Clinical trial NCT01773395
Conditions: Myelodysplastic Syndrome Acute Myeloid Leukemia Chronic Myelomonocytic Leukemia
Keywords: Advanced
Sponsor: Dana-Farber Cancer Institute
Start date: 2013-01-08; Completion date: 2021-11-24
Enrollment: 123 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This research study is a Phase II clinical trial. Phase II clinical trials test the effectiveness of an investigational intervention to learn whether the intervention, in this case, the GVAX vaccine, works in preventing MDS, CMML, or AML from relapsing after allogeneic stem cell transplantation. "Investigational" means that the vaccine is still being studied and that research doctors are trying to find out more about it-such as the side effects it may cause, and if the vaccine is effective. It also means that the FDA has not yet approved the vaccine for these types of cancer.

Participants are being asked to participate in this trial because they have advanced myelodysplastic syndrome (MDS), Chronic Myelomonocytic Leukemia (CMML), or acute myeloid leukemia (AML). Investigators have determined that participants are a candidate for an allogeneic stem cell transplant as treatment for MDS/CMML/AML. Allogeneic stem cell transplantation is a standard treatment for MDS/CMML/AML. It can be effective because the cells from the donor (also known as the graft) could form a new immune system that can fight against the MDS/CMML/AML cells in the body. This is also known as the "graft-versus-leukemia" or "GVL" effect. In patients with advanced MDS, CMML, or AML that is not in remission at the time of transplantation, relapse remains the number one cause of transplant failure. As such, this clinical trial is designed to assess whether adding a leukemia vaccine early after transplantation could stimulate donor cells to fight cancer and improve transplant outcomes.

In recent years, researchers at the Dana-Farber Cancer Institute have discovered that GVAX, a vaccine made from the patient's own cancer cells engineered to produce a protein called GM-CSF, can be effective in stimulating a powerful immune response specific to that cancer. GM-CSF is a naturally occurring hormone in the body that helps the immune system fight infections and diseases. The GVAX vaccine is made in the laboratory by using a virus (called adenovirus, which has been modified so it cannot cause illness) to insert the GM-CSF gene into tumor cells. The cells are then irradiated, which prevents them from being able to grow, before being administered to patients in a series of vaccinations.

A previous phase I clinical trial using this GVAX vaccine in patients with MDS/AML after allogeneic transplantation demonstrated that the GVAX vaccine is safe, and the survival outcomes were encouraging. The current randomized phase II study will investigate this vaccine further and gather more information to assess the activity.

Participants in this study will be "randomized" to receive either GVAX vaccination or placebo (a saline solution) vaccination. Randomization means participants are put into a group by chance. It is like flipping a coin. There is a 50% chance they will receive the GVAX vaccine and a 50% chance they will receive placebo. Neither participants nor investigators will know which participants will be receiving.

The primary goal of this trial is to assess if there will be a difference in the percentage of cancer free survivors in the vaccinated vs. placebo group at 18 months after transplant.

Detailed description:
This trial can be divided into four phases: 1) Pre-Transplant; 2) Allogeneic Transplant; 3) Vaccination; and 4) Post-Vaccination Follow-Up.

Phase 1: Pre-Transplant After signing the consent form participants will undergo some screening tests to find out if they can be in this research study. These tests include a medical history, physical examination, performance status, bone marrow aspirate and biopsy, blood tests, tuberculosis skin test, HLA antibody test, pregnancy test, urine test, ECHO, MUGA or RVG to measure heart function, chest x-ray, pulmonary function tests and dental consult. If these tests show that participants are eligible to participate in the research study, they will be enrolled on the trial and randomized to receive either the GVAX vaccine or the placebo vaccine after their transplant. After enrolling in the study participants will undergo additional research procedures including a blood draw and leukemia cell collection.

Phase 2: Allogeneic Transplant The transplant phase of the study will begin when participants are admitted to the hospital to receive the chemotherapy and stem cell transplant. In the week before participants receive the stem cells, they will be treated with chemotherapy. The combination of chemotherapy given before the donor cells are infused is called the conditioning regimen. The chemotherapy conditioning is given to suppress the immune system so that the donor blood stem cells will not be rejected after transplantation. The chemotherapy may also reduce the number of MDS/CMML/AML cancer cells in participants' body.

In this study the condition regimen will include 2 chemotherapy drugs: busulfan (twice a day or four times a day for 4 days) and fludarabine (once daily for 4 days). Depending on participants' age and other clinical factors, the transplant doctor will decide whether they receive a higher or lower dose of busulfan. Between 1-2 days after participants finish the chemotherapy, they will receive the blood stem cell or marrow from the donor. This is given as a transfusion through a central intravenous line (IV usually placed in the chest or arm).

Just prior to and immediately following the infusion of stem cells, participants receive medications to help prevent graft-versus-host disease (GVHD), a common complication of transplant where the donor's immune cells attack the body. The medications participants receive to prevent GVHD will include Tacrolimus and Methotrexate.

Participants will be closely monitored as per standard transplant care after their stem cell transplant. If participants received the higher dose chemotherapy conditioning, they will stay in the hospital for an average of about 3-4 weeks. If they received the lower dose conditioning transplant, their hospital admission for transplant may be shorter depending on clinical condition.

After participants' stem cell infusion, they may receive daily injections of a medication called rhGM-CSF, or Leukine, to help their white blood cells to recover faster. participants may receive this medication for up to 2 weeks. They will also be given antiviral and antibiotic medications to prevent infections as per standard practice after transplantation.

Between 20 to 30 days after stem cell infusion participants will have a physical examination, routine blood work and a blood draw for future immune tests.

Between 30 to 60 days after transplant participants will return to clinic for a visit that will include a physical examination, routine blood work, a blood draw for future immune tests and a bone marrow biopsy and aspirate to assess their MDS/CMML/AML.

Phase 3: Vaccination Participants may begin receiving the GVAX or placebo vaccination between 30 to 60 days following their transplant, provided their blood counts have recovered, and do not have any severe side effects from the transplant. If by day 61, participants' blood counts have not recovered sufficiently, or if they have developed side effects or GVHD from the transplant, and do not meet the conditions necessary to start the vaccination portion of this trial, then they will not receive any vaccinations and will be removed from the study. Participants will continue to receive standard post transplant care.

If participants are able to begin the vaccinations between day 30-60 after their transplant, the GVAX or placebo vaccine will be administered as an injection under and into the skin on the forearms or thighs, 6 times over a period of 9 weeks. The first 3 vaccinations will be administered once a week for 3 consecutive weeks and the last 3 vaccines will be given once every other week over 6 weeks. All vaccinations will be given either as an inpatient or outpatient in the clinic. On the days participants receive vaccination, they may have to wait several hours in the clinic while the laboratory makes final preparations on the vaccine/placebo.

During this 9 week period of vaccination, participants will continue to be followed by their doctor at least on a weekly basis to monitor for any transplant or possible vaccine side effects. Two to three days after the first and fifth vaccinations, investigators would encourage (but do not require) participants to return to the clinic to have a skin biopsy of the GVAX/Placebo vaccination site, especially if there is redness or swelling in the area. This will allow researchers to assess whether the new immune system is reacting to the injected leukemia cells under the microscope.

During the course of the study, investigators will also be drawing participants' blood on a regular basis to evaluate immune cells and the effect that the vaccinations may have on their new immune system.

If participants tolerate the vaccinations well, and do not have GVHD or any severe side effects from the transplant or the vaccinations, they will complete a total of 6 vaccines. However, vaccination may be terminated earlier if they develop any side effects (from transplant or vaccination) that do not resolve/improve after 2 weeks, if they develop GVHD that requires steroid treatment, or if their MDS/CMML/AML relapses and need to receive more treatment.

Phase 4: Post Vaccination Follow-Up About 1 month after the last vaccination, participants will have a physical examination, blood work, immune bloods and bone marrow biopsy and aspirate to assess the status of Their disease.

Participants will be followed at an appointment 6, 9, 12 and 18 months following their transplant with physical examinations, blood work and immune bloods. At the 12 and 18 month visit they will have a bone marrow biopsy and aspirate to assess the status of their AMLCMML//MDS.

