolled to this study. The table above presents the 
minimum number of subjects experiencing treatment-related SAEs (i.e., those SAEs judged to be 
possibly, probably, or definitely related to the study regimen) that would dictate suspension of the 
trial in accordance with the stopping rule. Using these assumptions the trial will be suspended if:

2 subjects experience treatment related SAE among the first 2 subjects enrolled

3 subjects experience treatment related SAE among 3 – 5 subjects or,

4 subjects experience treatment related SAE among 6 – 7 subjects or,

5 subjects experience treatment related SAE among 8 – 10 subjects or,

6 subjects experience treatment related SAE among 11 – 12 subjects,

7 subjects experience treatment related SAE among 13 – 15 subjects.

Any death not clearly due to the underlying disease or extraneous causes
At the completion of the study, all AEs will be summarized by weekly treatments and grade using 
frequencies and relative frequencies. 
Treatment Related SAEs for Safety Monitoring
Treatment Related SAE s will be defined as the following events that occur during the period of 
Day 1 through the End of Treatment visit:

≥ Grade 3 treatment-related non-hematologic toxicities, except:
o
The following grade ≥ 3 toxicities (lasting <7 days)
Flu-like symptoms/constitutional symptoms (i.e., fever, chills, arthralgias, 
myalgias)
Depression, anxiety, restlessness, or insomnia
GI symptoms (i.e., nausea, diarrhea)
AST/ALT (unless accompanied by Grade 2 increased bilirubin)
o
Please note, if the above grade 3 toxicities last ≥ 7 days, they will be defined as a 
DLT

≥ Grade 4 treatment related non-hematologic toxicity

Hy’s law criteria:
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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o
An elevated alanine transaminase (ALT) or aspartate transaminase (AST) lab value 
that is greater than or equal to three times (3X) the upper limit of normal (ULN) 
and
o
An elevated total bilirubin lab value that is greater than or equal to two times (2X) 
ULN and, at the same time, an alkaline phosphatase (ALP) lab value that is less 
than 2X ULN,
o
As a result of within-protocol-specific testing or, unscheduled testing
Safety Review and Study Suspension
The Roswell Park Data Safety and Monitoring Committee (DSMC) will assess the progress of the 
study, the safety data, and critical efficacy endpoints. The DSMC will review the study annually 
and will make recommendations that include but not limited to; (a) continuation of the study, (b) 
modifications to the design (c) or termination of the study.
Additionally, should the study be suspended due to safety; members of the research team, study 
statistician, and DSMC will meet to discuss safety concerns and possible adjustments to the study 
or study closure.
20 PROVISIONS TO MONITOR THE DATA TO ENSURE THE SAFETY OF 
SUBJECTS
This study will be reviewed at the scheduled RPCI Early Phase Clinical Trials (EPCT) meetings 
and the minutes are forwarded to the IRB for review.
21 VULNERABLE POPULATIONS

N/A
22 COMMUNITY-BASED PARTICIPATORY RESEARCH

N/A
23 SHARING OF RESULTS WITH SUBJECTS
Individual response data is shared with the participant as a part of their clinical care.
24 SETTING
Potential subjects with recurrent colorectal cancer will be identified and recruited during scheduled 
visits to the RPCI Gastrointestinal Center. Potential subjects, who are referred by their RPCI or 
community physicians, will be scheduled with an investigator in the clinic for evaluation. All 
participants related research procedures will be conducted at RPCI.
25 PROVISIONS TO PROTECT THE PRIVACY INTERESTS OF SUBJECTS
Any data, specimens, forms, reports, video recordings, and other records that leave the site will be 
identified only by a participant identification number (Participant ID, PID) to maintain 
confidentiality. All records will be kept in a limited access environment. All computer entry and 
networking programs will be done using PIDs only. Information will not be released without 
written authorization of the participant.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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26 RESOURCES AVAILABLE

N/A
27 PRIOR APPROVALS

N/A
28 COMPENSATION FOR RESEARCH-RELATED INJURY
Refer to informed consent document related to this study.
29 ECONOMIC BURDEN TO SUBJECTS
Refer to informed consent document related to this study.
30 CONSENT PROCESS
This study will not be initiated until the protocol and informed consent document(s) have been 
reviewed and approved by a properly constituted Institutional Review Board (IRB) or Independent 
Ethics Committee (IEC). Each participant (or legal guardian) shall read, understand, and sign an 
instrument of informed consent prior to performance of any study-specific procedure. It is the 
responsibility of the investigator to ensure that the participant is made aware of the investigational 
nature of the treatment and that informed consent is given.
The Investigator is responsible for the retention of the participant log and participant records; 
although personal information may be reviewed by authorized persons, that information will be 
treated as strictly confidential and will not be made publicly available. The investigator is also 
responsible for obtaining participant authorization to access medical records and other applicable 
study specific information according to Health Insurance Portability and Accountability Act 
regulations (where applicable).
This study will be conducted in compliance with all applicable laws and regulations of the state 
and/or country and institution where the participant is treated. The clinical trial should be 
conducted in accordance with the ethical principles embodied in the Belmont Report: Ethical 
Principles and Guidelines for the Protection of Human Subjects of Research, consistent with good 
clinical practice and the applicable regulatory requirements and according to the guidelines in this 
protocol, including attached appendices.
Informed consent will be obtained according to SOP: Informed Consent Process for Research 
(HRP-090).
31 PROCESS TO DOCUMENT CONSENT IN WRITING
The Investigator (or IRB specified designee) is responsible for obtaining written consent from each 
participant or the participant's legally authorized representative in accordance with GCP guidelines 
using the approved informed consent form, before any study specific procedures (including 
screening procedures) are performed. The informed consent form acknowledges all information 
that must be given to the participant according to applicable GCP guidelines, including the purpose 
and nature of the study, the expected efficacy and possible side effects of the treatment(s), and 
specifying that refusal to participate will not influence further options for therapy. Any additional 
information that is applicable to the study must also be included. Additional national or 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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institutionally mandated requirements for informed consent must also be adhered to. The 
participant should also be made aware that by signing the consent form, processing of sensitive 
clinical trial data and transfer to other countries for further processing is allowed.
The Investigator shall provide a copy of the signed consent form to the participant and the signed 
original shall be maintained in the Investigator File. A copy of the signed consent form must be 
filed in the participant file. At any stage, the participant may withdraw from the study and such a 
decision will not affect any further treatment options.
SOP: Written Documentation of Consent (HRP-091) will be followed.
32 DRUGS OR DEVICES
 RPCI will hold the IND for this study.
32.1
Celecoxib
A sulfa non-steroidal anti-inflammatory drug (NSAID) used in the treatment of osteoarthritis, 
rheumatoid arthritis, acute pain, painful menstruation and menstrual symptoms, and to reduce 
numbers of colon and rectum polyps in patients with familial adenomatous polyposis.
32.1.1 Other Names
Celebrex, Celebra or Onsenal (commercially available)
32.1.2 Formulation and packaging
Celecoxib as capsules in the following dosages: 100 mg and 200 mg.
32.1.3 Drug shipment
Celecoxib will be provided by RPCI.
32.1.4 Drug administration
Celecoxib 200mg will be administered orally twice a day approximately 12 hours apart on Days 
1-3, 8-10, and 15-17. The morning dose will be given to the participant at the same time as the 
other pre-medications for the CKM regimen. The evening dose of Celecoxib will be self-
administered by the participant at home and documented on the patient diary. See Appendix H.
32.1.5 Drug storage and accountability
The Investigator or designate will be responsible for ensuring that the investigational product is 
securely maintained in a locked, limited access facility in accordance with the applicable 
regulatory requirements.  
Store Celecoxib at room temperature at 77 °F (25 °C) away from light and moisture. Brief storage 
between 59-86 °F (15-30 °C) is permitted.
Drug storage temperature will be maintained and recorded, as applicable.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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32.2
Interferon Alpha-2b
Interferon Alpha-2b is approved around the world for the treatment of chronic hepatitis C, chronic 
hepatitis B, hairy cell leukemia, chronic myelogenous leukemia, multiple myeloma, follicular 
lymphoma, carcinoid tumor, and malignant melanoma. Interferon alpha-2b has many drug 
classifications 
including 
anti-infective, 
anti-neoplastic, 
antiproliferative, 
antiviral 
and 
immunological agent.
32.2.1 Formulation and packaging
50 million units/mL, lyophilized powder, which must be reconstituted prior to administration.

Vial size: 50million units/vial

Diluent: Compatible with normal saline, Ringer’s injection, lactated Ringer’s, and 5% 
sodium bicarbonate injection. Interferon Alpha-2b should be reconstituted with 1 mL to 
reach a final concentration of 10:1. IV dose should be diluted in sodium chloride 0.9%/100 
mL and given over 20 minutes. The final concentration of INTRON A should not be less 
than 10 million IU/100 mL