Arms: arm 1: GVAX vaccine

Participants in the GVAX vaccine arm will undergo a conditioning regimen with busulfan and fludarabine prior to allogeneic hematopoietic stem cell transplant. Immediately after allogeneic hematopoietic stem cell transplant participants will start tacrolimus and methotrexate to prevent GVHD. GVAX arm participants meeting criteria to begin vaccinations will be administered the GVAX vaccine at established study time points. arm 2: Placebo vaccine

Participants in the Placebo vaccine arm will undergo a conditioning regimen with busulfan and fludarabine prior to allogeneic hematopoietic stem cell transplant. Immediately after allogeneic hematopoietic stem cell transplant participants will start tacrolimus and methotrexate to prevent GVHD. Placebo vaccine arm participants meeting criteria to begin vaccinations will be administered the placebo vaccine at established study time points.
Interventions: intervention 1: GVAX intervention 2: Placebo Vaccine intervention 3: Allogeneic Hematopoietic Stem Cell Transplant intervention 4: Busulfan intervention 5: Fludarabine intervention 6: Tacrolimus intervention 7: Methotrexate
Intervention descriptions: intervention 1: GVAX or placebo vaccination will begin between 30 to 60 days following participant's transplant, provided participant meets vaccination initiation criteria. Only participants in the GVAX arm will receive GVAX vaccine. intervention 2: GVAX or placebo vaccination will begin between 30 to 60 days following participant's transplant, provided participant meets vaccination initiation criteria. Only participants in the placebo arm will receive placebo vaccine. intervention 3: Between 1-2 days after participant finishes the chemotherapy, the participant will receive the blood stem cell or marrow from their donor. This is given as a transfusion through a central intravenous line (IV usually placed in the chest or arm). intervention 4: In this study the condition regimen will include 2 chemotherapy drugs: busulfan (twice a day or four times a day for 5 days) and fludarabine (once daily for 4 days). Depending on participant's age, and other clinical factors, the transplant doctor will decide whether the participant will receive a higher or lower dose of busulfan. intervention 5: In this study the condition regimen will include 2 chemotherapy drugs: busulfan (twice a day or four times a day for 5 days) and fludarabine (once daily for 4 days). Depending on participant's age, and other clinical factors, the transplant doctor will decide whether the participant will receive a higher or lower dose of busulfan. intervention 6: Just prior to and immediately following the infusion of stem cells, the participant will receive medications to help prevent graft-versus-host disease (GVHD), a common complication of transplant where the donor's immune cells attack the recipient's body. The medications the participant will receive to prevent GVHD will include:

* Tacrolimus- This will be taken orally twice daily start 3 days before the transplant, and will continue for about 6-9 months.
* Methotrexate- This will be given a short intravenous infusion on days 1, 3, 6, and 11 after the transplant. intervention 7: Just prior to and immediately following the infusion of stem cells, the participant will receive medications to help prevent graft-versus-host disease (GVHD), a common complication of transplant where the donor's immune cells attack the recipient's body. The medications the participant will receive to prevent GVHD will include:

* Tacrolimus- This will be taken orally twice daily start 3 days before the transplant, and will continue for about 6-9 months.
* Methotrexate- This will be given a short intravenous infusion on days 1, 3, 6, and 11 after the transplant.

Protocol documents:
Prot_SAP_000.pdf: 
A randomized placebo-controlled phase II trial of irradiated, adenovirus vector 
transfected GM-CSF secreting autologous leukemia cell vaccination (GVAX) versus 
placebo vaccination in patients with advanced MDS/AML after allogeneic hematopoietic 
stem cell transplantation
01773395
21-OCT-2020


Phase II GVAX Following HSCT for AML/MDS
Version 14.6  October 21, 2020
CONFIDENTIAL
This document is confidential. Do not disclose or use except as authorized.
Protocol Version Date:  October 21, 2020
Local Protocol #:12-217
Title: A randomized placebo-controlled phase II trial of irradiated, adenovirus vector transfected 
GM-CSF secreting autologous leukemia cell vaccination (GVAX) versus placebo vaccination in 
patients with advanced MDS/AML after allogeneic hematopoietic stem cell transplantation
IND Sponsor: Robert Soiffer, MD BB-IND 17904
Principal Investigator: Vincent T. Ho, MD
                                   
                          
                               Dana- Farber Cancer Institute
Site Responsible Investigators: Jacalyn Rosenblatt, MD
     Beth Israel Deaconess Medical Center (BIDMC)
     Yi-Bin Chen, MD
                                                     Massachusetts General Hospital (MGH)
Statistician: Haesook Kim, PhD/DFCI
Responsible Research Nurses:
Jennifer Brock, RN/DFCI
Susan Stephenson, RN/DFCI
Agent: GM-CSF secreting autologous leukemia cell vaccine (GVAX) 


Phase II GVAX Following HSCT for AML/MDS
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This document is confidential. Do not disclose or use except as authorized.
SCHEMA
+30
Taper after VAX #6
VAX start window
         GVAX/Placebo Vaccination 
QWk x 3 doses
Q2Wks x 3 doses
 +0
P
B
S
C
T 
or 
B
M
T
GVHD prophylaxis (Tacrolimus)
Autologous tumor cells harvest
FluBu2 or 
FluBu4 
Conditioning
MTX
+60
Enrollment and  
Randomization
* Cytoreductive therapy for MDS or AML may be given between harvest and 
transplant conditioning, at the discretion of the treating MD
*


Phase II GVAX Following HSCT for AML/MDS
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TABLE OF CONTENTS
1.0 
OBJECTIVES.................................................................................................................................................6
1.1
Study Design.....................................................................................................................................................6
1.2
Primary Objective:...........................................................................................................................................6
1.3
Secondary Objectives:......................................................................................................................................6
2.0 BACKGROUND .....................................................................................................................................................7
2.1    Study Agent .......................................................................................................................................................7
2.2    Study Disease: Allogeneic SCT for Advanced MDS/AML................................................................................7
2.3    Rationale ...........................................................................................................................................................7
2.4    Correlative Studies Background .......................................................................................................................7
3.0  PARTICIPANT SELECTION ...........................................................................................................................11
3.1       Eligibility Criteria........................................................................................................................................11
3.2   Exclusion Criteria ........................................................................................................................................12
3.3 Inclusion of Women, Minorities and Other Underrepresented Populations .....................................................13
4.0
REGISTRATION PROCEDURES .................................................................................................................13
4.1
General Guidelines for DF/HCC and DF/PCC Institutions ..........................................................................13
4.2
Registration Process for DF/HCC and DF/PCC Institutions........................................................................13
5.0 TREATMENT PLAN...........................................................................................................................................14
5.1
Treatment can be administered on an either inpatient or outpatient basis. Expected toxicities and potential 
risks for irradiated, adenovirus vector transfected GM-CSF secreting autologous leukemia cell vaccination 
(GVAX) are described in Section 6 (Expected Toxicities and Dosing Delays/Dose Modification). No 
investigational or commercial agents or therapies other than those described below may be administered at the 
start of conditioning through vaccination with the intent to treat the participant’s malignancy. Pre-treatment 
criteria/Pre-transplant.............................................................................................................................................14
5.2
Allogeneic Hematopoietic Stem Cell Transplantation ...................................................................................16
5.3 GVAX/Placebo Vaccination...............................................................................................................................18
5.4 General Concomitant Medication and Supportive Care Guidelines.................................................................20
5.5
Duration of Vaccination..................................................................................................................................20
5.6
Duration of Follow Up...................................................................................................................................21
5.7
Criteria for Removal from Study ....................................................................................................................21
6.0   EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS......................................21
6.1 Anticipated Toxicities.........................................................................................................................................22
6.2 Toxicity Management.........................................................................................................................................24


Phase II GVAX Following HSCT for AML/MDS
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6.3
Dose Modifications/Delays ............................................................................................................................25
6.4
Unblinding......................................................................................................................................................25
7.0  DRUG FORMULATION AND ADMINISTRATION.....................................................................................25
7.1
GVAX/Placebo................................................................................................................................................25
8.0
CORRELATIVE/SPECIAL STUDIES...........................................................................................................28
9.0  STUDY CALENDAR ..........................................................................................................................................28
10.0
ADVERSE EVENT REPORTING REQUIREMENTS...........................................................................30
10.1
Definitions..................................................................................................................................................30
10.2
Procedures for AE and SAE Recording and Reporting.............................................................................30
10.3
AE Reporting Period and Requirements....................................................................................................31
10.4
Reporting to the NIH Office of Science Policy (OSP) ...............................................................................32
10.5
Reporting to the Institutional Biosafety Committee (IBC) ........................................................................33
10.6
Reporting to Hospital Risk Management...................................................................................................33
11.0
DATA AND SAFETY MONITORING......................................................................................................33
11.1
Data Reporting ..........................................................................................................................................33
11.2
Safety Meetings..........................................................................................................................................33
11.3
Monitoring.................................................................................................................................................34
12.0
STATISTICAL CONSIDERATIONS........................................................................................................34
12.1
 Endpoints ..................................................................................................................................................34
12.2
Study Design and Objectives .....................................................................................................................35
12.3
Accrual.......................................................................................................................................................35
12.4
Randomization...........................................................................................................................................35
12.5 Sample Size and Power Calculations...............................................................................................................35
12.6 Interim Analyses...............................................................................................................................................36
12.7
Guidelines for Grade III-IV acute GVHD and serious toxicity.................................................................37
12.8
Statistical Analysis Plan ............................................................................................................................37
12.9 Analysis of Laboratory Correlative Studies.....................................................................................................38
13.0
PUBLICATION PLAN................................................................................................................................38
14.0
REFERENCES .............................................................................................................................................39
15.0
APPENDIX ...................................................................................................................................................42
I. Vaccine Specific Toxicity Form............................................................................................................................42
II. cGVHD Survey ....................................................................................................................................................43


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Phase II GVAX Following HSCT for AML/MDS
Version 14.2 July 17, 2018
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This document is confidential. Do not disclose or use except as authorized.
6
1.0 
OBJECTIVES
This is a randomized placebo-controlled Phase II study of irradiated, adenovirus vector transfected GM-CSF 
secreting autologous leukemia cell vaccination (GVAX) vs. placebo given early after allogeneic HSCT for 
advanced MDS or AML patients with active disease going into transplantation.
1.1
Study Design
GVAX vaccines will be generated by adenoviral vector mediated GM-CSF gene transfer into 
myeloblasts harvested from study subjects prior to admission for hematopoietic stem cell transplant 
(HSCT).   Patients with Myelodysplastic syndromes (MDS) with excess marrow blasts or Acute 
myeloid leukemia (AML) not in remission are eligible. Leukemia cells will be harvested for vaccination 
generation after enrollment.  Patients will be randomized (1:1) to GVAX versus placebo arm prior to 
transplant admission.   The assignment of treatment arm will be blinded to the patients, treating 
physicians, nurses, research staff, and data assessors.  Between the leukemia cell harvest and admission 
for allogeneic HSCT, patients are allowed to receive additional therapy (e.g. HMA therapy, 
chemotherapy etc.) at the discretion of the treating physician.   Between day+30 to +60* after HSCT, 
patients with adequate hematologic recovery and no GVHD requiring systemic therapy will receive 
GVAX or placebo vaccine (normal saline) injections weekly x 3 week, then starting on week 5, every 
2 weeks for 6 weeks, to complete a set of six total vaccinations.  Patients will remain on tacrolimus for 
GVHD prevention during the vaccination period.  Tacrolimus taper may commence after completion of 
vaccination, at the discretion of the treating physician, with the goal to be off immune suppression by 
6-9 months post transplant in the absence of GVHD.  
* Day 60 or next business day, if day 60 occurs on a weekend or holiday
1.2
Primary Objective:
Progression-free survival (PFS) at 18 months after randomization
1.3
Secondary Objectives:
a) To assess the safety of vaccination following allogeneic (ablative or reduced intensity) stem 
cell transplantation
b) To assess incidence of grade 2-4 and grade 3-4 acute GVHD, and chronic GVHD after 
vaccination following allogeneic stem cell transplantation.
c) To assess PFS after start of vaccination
d) To assess relapse and non-relapse mortality after vaccination
e) To assess overall survival after vaccination 
f)
To assess biologic activity of GVAX as compared to placebo vaccination after HSCT (see 
Section 8.0)


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2.0 BACKGROUND
2.1    Study Agent
GVAX vaccines will be generated by adenoviral vector mediated GM-CSF gene transfer into 
myeloblasts harvested from study subjects prior to admission for HSCT.   
2.2    Study Disease: Allogeneic SCT for Advanced MDS/AML
Although allogeneic hematopoietic stem cell transplantation is a potential curative therapy for patients 
with advanced hematologic cancers, disease relapse remains the single most frequent cause of 
treatment failure.  Success of allogeneic HSCT relies heavily on the development of anti-tumor 
activity generated by the new donor derived immune system post transplant, also known as the graft-
versus-tumor effect (GVT).  Attempts to enhance GVT by early withdrawal of immune suppression or 
administration of donor lymphocyte infusions (DLI) have been hampered by increased rates of graft-
versus-host disease (GVHD). Strategies to safely inducing GVT without promoting GVHD are 
needed.
2.3    Rationale
The early post-transplant period after allogeneic HSCT provides an attractive platform for adoptive 
immunotherapy and cancer vaccination strategies that could elicit tumor specific responses from the 
resurging donor immune cells.  Vaccination during the first 2 months after transplantation may further 
capitalize upon the lymphodepletion resulting from the conditioning chemotherapy, and take advantage 
of the homeostatic lymphoid expansion that occurs during this period.   Indeed, our pilot study in patients 
with advanced MDS/AML (DFCI protocol 04-023), as described in section 2.4 below, demonstrated that 
vaccination with GVAX early after allogeneic HSCT is feasible, safe, and associated with very 
encouraging clinical outcomes with detectable immune responses.    
To extend this effort, we propose a randomized placebo controlled trial investigating the efficacy of 
vaccination using GM-CSF transfected autologous leukemia cells (GVAX) in patients with advanced 
MDS or high risk AML early after allogeneic HSCT.  
2.4    Correlative Studies Background  
2.4.1 GM-CSF Based Tumor Vaccines (GVAX)
Several animal tumor models have demonstrated potent and specific anti-tumor immune responses with 
appropriate immune stimulation.  The local release of immuno-modulatory cytokines has been shown to 
be a useful adjuvant to tumor cell-based vaccine strategies.  This can be most effectively achieved by 
transfection of the cytokine gene into the tumor cell, which is then irradiated and injected into the animal 
as a tumor-specific vaccine.  In one study in which over 10 cytokines were compared in poorly 
immunogenic murine tumors, GM-CSF was identified as the most potent cytokine capable of generating 
systemic immunity that was CD4+ and CD8+ T cell dependent.2  This vaccine approach has been shown 
to protect and cure mice after challenge with various cancer cell lines, including AML,3 and suggests 
that it is effective in treating minimal disease states. 


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The use of GM-CSF as a vaccine adjuvant has been explored in several phase I clinical trials, in diseases 
such as AML, melanoma, hepatocellular carcinoma, pancreatic cancer, prostate cancer and renal cell 
carcinoma.4-7  These GM-CSF augmented vaccines were safe and well tolerated in patients.  The vast 
majority of adverse events were grade 1-2 injection site reactions characterized by erythema, induration, 
tenderness and localized pruritis.  Systemic adverse events have included generalized pruritis, rash, 
fatigue, fever, headache and malaise. 
At DFCI, a series of vaccination studies using GM-CSF based vaccines have been performed.  In 
one phase I clinical trial, irradiated autologous melanoma cells engineered by retroviral mediated 
gene transfer to secrete GM-CSF (GVAX) were used to vaccinate 21 patients with metastatic 
melanoma.7  In subsequent studies, irradiated autologous tumor cells engineered to secrete GM-CSF 
by adenoviral mediated gene transfer were administered by intradermal and subcutaneous injection 
at weekly and biweekly intervals in 34 patients with metastatic melanoma6 and 34 patients with 
metastatic lung cancer 5 (average GM-CSF secretion 745 ng/106 cells/24 hours and 513 ng/106 
cells/24 hours, respectively).  In each of these studies, a common feature was the development of 
intense localized skin reaction at the vaccine injection sites, associated with a dramatic influx of 
dendritic cells, macrophages, eosinophils and T lymphocytes which were not present prior to 
vaccination.  These reactions were associated with subsequent immune mediated tumor rejection at 
distant metastatic sites.  Collectively, these studies showed that local production of GM-CSF 
improves tumor antigen presentation by increasing the number and activity of professional antigen 
presenting cells in the tumor microenvironment.  In the adenoviral melanoma trial, at a minimum 
follow up of 36 months, 10 patients are alive (29%) and 4 with NED.6  Studies to elucidate the targets 
of the immune response have provided evidence of the presence of a coordinated humoral and 
cellular response to disease specific antigens.8, 9  
2.4.2 GVAX after Allogeneic HSCT for MDS/AML
We have previously completed a pilot clinical trial using AML-GVAX in patients with advanced MDS 
or refractory AML after allogeneic stem cell transplantation (DFCI protocol 04-023), the results of which 
have recently been published.10 In this study, patients with MDS-RAEB or AML not in remission who 
have a donor matched at HLA-A,B, and DRB1 were eligible.  Leukemia blasts were collected for GVAX 
generation prior to start of conditioning.  The preparative regimen consisted of fludarabine 30mg/m2/d 
IV x 4, and busulfan 0.8mg/kg IV q12H x 8 doses.  G-CSF mobilized PBSC was infused on day 0.  
GVHD prophylaxis included tacrolimus starting day -3, and methotrexate 5 mg/m2 days 1,3,6,11.  GM-
CSF (Leukine) 250 mg/m2 SC QD was administered from day+1 until neutrophil engraftment.  GVAX 
was initiated between day +30 to +45 if there was adequate hematologic count recovery and no grade II-
IV acute GVHD.  GVAX was administered weekly for the first three doses, and q2weeks for the last 
three doses.  Taper of tacrolimus began after vaccine completion.  Irradiated autologous tumor cell DTH 
were given pre and post vaccinations to assess immune responses.  
A total of 24 patients were transplanted on this study (13 unrelated, 11 related donors).  Vaccines were 
successfully produced for all subjects. The average GM-CSF secretion rate was 52 ng/106 cells/24 hours.  
The average pre-freeze viability was 98%.  Diseases included: AML (16), MDS/RAEB (6), CML 
myeloid blast crisis (2). Median age was 62 years (range, 41-71). All patients had active disease at the 
time of transplant admission.  Median marrow blast content prior to HCT was 20% (range, 6-91%). 
Median vaccine cell dose was 1.0 x 107 cells (range, 0.1-1.0 x107).  Nine patients did not initiate 