Source: Schering Plough Corp.
32.2.2 Drug Shipment
Interferon Alpha-2b will be provided by RPCI.
32.2.3 Preparing and dispensing
The lyophilized product is reconstituted as directed by the manufacturer. Investigational Drug 
Service Pharmacy (IDS) will prepare and dispense.
For IV injection, it is recommended that Interferon Alpha-2b be administered as a 100,000 U/mL 
solution to minimize adsorption of the drug to glass and plastic containers.
32.2.4 Drug administration
Interferon Alpha-2b (20 million units/M2) will be administered intravenously over 20 minutes once 
a day on Days 1-3, 8-10, and 15-17.
32.2.5 Drug storage and accountability
The Investigator or designate will be responsible for ensuring that the investigational product is 
securely maintained in a locked, limited-access facility in accordance with the applicable 
regulatory requirements.
Powder for injection should be stored at 2 to 8°C (36-46°F). After reconstitution, the solution 
should be used immediately but may be stored up to 24 hours at 2-8°C (36-46°F).
Drug storage temperature will be maintained and recorded, as applicable.
32.2.6 Concomitant medications
Interactions between Interferon Alpha-2b and other drugs have not been fully evaluated. Caution 
should be exercised when administering Interferon Alpha-2b therapy in combination with other 
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 40 of 63
potentially myelosuppressive agents such as zidovudine. Concomitant use of Interferon Alpha-2b  
and theophylline decreases theophylline clearance, resulting in a 100% increase in serum 
theophylline levels. Concomitant Interferon Alpha-2b and REBETOL (Ribavirin) use is 
contraindicated. A more detailed guide concerning drug interactions can be found in Appendix B.
32.3
Rintatolimod (poly IC analog)
A substituted double stranded poly-ribonucleic acid (polyI:polyC12U), rintatolimod preserves 
activity of poly-IC with a much improved systemic toxicity profile. The product has been studied 
extensively for use as a vaccine adjuvant and for its direct antiviral activity, as well in several 
cancer studies as a monotherapy, but most extensively in chronic fatigue syndrome (CFS).
32.3.1 Other names
polyIC12U, Ampligen®, poly I: polyC12U; Polyinosinic: polycytidylic-polyuridylic acid; 
polyriboinosinic-polyribocytidylic (uridylic) acid.
32.3.2 Formulation and packaging
Rintatolimod is supplied as a liquid solution in glass bottles containing 200 mg (100 mg in case of 
toxicity) per 80 mL. Rintatolimod is a colorless solution containing 2.5 mg/mL in physiological 
salts (0.15 M NaCl, 0.01 M phosphate, 0.001 M Mg++). The product does not contain 
preservatives or antioxidants.
32.3.3 Drug Shipment
Rintatolimod will be provided by Hemispherx and shipped to the participating site.
The date of receipt and the amount of drug received will be documented. Drug shipment records 
will be retained by the investigational pharmacist or designee.
32.3.4 Preparing and Dispensing
A vial of rintatolimod is suitable for direct IV infusion. IDS will prepare and dispense. Each vial 
should be taken from the refrigerator and allowed to equilibrate to room temperature.
32.3.5 Drug administration
Rintatolimod 200 mg will be administered by intravenous infusion after Interferon Alpha-2b on 
Days 1-3, 8-10, and 15-17. Additional details on the procedures for receiving, storing and using 
rintatolimod (Ampligen®) can be found in a separate document entitled “Procedures for 
Receiving, Storing, and Using Ampligen® (Poly I:Poly C12U) Liquid Solution”.
The initial administration should begin at a slow rate of infusion (approx. 20 cc/hour) and increase 
to 40cc/hour after 30 minutes. Tubing should be flushed with 30 to 50 mL of normal saline solution 
upon completion.
32.3.6 Drug storage and accountability
The Investigator or designate will be responsible for ensuring that the investigational product is 
securely maintained in a locked, limited-access facility, as specified by Hemispherx and in 
accordance with the applicable regulatory requirements.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
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Rintatolimod should be stored at 2 to 8°C, but should be infused at room temperature. Used vials 
should be accounted for and destroyed according to institutional procedure.
Drug storage temperature will be maintained and recorded, as applicable.
32.4
Handling and Disposal
The Investigator or designee will be responsible for dispensing and accounting for all 
investigational drug provided by Hemispherx exercising accepted medical and pharmaceutical 
practices. Study drugs must be handled as cytotoxic agents and appropriate precautions taken per 
the institution’s environmentally safe handling procedures. All investigational drugs will be 
dispensed in accordance with the Investigator’s prescription or written order.
All products dispensed will be recorded on a product accountability record. Records of product lot 
numbers and dates received will be entered on a product accountability form. This record will be 
reviewed by the Sponsor’s staff or representative during periodic monitoring visits. It is the 
Investigator’s responsibility to ensure that an accurate record of investigational drug issued and 
returned is maintained.
Used vials (excess drug) will be destroyed according to standard practices after properly 
accounting for the dispensing. Partially used vials of study drug will not be re-used for other 
participants.
Under no circumstances will the Investigator supply investigational drug to a third party or allow 
the investigational drug to be used in a manner other than as directed by this protocol.
In regards to drug receipt, accountability and storage, SOP IDS-601 will be followed.
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PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
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Basu, G.D., et al., Cyclooxygenase-2 inhibitor enhances the efficacy of a breast cancer 
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Joshi, G.P., R. Gertler, and R. Fricker, Cardiovascular thromboembolic adverse effects 
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McGettigan, P. and D. Henry, Cardiovascular risk and inhibition of cyclooxygenase: a 
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Andersohn, F., S. Suissa, and E. Garbe, Cyclooxygenase inhibitors and cardiovascular 
risk. JAMA, 2007. 297(6): p. 586-7; author reply 587-8.
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Muthuswamy, R., et al., Ability of mature dendritic cells to interact with regulatory T 
cells is imprinted during maturation. Cancer Res, 2008. 68(14): p. 5972-8.
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Muthuswamy, R., et al., NF-kappaB hyperactivation in tumor tissues allows tumor-
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Kalinski, P. and H. Okada, Polarized dendritic cells as cancer vaccines: directing 
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Mailliard, R.B., et al., alpha-type-1 polarized dendritic cells: a novel immunization tool 
with optimized CTL-inducing activity. Cancer Res, 2004. 64(17): p. 5934-7.
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Watchmaker, P.B., et al., Independent regulation of chemokine responsiveness and 
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34 APPENDICES/ SUPPLEMENTS
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Appendix A
NYHA CLASSIFICATION
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Appendix B
DESCRIPTION OF INTRON A POTENTIAL INTERACTIONS