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vaccination because of rapidly progressive disease post-HCT (4), grade II-IV acute GVHD (3), sepsis 
(1), pneumonitis (1).  Fifteen patients initiated vaccination.  Ten patients completed all six vaccinations.  
5 patients did not complete all vaccinations (progressive leukemia-3, appendicitis-1, and grade II skin 
acute GVHD-1).  Two patients developed late acute GVHD in the setting of tacrolimus taper after all 
vaccinations were completed.  No patient develop grade 3-4 GVHD. The cumulative incidence of grade 
2 acute GVHD for vaccinated patients was 20%. Seven of 15 patients vaccinated developed chronic 
GVHD (6 mild, 1 moderate). All responded to corticosteroid therapy. The cumulative incidence of 
chronic GVHD was 47%.  Among the 15 patients who started vaccination after transplant, 9 are alive 
and in complete remission with a median follow up of 45 months (range 33-63 months).  Kaplan-Meier 
estimate for 2-yr overall survival (OS) for all vaccinated patients was 56 ± 14% (Figure 1). Nine of 10 
patients who completed all 6 vaccines remain in complete remission with an estimated Kaplan-Meier 
overall survival of 88 + 12%.
Figure 1. Survival after RIC HCT for advanced AML and MDS. 
OS is displayed for all pts (blue line), those that received at least 
1 vaccination (green line), and those that completed all 
vaccinations (red line).
To obtain a historical control cohort most comparable to patients who 
started vaccination in this trial, we analyzed our institutional data for 
contemporaneous patients aged >40 years undergoing RIC SCT 
between 2004-2007 with similar Bu/Flu conditioning for untreated 
MDS RAEB or AML not in remission.  We further restricted the population to those who did not develop 
grade II-IV GVHD before day+45, and who were alive at day +60 to render them most similar to patients 
on our trial who would have started GVAX.  Using these criteria, we identified 34 patients (16 AML, 
18 MDS RAEB) in the historical control group.   The 2-year overall survival for this group of patients 
was 18% as compared to 56% among patients who received at least 1 vaccination in this study (DFS 
(18% vs. 56%, p = 0.02).     
Injections of irradiated, autologous, GM-CSF secreting leukemia cells elicited local skin reactions in 14 
assessable patients, and the intensity of these responses typically increased with subsequent 
inoculations.  Clinically, the vaccine sites were characterized by erythema and induration that resolved 
within 72 hours.  Punch biopsies demonstrated accumulations of dendritic cells, macrophages, 
neutrophils, eosinophils, and lymphocytes.  Immunohistochemistry revealed abundant CD1a+ dendritic 
cells and CD4+ and CD8+ T cells, with scattered CD20+ B cells.  Intensity of histologic response 
increased between the first and fifth vaccine.  To assess DTH response to vaccination, we injected 
irradiated, autologous, non-transduced myeloblasts before and after vaccination.  Initial DTH responses 
revealed no significant infiltrates in all thirteen patients assessed.  However, when tested again at the 
time of the fifth vaccine while still on immune suppression or thereafter, seven of eight subjects 
developed significant DTH responses with brisk cellular infiltrates (Figure 2).  All 7 patients with DTH 
reactions achieved long-term clinical remissions. In one long term surviving patient, a bone marrow 
specimen obtained shortly after completing immunization demonstrated the presence of abundant CD3+ 
T cells that were associated with malignant myeloblasts and frequent eosinophils distributed through 
the marrow (Figure 3).  Three months later, no leukemia was evident in the bone marrow, which instead 
displayed normal hematopoietic differentiation.  These findings suggest vaccination early after HCT can 
provoke reactions in distant sites of disease.


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Figure 2.  DTH reactions to irradiated non-    transduced leukemia 
cells after vaccination. Depicted is infiltration of CD4, CD8, CD20, 
and CD1a cells.
Figure 3. Vaccination after HCT is associated with anti-leukemic 
immune response in the bone marrow. CD3+ T cells (right) and 
eosinophilic infiltrates (left) are highlighted.
In solid tumor patients that responded to GM-CSF secreting tumor cell 
vaccines, we have identified a correlation between immune-mediated 
tumor destruction and decreases in the levels of circulating soluble MHC class I chain-related protein A 
(MICA).11  MICA and the closely related MHC class I chain-related protein B (MICB) are ligands for 
NKG2D, an activating receptor expressed on NK cells and CD8+ T lymphocytes that contributes to anti-
tumor cytotoxicity.12  Tumor cells may escape from NKG2D mediated immune destruction through the 
shedding of surface MICA and possibly other ligands.  Prior to vaccination, 13/15 patients had high 
levels of shed MICA and/or MICB.  Six of 7 long-term responding subjects with detectable ligands 
showed marked decreases in response to therapy.  In the 3 patients who achieved complete remissions 
following vaccination and tacrolimus withdrawal, the levels of soluble ligands closely mirrored the 
disease course. In contrast, patients who did not have sustained remissions failed to display persistent 
decreases in shed MICA and MICB. To determine whether declines in soluble NKG2D ligands are 
linked to clinical response, we examined serial serum samples obtained from 35 patients who maintained 
a complete remission after allo-HCT alone.  Only a minority showed high pre-treatment levels of soluble 
MICA in a range similar to the vaccinated subjects, perhaps indicative of the advanced disease-risk 
status of the immunized patents.  Nonetheless, none of the control subjects with high levels of shed 
MICA exhibited the marked decrease in ligands detected in the vaccinated patients.
We also investigated whether we could identify potential targets of vaccination post-HSCT. One target, 
protein disulfide isomerase (PDI) has been identified through screening a murine renal cell carcinoma 
cDNA expression library with sera from mice that received GVAX.  ERp5, a closely related disulfide 
isomerase involved in MICA shedding, evokes potent humoral reactions in solid tumor patients who 
clinically respond to GM-CSF-secreting tumor cell vaccines. High titer antibodies to human PDI were 
similarly induced in an AML patient who achieved a complete response after post-HSCT vaccination.13 
In addition, sera from 5 of 9 long term survivors recognize L1CAM (CD171), a surface protein 
overexpressed in a variety of tumors, where it promotes transformation through MAP kinase pathways.14  
Monoclonal antibodies targeting L1CAM mediate tumor destruction in xenograft models.15 These 


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findings raise the possibility that vaccination-induced antibodies might mediate tumor eradication.
Given that all of the patients in this trial had active disease at the time of transplant and then received a 
reduced intensity conditioning regimen, we would have expected few to enter complete and sustained 
remission. These promising results suggest GVAX vaccination is safe and may have anticancer activity 
in patients with MDS/AML after allogeneic HSCT.
3.0  PARTICIPANT SELECTION
3.1       Eligibility Criteria
Participants must meet the following criteria on screening examination to be eligible to participate 
in the study:
3.1.1
AML, MDS-RAEB (including CMML with excess blasts and MDS/MPN overlap syndrome) 
not in remission (defined as  5% blast in bone marrow or peripheral blood) prior to leukemia 
cell harvest.  Patients may receive additional cytoreductive therapy after leukemia cell harvest 
and before admission for transplant, at the discretion of the treating physician.  For patients 
with MDS-EB1(<10%blasts) or CMML-1, it is recommended that they proceed directly to 
transplant after the harvest if donor is available.  If there is an extended delay, interval therapy 
with HMA is allowed.  
3.1.1.1 Patients may or may not have active disease at the time of transplant conditioning, but 
for RIC candidates, it is strongly recommended that disease is cytoreduced such that the pre-
transplant admission marrow shows:
<30% blasts in a normocellular marrow (>=50% cellularity), or
<50% blasts in a hypocellular marrow (<50% cellularity)
3.1.2
HLA 8/8 or 7/8 matched related or unrelated donor available, as determined by antigen or 
allele level typing at HLA A, B,C, and allele level typing at HLA DRB1.
3.1.3
ECOG performance status 0-2.
3.1.4
Age 18 years.  Because no dosing or adverse event data exist on the use of GVAX in 
participants <18 years of age, children are excluded from this study.
3.1.5
Patient deemed to be suitable candidate for myeloablative or reduced intensity conditioning 
allogeneic HSCT using PBSC or marrow as stem cell source.
3.1.6
Participants must have normal organ function as defined below: 
Total bilirubin < 2.0 mg/dL
(In patients with Gilbert’s Syndrome, Total Bilirubin  2.0 is permitted)


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AST (SGOT)/ALT (SGPT) < 3 X institutional upper limit of normal
 
  Serum creatinine < 2.0 mg/dL
3.1.7
The effects of GVAX on the developing human fetus are unknown. For this reason, women of 
child-bearing potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for the duration of study 
participation. Should a woman become pregnant or suspect she is pregnant while participating 
in this study, she should inform her treating physician immediately.
3.1.8
Ability to understand and the willingness to sign a written informed consent document.
3.2   Exclusion Criteria
Participants who exhibit any of the following conditions at screening will not be eligible for 
admission into the study.
3.2.1
Leukemia with active CNS involvement
3.2.2
Positive HIV or HTLV-1 serology. 
3.2.3
Participants may not be receiving any other Non-FDA approved study agents at the start of 
conditioning for stem cell transplantation.  Patients may receive Non-FDA approved agents at 
the time of screening/enrollment as long as such agent(s) will be discontinued by the start of 
conditioning for transplantation.
3.2.4
History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to GM-CSF.
3.2.5
Uncontrolled intercurrent illness including, but not limited to ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or 
psychiatric illness/social situations that would limit compliance with study requirements.
3.2.6
Pregnant women are excluded from this study because pregnancy is an exclusion for 
chemotherapy and stem cell transplantation
3.2.7
Individuals with a history of a different malignancy are ineligible except for the following 
circumstances. Individuals with a history of other malignancies are eligible if they have been 
disease-free for at least 2 years.  Individuals with the following cancers are eligible if 
diagnosed and treated within the past 2 years: cervical cancer in situ, and basal cell or 
squamous cell carcinoma of the skin.
3.2.8      Prior allogeneic transplant 
3.3 Inclusion of Women, Minorities and Other Underrepresented Populations


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This study will be open to all participants with AML/MDS, including women, minorities, and other 
underrepresented populations, as long as they meet the conditions of eligibility outlined above.  
4.0 REGISTRATION PROCEDURES
4.1 General Guidelines for DF/HCC and DF/PCC Institutions
Institutions will register eligible participants with the DF/HCC Quality Assurance Office for 
Clinical Trials (QACT) central registration system. Registration must occur prior to the initiation 
of therapy. Any participant not registered to the protocol before treatment begins will be considered 
ineligible and registration will be denied. 
A member of the study team will confirm eligibility criteria and complete the protocol-specific 
eligibility checklist.
Following registration, participants may begin protocol treatment. Issues that would cause 
treatment delays should be discussed with the Principal Investigator. If a participant does not receive 
protocol therapy following registration, the participant’s protocol status must be changed. Notify the 
QACT Registrar of participant status changes as soon as possible.
4.2 Registration Process for DF/HCC and DF/PCC Institutions
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 5:00 PM Eastern 
Standard Time.  QACT does not randomize after hours.  Subjects must be registered between 8 A.M. 
and 5 P.M. Monday – Friday. 
The registration procedures are as follows:
1.
Obtain written informed consent from the participant prior to the performance of any study 
related procedures or assessments.
2.
Complete the protocol-specific eligibility checklist using the eligibility assessment documented 
in the participant’s medical/research record. To be eligible for registration to the study, the 
participant must meet each inclusion and exclusion criteria listed on the eligibility 
checklist.
 
Reminder: Confirm eligibility for ancillary studies at the same time as eligibility for the 
treatment study. Registration to both treatment and ancillary studies will not be completed if 
eligibility requirements are not met for all studies.
 
3.
Fax the eligibility checklist(s) and all pages of the consent form(s) to the QACT at 617-632-
2295.
 


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4.
The QACT Registrar will (a) validate eligibility, (b) register the participant on the study, and 
(c) randomize the participant. 
 
5.
The QACT Registrar will send an email confirmation of the registration to the person initiating 
the registration immediately following the registration. Randomization result/ study arm 
assignment will be emailed to Cell Manipulation Core Facility (CMCF).  All other study 
personnel will remain blinded to the study arm assignment.
 
5.0 TREATMENT PLAN
5.1 Treatment can be administered on an either inpatient or outpatient basis. Expected toxicities and potential 
risks for irradiated, adenovirus vector transfected GM-CSF secreting autologous leukemia cell 
vaccination (GVAX) are described in Section 6 (Expected Toxicities and Dosing Delays/Dose 
Modification). No investigational or commercial agents or therapies other than those described below 
may be administered at the start of conditioning through vaccination with the intent to treat the 
participant’s malignancy. Pre-treatment criteria/Pre-transplant
  5.1.1
Pre-transplant evaluation:  All subjects enrolled on this study will undergo standard pre-
transplant evaluation before the transplant date as required by Foundation for the Accreditation of 
Cellular Therapy (FACT) regulations and according the institutional standard operating procedure. 
 
5.1.2   Randomization:  After enrollment, patients will be randomized in a 1:1 fashion to one of 2 arms 
on the study: “GVAX” vs. “Placebo”.  Randomization will be stratified by center (DFCI, 
BIDMC, MGH), disease, age 
 vs. <50), and conditioning intensity (myeloablative Flu/Bu4 
vs. reduced intensity conditioning Flu/Bu2).  Leukemia cell harvest will be performed on all 
patients regardless of their randomization status.  
  5.1.3
Leukemia cell harvest: Blood for infectious disease marker (IDM) testing will be drawn prior to, 
or on the day of leukemia cell harvest.  Leukemia cells for vaccine generation will be harvested 
via bone marrow aspiration and/or peripheral blood draw. Please note that the DFCI Cell 
Manipulation Core Facility can only accept collections Monday-Wednesday.  The procedure for 
vaccine generation is detailed below:
5.1.3.1
Bone marrow collection:    40 cc of marrow aspirate will be taken to collect leukemic 
blasts for vaccine generation and laboratory immune studies. If the patient’s most recent marrow 
biopsy was performed within 2 weeks of the collection, an additional aspirate and core biopsy 
for routine clinical staging might be performed as a part of the marrow harvest at the discretion 
of the treating physician, and based on standard clinical practice. 
5.1.3.2
Peripheral blood draw: If the patient has blasts in peripheral blood, tumor cells may 
be collected by blood draw.  The amount of blood required may vary depending on calculations 
of blood volume needed to yield a desired target of 2 x 107 leukemia cells.  If the calculated 
volume of blood draw exceeds 50 ml, it is recommended that bone marrow aspiration be used 
as the method for tumor cell harvest.
5.1.3.3
Leukapheresis:  In cases where peripheral blood draw and/or marrow harvest is 
infeasible or unsuccessful, and the patient has circulating blasts, a single leukapheresis may be 