Aldesleukin: Interferons (Alfa) may enhance the adverse/toxic effect of Aldesleukin. In 
particular, risks of myocardial and renal toxicity may be increased by this combination. 
Risk D: Consider therapy modification
Methadone: Interferons (Alfa) may increase the serum concentration of Methadone. Risk C: 
Monitor therapy
Ribavirin: Interferons (Alfa) may enhance the adverse/toxic effect of Ribavirin. Hemolytic 
anemia has been observed. Risk C: Monitor therapy
Telbivudine: Interferon Alfa-2b may enhance the adverse/toxic effect of Telbivudine. 
Specifically, the risk for peripheral neuropathy may be increased. Risk X: Avoid 
combination
Theophylline Derivatives: Interferons may decrease the metabolism of Theophylline 
Derivatives. Exceptions: Dyphylline. Risk C: Monitor therapy
Zidovudine: Interferons may enhance the adverse/toxic effect of Zidovudine. Interferons may 
decrease the metabolism of Zidovudine. Risk C: Monitor therapy
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Appendix C
ECOG Performance Status Scores
Description
Status
Fully active, able to carry on all pre-disease performance without restriction.
0
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, e.g., light housework, office work.
1
Ambulatory and capable of all self-care but unable to carry out any work 
activities.
2
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours.
3
Completely disabled. Cannot carry on any self-care. Totally confined to bed or 
chair.
4
Dead
5
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Appendix D
INVESTIGATOR STUDY ELIGIBILITY VERIFICATION FORM:
INCLUSION CRITERIA
Participant Name : ________________________________________________
Medical Record No. : _______________________________________________
Title: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients with Colorectal 
Cancer Metastatic to the Liver
INCLUSION CRITERIA
Yes
No
N/A
All answers must be “Yes” or “N/A” for participant enrollment.
Date
1. Recurrent and/or metastatic unresectable colorectal 
cancer with hepatic metastases.
2. Hepatic metastases present which are amenable to 
biopsy
3.  Prior treatment with, contra-indication to or refusal of a 
fluoropyrimidine, irinotecan, oxaliplatin and an anti-
EGFR targeted therapy (if RAS-wt), as well as a PD-1 
or PD-L1 targeted drug if MSI-H/dMMR.
4. No chemotherapy, radiotherapy, major surgery, or 
biologic therapy within 3 weeks of protocol treatment 
5. An ECOG performance status of 0, 1, or 2. Refer to 
Appendix C.
6. Have measurable disease per RECIST 1.1 criteria 
present.
7. Ability to swallow and retain oral medications.
8. Participants of child-bearing potential must agree to use 
adequate contraceptive methods (e.g., hormone or 
barrier method of birth control; abstinence) prior to 
study entry. Should a woman become pregnant or 
suspect she is pregnant while she or her partner is 
participating in this study, she should inform her 
treating physician immediately.
9. Age equal to 18 years or older.
10. Must have normal organ and marrow function as 
defined below:
o
Platelet ≥ 75,000/µL
o
Hemoglobin ≥ 9 g/dL
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INCLUSION CRITERIA
Yes
No
N/A
All answers must be “Yes” or “N/A” for participant enrollment.
Date
o
Hematocrit ≥ 27%
o
Absolute Neutrophil Count (ANC) ≥ 1500/µL
o
Creatinine < institutional upper limit of normal 
(ULN)
OR
Creatinine clearance ≥ 50 mL/min for patients 
with creatinine levels greater than ULN (refer to 
Appendix I for Cockcroft-Gault Equation)
o
Total bilirubin ≤ 1.5 X institutional ULN or for 
patients with known Gilbert’s syndrome total 
bilirubin ≤ 3 x ULN
o
AST(SGOT) and ALT(SGPT) ≤ 2.5 X 
institutional ULN
o
Plasma amylase and lipase ≤1.5 X institutional 
ULN.
11. Participant or legal representative must understand the 
investigational nature of this study and sign an 
Independent Ethics Committee/Institutional Review 
Board approved written informed consent form prior to 
receiving any study related procedure.
Investigator Signature: ___________________________________
Date: ___________
Printed Name of Investigator: __________________________________________________
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Appendix E
INVESTIGATOR STUDY ELIGIBILITY VERIFICATION FORM:
EXCLUSION CRITERIA
Participant Name: _________________________________________________
Medical Record No. : _______________________________________________
Title: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients with Colorectal 
Cancer Metastatic to the Liver
EXCLUSION CRITERIA
Yes
No
N/A
All answers must be “No” or “N/A” for participant enrollment.
Date
1. Patients currently treated with systemic 
immunosuppressive agents, including steroids, are 
ineligible until 3 weeks after removal from 
immunosuppressive treatment.
2. Patients with active autoimmune disease, requiring 
ongoing immunosuppressive therapy or history of 
transplantation.
3. Patients who are pregnant or nursing. Women of 
childbearing potential (WOCBP) will have to undergo a 
urine pregnancy test as part of screening.
4. Untreated CNS metastases
5. Cardiac risk factors including: 
o
Patients experiencing cardiac event(s) (acute 
coronary syndrome, myocardial infarction, or 
ischemia) within 3 months of signing consent
o
Patients with a New York Heart Association 
classification of III or IV (Appendix A)
6. History of upper gastrointestinal ulceration, upper 
gastrointestinal bleeding, or upper gastrointestinal 
perforation within the past 3 years. Patients with 
ulceration, bleeding or perforation in the lower bowel 
are not excluded.
7. Prior allergic reaction or hypersensitivity to celecoxib 
,NSAIDs, or any study agents which would prevent 
completion of protocol-therapy.
8. Patients are ineligible if they plan on regular use of 
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EXCLUSION CRITERIA
Yes
No
N/A
All answers must be “No” or “N/A” for participant enrollment.
Date
NSAIDs at any dose more than 2 times per week (on 
average) or aspirin at more than 325 mg at least three 
times per week, on average. Low-dose aspirin not 
exceeding 100 mg/day is permitted. Patients who agree 
to stop regular NSAIDs or higher dose aspirin are 
eligible and no wash out period is required.
9. Received an investigational agent within 30 days prior 
to enrollment.
10. Unwilling or unable to follow protocol requirements.
11. Patients with known serious mood disorders.
12. Any additional condition which in the Investigator’s 
opinion deems the participant an unsuitable candidate 
to receive the study drugs
Participant meets all entry criteria:
  Yes
  No
If “NO”, do not enroll participant in study.
Investigator Signature: ___________________________________
Date: __________
Printed Name of Investigator: _________________________________________________
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Appendix F
Study Calendar
Baseline and/or Screening assessments must be performed within 14 days prior to the first dose of investigational product unless 
otherwise stated. Any results falling outside of the reference ranges may be repeated at the discretion of the investigator. All on-study 
visit procedures are allowed a window of ± 1 day unless otherwise noted.
Evaluation1
Informed 
Consent
Screening
(Day -14 
through 
Day -1)
Day 1
Days
2 & 3
Day 8 
 Days
9, 10
Day 15
Days
16 & 17
Day 20 
(± 2 days)
EOT 
Day 29 
(± 10 
days)
F/U
Day 
46   
(± 3 
days)
Written 
Informed 
Consent prior to 
any Screening 
Procedures
X
Recording of 
Concomitant 
Medications
X
X
X
X
X
X
X
X
Recording of 
Adverse Events
X
X
X
X
X
X
X
X
X9
Survival 
Follow-up
X11
Clinical 
Assessments
Medical & 
Surgical 
History
X


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Evaluation1
Informed 
Consent
Screening
(Day -14 
through 
Day -1)
Week 1
Day 1
Week 1
Days
2 &3
Day 8 
 Days
9, 10
Day 15
Days
16 & 17
Day 20 
(± 2 days)
EOT 
Day 29 
(± 10 
days)
F/U
Day 
46   
(± 3 
days)
Physical 
Examination 
including height 
and weight2
X2
X2
X2
X2
X2
Vital Signs8
X8
X8
X8
X8
X8
X8
X8
X8
ECOG 
Performance 
Status
X
X
X
X
X
Laboratory 
Procedures
Hematology3
X
X
X
X
X
Chemistry4
X
X
X
X
X
Serum hCG5
X5
CEA level
X
ANA testing
X
Blood (60cc) 
for in vitro 
assays6
X
X6a
X
X
Imaging/
Other 
Procedures
12-Lead ECG
X
Liver Biopsy
X
X


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Evaluation1
Informed 
Consent
Screening
(Day -14 
through 
Day -1)
Week 1
Day 1
Week 1
Days
2 &3
Day 8 
 Days
9, 10
Day 15
Days
16 & 17
Day 20 
(± 2 days)
EOT 
Day 29 
(± 10 
days)
F/U
Day 
46
 (± 3 
days)
Tumor/Disease 
Assessment 
(CT and/or 
MRI)
X7
X10
Study Drug 
Administratio
n
CKM regimen
administration
X
X
X
X
X
X
1.
Assessments to be performed at the times stipulated in the table and as clinically required in the management of the subject.
2.
At each time point, Physical exam to include assessment of Head/Ears/Eyes/Nose/Throat (HEENT), Skin, Chest/Lungs, Heart, Neck/lymph 
nodes, Abdomen including liver/spleen, Extremities and weight. Height to be collected at screening only. Physical exam does not need to be 
repeated on Day 1 if performed within 3 days prior to Day 1.  
3.
CBC with auto differential.
4.
Glucose, BUN, creatinine, sodium, potassium, chloride, CO2, calcium, total protein, albumin, alkaline phosphatase, AST, ALT, total 
bilirubin, amylase, lipase.
5.
Within 7 days of Day 1 and as clinically indicated once on treatment in women of child-bearing potential only.
6.
Blood (60cc) for in vitro assays will be drawn as outlined in section 11.2.  
6a.   Day 3 only within 1 hour after end of infusion
7.
Within 28 days prior to Day 1.
8.
Vital Signs (blood pressure, pulse, respiratory rate and temperature) will be obtained at screening and end of treatment visits. On dosing 
days, vital signs will be obtained pre-treatment, 30 and 60 minutes post Rintatolimod (± 5 minutes).
9.
Patients will be followed for survival status for 12 months after end of treatment visit. Phone contact/chart review is acceptable.  
10. Restaging imaging CT/MRI to be performed on day 46 ± 3 days. If this scan demonstrates stable disease/response, patients will continue in 
follow-up with CT imaging every 8 weeks until progression, clinical deterioration or withdrawal from study. If in the clinical judgement of 
the treating team, it is in the best interest of the patient to pursue another therapeutic option, the patient will come off study and CT imaging 
will be obtained only as SOC/protocol.
11. Once every 3 months for up to 12 months after EOT visit to ascertain survival – both chart review and/or phone contact are acceptable