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performed to harvest leukemia blasts.  The leukapheresis collection will follow standard 
institutional leukapheresis guidelines.   
5.1.3.4
Multiple harvests: If the first attempt to collect sufficient cells to generate six vaccines 
is insufficient, a second harvest may be performed. If the second harvest is insufficient, the 
participant will be taken “off-study.” 
5.1.3.5 All leukemia cells harvested through bone marrow aspiration and/or peripheral blood 
and/or leukapheresis draw will be sent to DFCI for vaccine/placebo preparation. 
5.1.4 Vaccine preparation:  For study participants randomized to the GVAX arm, autologous 
myeloblasts will be introduced into short-term tumor culture in the presence of G-CSF, and 
transduced with a replication defective adenoviral vector encoding human GM-CSF.  
After transduction, the tumor cells will be washed extensively and irradiated with 10,000 cGy.  A 
small aliquot of the transduced cells will be placed into culture and GM-CSF secretion will be 
determined by ELISA.  The target level for GM-CSF production will be at least 40 ng/106 cells/24 
hours, although achieving this secretion will not be required for vaccine administration.  Routine 
sterility cultures and testing for endotoxin and mycoplasma contamination will be performed.
Tumor cells for vaccination and immunologic evaluation will be cryopreserved and stored in the 
vapor phase of liquid nitrogen.  Six individual vaccine aliquots will be prepared for each patient.  
Cell dose per aliquot will be fixed for an individual patient and will range from about 1x106 cells 
per aliquot to 1x107 cells per aliquot.  The exact vaccine cell dose in each patient will vary 
depending on the total yield of myeloblasts harvested.  The dosage will be determined by dividing 
the total cell yield following transduction into six aliquots.  For total cell yields greater than 6x107, 
individual aliquots will remain at a maximum of 1x107 cells per dose. Thus, vaccine cell dosage 
will vary depending on the final vaccine cell yield after processing.  This variation in cell dosage 
is designed to maximize each patient’s opportunity of receiving vaccinations and is not based on 
any expectation of significant differences in toxicity as a function of cell number.  On the day of 
vaccine administration, cells will be thawed in a dedicated laminar flow biosafety cabinet in the 
CMCF and washed.  Cells will be re-suspended in a volume of 1 ml. for administration via a 
masked syringe
Details of the construction of the adenoviral producer cell line and safety tests on this line are 
included in the Appendix (vector manufacturing process).  The adenoviral vector was 
manufactured by Cell Genesys and approved for clinical use by the Food and Drug Administration.
5.1.5    Placebo Vaccine Preparation:  The placebo vaccine will be composed of 1 ml sterile Normal 
Saline in a masked syringe. The vaccine will be thawed, and the thawed placebo/vaccine will be 
drawn into a masked syringe at DFCI to protect blinding. The syringe will then be released for 
administration.
5.1.6  Cytoreductive therapy between harvest and HSCT:  Patients may receive additional 
cytoreductive therapy after leukemia cell harvest and before admission for transplant, at the 
discretion of the treating physician.   For patients with MDS-RAEB1, it is recommended that they 
proceed directly to transplant after the harvest if donor is available.  If there is an extended delay, 


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interval therapy with HMA is allowed.  
5.1.6.1 Patients may or may not have active disease at the time of transplant conditioning, but 
for RIC candidates, it is strongly recommended that disease is cytoreduced such that the pre-
transplant admission marrow shows:
<30% blasts in a normocellular marrow (>=50% cellularity), or
<50% blasts in a hypocellular marrow (<50% cellularity)
5.2 Allogeneic Hematopoietic Stem Cell Transplantation
5.2.1 Flu/Bu2 RIC Transplant:  The reduced intensity conditioning regimen will consist of fludarabine 
(120 mg/m^2 total) and low dose intravenous busulfan (6.4 mg/kg total).  Fludarabine 30 mg/m2/d 
will be administered as a bolus intravenous infusion once a day for 4 days on days -5, -4, -3,-2 
(based on actual body weight).  Busulfan 0.8 mg/kg (based on actual body weight) will be 
administered intravenously twice daily (approximately 12 hours apart) on day-5,-4,-3,-2 for a total 
of 8 doses.  Since it is dose twice daily, it is suggested that the busulfan be administered first, with 
the fludarabine dose sandwiched in between.  Fludarabine and busulfan can be diluted per 
institutional practice. The rate of the fludarabine and busulfan infusions can be done according to 
institutional practice. In conjunction with chemotherapy, patients will receive pre-hydration and 
intravenous fluids and/or diuretics as needed, and antiemetics as per institutional guidelines.  Day 
0 is defined as the first day of infusion of donor PBSC (or bone marrow).  In instances where the 
donor product arrival is delayed, the day 0 of transplant may be pushed back a day. Donor PBSC 
or marrow cells will be administered according to standard practice.  For PBSC products, the stem 
cell dose will be a minimum of 2x106, with a recommended target of 5x106 CD34+ cells/kg.  For 
marrow products, the recommended target is 2 x 10^8 TNC/kg.Following stem cell infusion, RIC 
SCT patients will receive GM-CSF 500 mcg SC qd starting on day +1, until absolute neutrophil 
count is>1000 on 2 consecutive values over 2 or more days. GM-CSF may be held if patient has 
circulating blasts, develops severe bone pain, or at the discretion of the transplant MD based on 
clinical judgment.  Levofloxacin 500mg PO QD (or 250mg PO QD if CrCl < 50) or another 
antibiotic is recommended as bacterial prophylaxis until ANC is >500 µL.  Prophylactic antibiotics 
for Pneumocystis carinii and HSV/VZV will be administered as per standard institutional 
guideline for RIC SCT. CMV PCR surveillance and preemptive therapy for reactivation should 
follow standard institutional guideline.
5.2.2 Flu/Bu4 Myeloablative transplantation- The myeloablative conditioning regimen will consist 
of Fludarabine and high dose intravenous Busulfan approximately q6hrs for 4 days, as follows:
5.2.2.1
Fludarabine 40 mg/m2 per day will be administered as a bolus infusion administered by 
IV infusion over approximately 1 hour for 4 days on days -5, -4, -3, -2 (based on actual 
body weight; or adjusted ideal body weight for those >125% of ideal body weight). 
Adjusted ideal body weight will be defined as ideal weight plus 25% of the difference 
between ideal and actual weight).  Fludarabine can be diluted per institutional practice.
AIBW = IBW + (0.25)(ABW-IBW)
AIBW – adjusted ideal body weight
IBW – ideal body weight


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ABW – actual body weight
5.2.2.2
Busulfan 0.8mg/kg will be administered intravenously 4 times daily (approximately 
q6hrs apart) for 5 days on day -5,-4,-3,-2, -1 for a total of 16 doses, as per institutional 
guidelines.  The rate of the busulfan infusions can be done according to institutional 
practice.  Dosing of busulfan will be based on actual body weight, or adjusted ideal body 
weight for patients >125% of ideal body weight. Adjusted ideal body weight will be 
defined as ideal weight plus 25% of the difference between ideal and actual weight. 
AIBW = IBW + (0.25)(ABW-IBW)
AIBW – adjusted ideal body weight
IBW – ideal body weight
ABW – actual body weight
In conjunction with chemotherapy, patients will receive seizure prophylaxis with Keppra 
from day -5 until day-1. Pre-hydration and intravenous fluids and/or diuretics will be as 
per the HSCT standard practice. Anti-emetics will be as per institutional guidelines.
The donor PBSC (or bone marrow) product will be infused on day 0.  In instances where 
the donor product arrival is delayed, the day 0 of transplant may be pushed back a day. 
Stem cells will be administered according to standard practice.  Stem cell dose will be a 
minimum of 2 x106, with a recommended target of 5x106 CD34+ cells/kg.  GM-CSF will 
be given to hasten white blood count recovery starting on day+12, until absolute 
neutrophil count (ANC) is >1000/ul on 2 consecutive values over 2 or more days. GM-
CSF may be held if ANC is already > 500 on day +12 or at the discretion of the treating 
physician based on clinical judgment. Infection prophylaxis for herpes viruses and 
Pneumocystis carinii will follow standard institutional practice. CMV PCR surveillance 
and preemptive therapy for reactivation should follow standard institutional guideline.
5.2.3
GVHD prophylaxis: GVHD prophylaxis for both myeloablative or RIC  HSCT will 
include oral tacrolimus starting on day –3, and methotrexate on Days +1,3,6,11, as 
follows: 
5.2.3.1 Tacrolimus (FK506) will be given orally at a dose of 0.05 mg/kg PO bid starting 
day –3.  Subsequent dosing will be based on clinical toxicity, and trough blood 
levels with recommended target of 5-10 ng/ml.  Doses may be rounded to the 
nearest 0.5 mg dose and adjusted as needed to maintain therapeutic serum 
tacrolimus levels.   The dose may be replaced if the patient vomits within 15 
minutes of taking a dose, at the discretion of the transplant physician.   
Tacrolimus may be switched to intravenous dosing to maintain the same 
therapeutic goal level if necessary. 
5.2.3.2 Methotrexate
    
For the RIC cohort (FluBu2)- The methotrexate dose will be 5 mg/m2 IV on 
day+1,3,6,11, infused as per standard institutional guidelines.  In cases where 
stem cell infusion (day 0) spans more than 1 day, the day +1 dose of methotrexate 


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should start 1 day after the end of the SC infusion.
       