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Appendix G
RECIST 1.1 Criteria 
Objective Tumor Response
All protocol-defined imaging studies must be performed at the investigative site or sponsor-
approved facility using protocol-defined parameters. The same method of assessment and the same 
technique should be used to characterize each identified and reported lesion at baseline and during 
follow-up. RECIST 1.1 will be used to assess objective tumor response.
Target Lesions
All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, representative 
of all involved organs, will be identified as target lesions and recorded and measured at baseline. 
Target lesions will be selected on the basis of their size. Lesions with the longest diameter (short 
axis for lymph nodes) and are ≥ 10 mm (CT and MRI), ≥ 15 mm lymph nodes, > 20 mm CXR and 
are for accurate repetitive measurements (either by imaging techniques or clinically) will be 
chosen. A sum of the longest diameter (short axis for lymph nodes) of all target lesions will be 
calculated and reported as the baseline sum diameters. This will be used as reference to further 
characterize the objective tumor response of the measurable dimension of the disease.

Complete Response (CR): Disappearance of all target lesions. Any lymph nodes must 
have a reduction in short axis to < 10 mm. Changes in tumor measurements must be 
confirmed by repeat studies performed no less than 6 weeks after the criteria for 
response are first met.

Partial Response (PR): At least a 30% decrease in the sum of diameters of target 
lesions, taking as reference the baseline sum diameters. Changes in tumor 
measurements must be confirmed by repeat studies performed no less than 6 weeks 
after the criteria for response are first met.

Progressive Disease (PD): At least a 20% increase in the sum of diameters of target 
lesions, taking as references the smallest sum on study (this includes the baseline sum 
if that is the smallest on study). In addition to the relative increase of 20%, the sum 
must also demonstrate an absolute increase of at least 5 mm. The appearance of one or 
more new lesions is also considered progression.

Stable Disease (SD): Neither a sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest sum diameter while on 
study. Participants having a documented response with no confirmation of the response 
will be listed with stable disease.
Non-Target Lesions
All other small lesions (longest diameter < 10 mm or lymph nodes ≥ 10 mm to < 15 mm short 
axis) and non-measurable lesions (i.e., leptomeningeal disease, ascites, pleural or pericardial 
effusion, inflammatory breast disease, lymphangitic involvement of skin or lung, blastic bone 
lesions, or abdominal masses / abdominal organomegaly identified by physical exam that is not 
measurable by imaging) should be identified as non-target lesions and indicated as present in the 
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source documents at baseline. The general location will also be documented on the images drawing 
a regularly-shaped Region of Interest. Measurements of the non-target lesions will not be 
performed, but the presence or absence of each should be noted throughout follow-up and 
evaluation.
Complete Response: Disappearance of all non-target lesions and normalization of tumor 
marker level, if applicable. All lymph nodes must be non-pathological in size (< 10 mm 
short axis).
Non-Complete Response/Non-Progressive Disease: Persistence of 1 or more non-target 
lesion(s) and/or maintenance of tumor marker level above the upper limits of normal.
Progressive Disease: Appearance of 1 or more new lesions or the unequivocal progression of 
existing non-target lesions. Although a clear progression of non-target lesions is 
exceptional, in such circumstances, the opinion of the treating physician should prevail and 
the progression status should be confirmed at a later time.
Evaluation of Response
Time point response assessments will be performed every 8 weeks [starting with Day 46 
(± 3 days)]. To determine time point response, refer to the tables below:
Time Point Response Criteria: target (± non-target disease)
Target Lesions
Non-Target Lesions
New Lesions
Overall Response
CR
CR
No
CR
CR
Non-CR/Non-PD
No
PR
CR
Not evaluated
No
PR
PR
Non-PD or not all evaluated
No
PR
SD
Non-PD or not all evaluated
No
SD
Not all evaluated
Non-PD
No
NE
PD
Any
Yes or No
PD
Any
PD
Yes or No
PD
Any
Any
Yes
PD
Time Point Response Criteria: non-target disease only
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD1
Not all evaluated
No
NE
Unequivocal PD
Yes or No
PD
Any
Yes
PD
1
Non-CR/non-PD is preferred over SD for non-target disease since SD is used as endpoint for assessment of 
efficacy in trials so to assign this category when no lesions can be measured is not advised.
The best overall response is the best response recorded from the start of study treatment until 
disease progression, taking into account any requirement for confirmation. In general, the 
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participant’s best response assignment will depend on the achievement of both measurement and 
confirmation criteria and will be determined by combining the participant’s status of target lesions, 
non-target lesions, and new lesions.

Symptomatic Deterioration: Participants with global deterioration of health status 
requiring discontinuation of treatment without objective evidence of disease 
progression at that time, and not related to study treatment or other medical conditions 
should be reported as progressive disease due to “symptomatic deterioration.” Every 
effort should be made to document objective progression even after discontinuation of 
treatment due to symptomatic deterioration. Symptomatic deterioration that may lead 
to discontinuation of treatment include, but is not limited to, symptoms such as:

Weight loss > 10% of body weight.

Worsening of disease-related symptoms (e.g., worsening dyspnea, increasing 
pain/increasing requirement for narcotic analgesics).

Decline in performance status of > 1 level on ECOG scale.
Confirmation Measurement
If Day 46 CT scan demonstrates stable disease/response, patients will continue in follow-up with 
CT imaging every 8 weeks until progression, clinical deterioration or withdrawal from study.
Guidelines for Evaluation of Measurable Disease
All measurements should be taken and recorded in metric notation. All baseline evaluations should 
be performed as closely as possible to the beginning of treatment and never more than 4 weeks 
before the beginning of the treatment.
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is 
preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be 
imaged but are assessable by clinical exam.

Clinical Lesions: Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes) and ≥ 10 mm diameter as 
assessed using calipers (e.g., skin nodules). In the case of skin lesions, documentation 
by color photography, including a ruler to estimate the size of the lesion, is 
recommended.

Chest x-ray: Lesions on chest x-ray are acceptable as measurable lesions when they 
are clearly defined and surrounded by aerated lung. However, CT is preferable.