For the Myeloablative cohort (FluBu4)- The methotrexate dose will be 15 mg/m2 
IV on day +1, and 10mg/m2 on days +3,6, and 11.   Methotrexate should be 
infused as per standard institutional guidelines.  In cases where stem cell infusion 
(day 0) spans more than 1 day, the day +1 dose of methotrexate should start 1 day 
after the end of the stem cell (SC) infusion.  Leucovorin rescue is allowed per 
standard practice guidelines if necessary, at the discretion of the transplant 
physician.  The day 11 dose of MTX may be reduced 50% or omitted if deemed 
necessary based on the clinical situation, and at the discretion of the transplant 
physician.  In cases where clinical toxicities, e.g. renal failure, pleural effusion, 
etc. would render completing at least 3 doses of methotrexate unsafe, substitution 
with mycophenolate mofetil (cellcept) 1000mg PO/IV BID or other agent such as 
sirolimus is allowed at the discretion of the treating physician.  In instances where 
MTX is substituted by cellcept, it is recommended that the cellcept be 
discontinued around day +28 in the absence of GVHD.
5.2.4 Tacrolimus Taper: 
5.2.4.1
Tacrolimus taper is NOT allowed during the vaccination period.  Taper may 
commence 1 week after the last GVAX/Placebo vaccine, at the discretion of the 
transplant physician, with the goal to be off immune suppression by 6-9 months in the 
absence of GVHD.
5.2.4.2
Tacrolimus taper for patients with progressive disease before completion of 
vaccinations:  Patients with evidence of progressive disease AND requiring additional 
therapy or taper of immune suppression will receive no further vaccinations.  In these 
cases, the tacrolimus taper will be performed at the discretion of the treating physician.
5.3 GVAX/Placebo Vaccination
Vaccination with GVAX or placebo vaccine will commence after hematologic recovery has occurred and 
the patient is between day +30 to day +60* post transplant.  Vaccine administration can occur on an either 
inpatient or outpatient basis. At any time between day+30 to day +60*, the patient may undergo a bone 
marrow aspirate/biopsy and GVAX/placebo vaccination may commence provided the following criteria 
are satisfied:
            * Day 60 or next business day, if day 60 occurs on a weekend or holiday 
5.3.1 Criteria for starting GVAX/Placebo administration:
No grade II-IV acute GVHD
No systemic corticosteroid therapy*
No uncontrolled acute infection
No CTC grade  3 non-hematologic toxicity
Absolute neutrophil count   500/ul off growth factor


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Platelet count  10K/ul without transfusion.
Absolute eosinophil count  5000/ul
* Except for physiologic doses of steroids for adrenal insufficiency  
Participants who do not meet the above criteria to start vaccination by day +60 will be 
considered “off treatment”, and followed for survival.
5.3.2
GVAX/Placebo Administration:  
5.3.2.1 Vaccinations will be administered weekly x 3 weeks, then q2weeks x 6 weeks for a total 
of 6 vaccines.  The weekly scheduling of vaccination can be +/- 2 days for scheduling 
flexibility.  A physician, PA, NP, RN, or research RN can administer the injections in either 
an outpatient or inpatient clinical setting. Injections will be administered according to 
standard nursing procedure in the patient’s arms and thighs on a rotating basis.  Injections 
must be performed without the prior application of EMLA or other topical or local 
anesthetics, as such compounds both could obscure local reactions to the vaccination and 
could cause reactions that might be interpreted as vaccine reactions. Approximately half of 
the vaccine dose should be administered subcutaneously, and remaining half the vaccine 
dose intradermally.  It is suggested that about half of the vaccine be given first 
intradermally, and the rest subcutaneously by changing that angle of the needle.  
5.3.2.2 Information regarding the number and location of the injections, the date of vaccination, 
route of administration, total volume of vaccine administered and vaccine site injection 
reactions will be collected for each vaccination and recorded in the patient medical record.
5.3.2.3 A skin punch biopsy of the vaccine site is strongly encouraged (but not required) for 
histologic and laboratory correlative examination 2-3 days after the 1st and 5th vaccination. 
Skin punch biopsies will be sent to DFCI.
5.3.2.4 The Vaccine Specific Toxicity Form (Appendix I) must be completed by a study 
investigator at weekly during vaccination period, and at 1 month after the last vaccination.
5.3.3 Early discontinuation of GVAX/Placebo vaccination 
5.3.3.1
Disease relapse or progression requiring taper or withdrawal of tacrolimus, or additional 
systemic therapy.
5.3.3.2
Acute GVHD or chronic GVHD requiring systemic steroid therapy.
5.3.3.3
CTC grade  4 non-hematologic toxicity possibly, probably or definitely related to 
vaccination.
5.3.3.4
Delay of vaccination over 14 days (see below)


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5.3.4 Delay of GVAX/Placebo vaccination:  If severe hematologic toxicity (defined as ANC <500/ul, 
platelet < 10K/ul, or absolute eosinophil count > 5000/ul), CTC grade  3 non-hematologic 
toxicity develops during the vaccination period, vaccination may be delayed up to 14 days 
until the event has improved by at least 1 CTC grade.  If condition is not improved after 14 
days in the opinion of the treating physician and/or study PI, or if the toxicity recurs upon re-
initiation of vaccination, no further vaccination will be given. In an event where the toxicity 
is grade < 3, vaccination may also be delayed at the physician’s discretion.  
5.3.5 Off Treatment Criteria with continued study visits:  Patients who receive at least 1 
vaccination, but do not complete 6 vaccines for any reason other than disease relapse requiring 
additional therapy or hospice will be considered “off treatment”.  These patients will continue 
“on study” for study visits, tests/procedures, and assessment of toxicity and survival end 
points. It is preferred that study specific blood samples be drawn and bone marrow biopsies 
are performed according to the study calendar, but these may be foregone for clinical reasons 
or if the patient declines to have one performed.  
5.3.6 Off Treatment Criteria with survival follow-up only:  Patients meeting the following criteria 
will be considered “off treatment” and no further study visits, or study related testing will be 
performed.  Survival information will be recorded.
5.3.6.1 Patients who have disease relapse after starting vaccination and require additional therapy 
(chemotherapy or immune therapy) or hospice placement.  
5.4 General Concomitant Medication and Supportive Care Guidelines
Guidelines for use of concomitant medications, and supportive care medications should follow standard 
practice for patients after allogeneic stem cell transplantation. 
Growth factor (G-SCF or GM-CSF) use to stimulate white blood cells during the vaccination 
period is not allowed during weeks where patients are scheduled to receive vaccinations. This 
may be given on weeks during the vaccination period where no vaccinations are given. 
As described above, patients should remain on tacrolimus without active taper during the 
vaccination period. Routine adjustment of tacrolimus dosing to maintain trough level in 
therapeutic range should be performed as per standard of practice.  
Addition of other systemic immune suppressive medications, including steroids, for the 
treatment graft-versus-host disease will lead to discontinuation of vaccination.  
Short term use of systemic steroids, such as for blood or platelet transfusion reactions, hives, 
or other acute allergic reaction is allowed. 
5.5 Duration of Vaccination
Duration of vaccination will depend on individual response, evidence of disease progression and 
tolerance. In the absence of treatment delays due to adverse events, treatment may continue for 
administration of all 6 vaccines or until one of the following criteria applies:


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General:
Intercurrent illness that prevents further administration of the vaccine
Unacceptable adverse event(s),
Participant demonstrates an inability or unwillingness to comply with the regimen and/or 
documentation requirements
Participant decides to withdraw from the study, or
General or specific changes in the participant's condition render the participant unacceptable 
for further treatment in the opinion of the treating investigator.
GVAX discontinuation based on criteria as set previously.
5.6 Duration of Follow Up 
Because this is a gene transfer study, all participants who received at least one vaccination will 
be followed for safety for up to 15 years after removal from study, or until death, whichever 
occurs first. Participants removed from study for unacceptable adverse events will be followed until 
resolution or stabilization of the adverse event.
5.7 Criteria for Removal from Study 
Participants will be removed from study if they withdraw consent or if they do not start 
vaccination by day+60* after HSCT as specified in the protocol.   The reason for study removal 
and the date the participant was removed will be documented in the patient’s medical record 
* Day 60 or next business day, if day 60 occurs on a weekend or holiday
6.0   EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS 
Dose delays will be made using the following recommendations. Toxicity assessments will be done using 
NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 which is identified and 
located on the CTEP website at: 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference
_5x7.pdf
All adverse events experienced by participants will be collected from the time of the first vaccination, 
through the study and until the final study visit (18 months from SCT). Participants continuing to 
experience toxicity at the off study visit will be contacted for additional assessments until the toxicity has 
resolved or is deemed irreversible.
6.1 Anticipated Toxicities