Conventional CT and MRI: This guideline has defined measurability of lesions on 
CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans 
have slice thickness greater than 5 mm, the minimum size for a measurable lesion 
should be twice the slice thickness. MRI is also acceptable in certain situations (e.g., 
for body scans).
Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal resolution; 
however, there are many image acquisition variables involved in MRI, which greatly impact image 
quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable 
globally. As with CT, if an MRI is performed, the technical specifications of the scanning 
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sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, 
as with CT, the modality used at follow-up should be the same as was used at baseline and the 
lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the 
RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body 
parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition 
protocol should be followed as closely as possible to prior scans. Body scans should be performed 
with breath-hold scanning techniques, if possible.

Ultrasound: Ultrasound is not useful in assessment of lesion size and should not be 
used as a method of measurement. Ultrasound examinations cannot be reproduced in 
their entirety for independent review at a later date and, because they are operator 
dependent, it cannot be guaranteed that the same technique and measurements will be 
taken from one assessment to the next. If new lesions are identified by ultrasound in 
the course of the study, confirmation by CT or MRI is advised. If there is concern about 
radiation exposure at CT, MRI may be used instead of CT in selected instances.

Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor 
evaluation is not advised. However, such techniques may be useful to confirm complete 
pathological response when biopsies are obtained or to determine relapse in trials where 
recurrence following complete response (CR) or surgical resection is an endpoint.

Tumor Markers: Tumor markers alone cannot be used to assess response. If markers 
are initially above the upper normal limit, they must normalize for a participant to be 
considered in complete clinical response.

Cytology, Histology: These techniques can be used to differentiate between partial 
responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in 
tumor types, such as germ cell tumors, where known residual benign tumors can 
remain).
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease.

FDG-PET: While FDG-PET response assessments need additional study, it is 
sometimes reasonable to incorporate the use of FDG-PET scanning to complement CT 
scanning in assessment of progression (particularly possible 'new' disease). New 
lesions on the basis of FDG PET imaging can be identified according to the following 
algorithm:

Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion.

No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive FDG-
PET at follow-up corresponds to a new site of disease confirmed by CT, this is PD. If 
the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, 
additional follow-up CT scans are needed to determine if there is truly progression 
occurring at that site (if so, the date of PD will be the date of the initial abnormal FDG-
PET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of 
disease on CT that is not progressing on the basis of the anatomic images, this is not 
PD.
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
FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy 
in cases where a residual radiographic abnormality is thought to represent fibrosis or 
scarring. The use of FDG-PET in this circumstance should be prospectively described 
in the protocol and supported by disease-specific medical literature for the indication. 
However, it must be acknowledged that both approaches may lead to false positive CR 
due to limitations of FDG-PET and biopsy resolution/sensitivity.
Note: A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image.
APPROVED RPCI IRB
11/16/2020


PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 62 of 63
Appendix H
Celecoxib Patient Diary
Protocol # __________________
                
     Patient Name:  ______________
Drug Name: Celecoxib
     
Treatment Week: ________
     Med. Record #: ___ ___ ___ ___ ___ ___
Study Medication Calendar
You are participating in a study that requires Celecoxib 200 mg to be given twice daily, 
approximately 12 hours apart for three consecutive days.  This dose will be given three days a 
week for three consecutive weeks.  Your morning dose of Celecoxib will be given to you along 
with your pre-medications while you are in clinic. Please complete this calendar to document your 
evening doses of Celecoxib. Your nurse will let you know what time you receive your morning 
dose of Celecoxib so you can take your evening dose approximately 12 hours after.
 
Day 
Dose
Time
Please remember to bring this calendar and your pill bottle (including any unused pills) with you 
to your next study appointment.
______________________________________________________________________________________
Coordinator use only
Date of return: __________________
# of pills
(dispensed: _______     --   returned: _______)
       
_____________________________________     x   100   =    % adherence: __________
    
 # of pills scheduled _______        
 
______________________________________________________________________________________
Patient signature: _________________________________________                           Date: ____________
Investigator signature: _____________________________________                           Date: ____________
                                                                                                                  
                                           Clinical Research Services
APPROVED RPCI IRB
11/16/2020


PROTOCOL TITLE: Phase 2A Study Evaluating a Chemokine-Modulatory Regimen in Patients 
with Colorectal Cancer Metastatic to the Liver 
Date 102920
Page 63 of 63
Appendix I
Creatinine Clearance Calculation
Cockcroft-Gault Equation*
Men: CrCl = [(140-YR) x weight in kg] / (PCr x 72)
Women: CrCl = 0.85 x [(140-YR) x weight in kg] / (PCr x 72)
Where:
CrCl is creatine clearance (mL/min)
PCr is plasma creatinine (mg/dL)
YR is age (years)
APPROVED RPCI IRB
11/16/2020