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A list of the adverse events and potential risks associated with the GVAX vaccination administered in 
this study appear below and will determine whether dose delays and modifications will be made or 
whether the event requires expedited reporting in addition to routine reporting.
6.1.1
Anticipated toxicities of GVAX vaccine:
6.1.1.1 Localized skin reaction: In previous studies using GM-CSF secreting tumor cell vaccines, 
little toxicity other than injection site discomfort was observed.  The most common adverse 
events were injection site reaction with erythema, induration, and local pruritis that was 
easily controlled with topical emollients.  Grade I fatigue and nasal congestion were 
occasionally noted. No organ toxicities or autoimmune events were noted. GVAX is an 
investigational product and may have other side effects that are unknown at this time.
6.1.1.2 Potential toxicities of GM-CSF:  GM-CSF is widely used for accelerating hematopoietic 
recovery and its spectrum of toxicity well established.  It is likely that the highest level of 
GM-CSF secreted by the cells in the vaccine will be far lower than the usual starting dose 
for systemic application (350 mcg/day).  While we cannot predict the exact toxicities 
attributable to local secretion of GM-CSF delivered by adenoviral mediated gene transfer, 
toxicities observed from the previous trial were restricted to erythema, pruritus, and 
swelling.  Local toxicities of GM-CSF protein injection have included pustular eruption, 
necrotizing vasculitis, erythema, pruritus, recall erythema at previous injection sites, general 
papular rash, and phlebitis.  Systemic toxicities have included fever, bone pain, malaise, 
diarrhea, transient liver function test (LFT) abnormalities, leukopenia, leukocytosis, 
eosinophilia, arthralgia, dyspnea, fluid retention, serous effusions, and recrudescence of 
various auto-immune diseases.
6.1.1.3 Potential for prolonged survival of leukemia vaccine cells:  All GM-CSF transfected 
autologous vaccine cells used in this trial will be irradiated with 10,000 rads to ensure they 
will die after several days.  It is thus unlikely, but theoretically possible, that some tumor 
cells can survive the radiation, secrete GM-CSF long-term, or even cause leukemia relapse.   
These events have not been observed in any of the prior studies using retroviral or 
adenoviral transfected autologous tumor cell GVAX.  However, in another study using a 
different type of GVAX vaccine composed of K562 leukemia cells transfected with GM-
CSF and mixed with autologous tumor cells (DFCI Protocol 08-160), there was one case 
where the GM-CSF secreting K562 cells persisted at the vaccine site, and resulted in severe 
eosinophilia that proved to be ultimately fatal.  It should be noted that K562 cells are not 
being used in this trial.
6.1.1.4 Auto-immune diseases: This is a theoretic possibility for which patients will be monitored. 
In principle, the mechanisms that allow the immune system to recognize tumor antigens 
could also lead to breakdown of tolerance to normal or self-antigens, generating an 
autoimmune reaction. In the B16 murine melanoma model, vaccination with GM-CSF 
expressing tumor has been associated with depigmented patches of skin, an indication of 
tissue-specific autoimmunity.  No examples of autoimmunity were seen in previous GVAX 
trials in AML, melanoma, renal cell carcinoma, prostate cancer, pancreatic cancer and lung 
cancer.
6.1.1.5 DMSO toxicity.  This toxicity is unlikely since the vaccine will be washed prior to 
administration. The cells are cryopreserved in 10% DMSO.  DMSO is a hydrophilic 


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23
molecule, which diffuses through tissue rapidly.  Although toxicities associated with 
intradermal administration of 10% DMSO in humans have not been published, toxicities 
associated with topical administration of 50% or more DMSO include skin irritation 
(vesiculation, urticaria, erythema, induration, pruritus, pain, bleeding, scaling, heat 
generation), garlic-like taste and odor on the breath and skin, transient disturbances of color 
vision, photophobia and diarrhea.  The FDA has authorized the use of 50% DMSO for the 
treatment of interstitial cystitis in humans.  Numerous studies in humans have demonstrated 
the relative safety of intravenous infusion of cells cryopreserved in 10% DMSO solutions, 
as this has become standard medical practice for infusion of cryopreserved peripheral blood 
and bone marrow stem cell collections in the setting of stem cell transplantation.
6.1.1.6 Potential toxicity from Adenovirus Vector.  Wild type adenovirus serotype 5 (from which 
the vector used in this study is derived) is associated with an upper respiratory infection and 
conjunctivitis.  There is controversy regarding a role in infantile intussusception.  Other 
adenovirus serotypes are associated with cystitis, gastroenteritis, and pneumonia in military 
recruits during basic training.  The adenoviral vector used in this study will be certified to 
contain less than one replication competent serotype 5 viral particles per vaccine inoculum.  
In the event that recombination between a latent wild type adenovirus and the introduced 
adenoviral vector occurs in the tumor cell, this will not lead to production of a replication 
competent GM-CSF expressing virus, as the GM-CSF cDNA is inserted in the E1 deleted 
region of the vector.  Transduced cells will be injected into the skin; thus in the absence of 
an open wound, there is no significant risk of transmitting the virus to close contacts.  If skin 
breakdown does occur, the skin should be covered with an adherent bandage until healing 
has occurred.
6.1.1.7 Acute and chronic GVHD.  While we hypothesize that this vaccine may elicit a leukemia 
specific response by the donor immune system, the possibility that it may elicit or aggravate 
GVHD also exists.  In our previous trial using this GVAX platform after RIC SCT (04-023), 
we did not observe any increase in acute or chronic GVHD in excess of what is expected at 
baseline.  Differences in grade 3-4 acute GVHD between the vaccine and no vaccine arms 
will be assessed in planned interim analyses, see section 13.7.
6.1.1.8 Unexpected vaccine related toxicity:  Any severe adverse event (CTC grade  3) that is 
not readily explained as a transplant or disease associated complication will be assessed as a 
possible vaccine related toxicity. 
6.1.1.9 Anticipated Toxicities of Allogeneic transplantation
Fludarabine- The most common adverse events include myelosuppression (neutropenia, 
thrombocytopenia and anemia), fever and chills, infection, and nausea and vomiting. 
Other commonly reported events include malaise, fatigue, anorexia, and weakness. 
Serious opportunistic infections have occurred in CLL patients treated with fludarabine. 
Busulfan- The most frequent, serious, toxic effect of busulfan is myelosuppression 
resulting in leukopenia, thrombocytopenia, and anemia. Hepatic veno-occlusive disease, 
which may be life-threatening, has been reported following the use of very high doses of 
busulfan in combination with cyclophosphamide or other chemotherapeutic agents prior 
to bone marrow transplantation. Possible risk factors for the development of hepatic 
veno-occlusive disease include: total busulfan dose exceeding 16 mg/kg based on ideal 


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24
body weight, high busulfan levels, and concurrent use of multiple alkylating agents. A 
clear cause-and-effect relationship with busulfan has not been demonstrated.  At high 
doses, busulfan has been shown to induce clinical seizures, and as such, all patients will 
receive seizure prophylaxis during conditioning with high dose busulfan.  Interstitial 
pulmonary fibrosis has been reported rarely.  Busulfan is capable of inducing cataracts in 
rats and there have been several reports indicating that this is a rare complication in 
humans. In the few cases reported in humans, cataracts have occurred only after 
prolonged administration of busulfan.  Hyperpigmentation is the most common adverse 
skin reaction and occurs in 5% to 10% of patients, particularly those with a dark 
complexion.
Tacrolimus - Primary toxicities include renal insufficiency, hypertension, 
hyperglycemia, hypomagnesemia, hypokalemia, and neurologic toxicity, including 
seizure and visual blindness.  Rarely, tacrolimus may thrombotic microangiopathy, a 
severe condition characterized by acute renal failure, neurologic symptoms (confusion, 
seizures), anemia and thrombocytopenia.
Methotrexate- The primary toxicities expected are myelosuppression and mucositis.  
These effects are expected to be mild since dosing in mini-methotrexate is reduced.  At 
high doses, MTX is also known to cause liver and/or renal damage.  MTX can collect in 
extra-cellular fluid compartments, leading to delayed clearance and increased side effects.  
Therefore, in patients with significant third space fluid collections (e.g. ascites, pleural, 
pericardial effusions), leucovorin rescue may be administered at the discretion of the 
transplant physician.
GM-CSF- Short term administration of GM-CSF to hasten neutrophil recovery may lead 
to bone pain, back pain, headaches, and an elevated white blood cell count in the blood.   
Pancytopenia- Pancytopenia is common and expected early after HSCT.  If 
pancytopenia is prolonged, this may lead to infections, bleeding, or death.  For patients 
with graft failure/prolonged pancytopenia, infusion of additional allogeneic stem cells or 
re-infusion of stored autologous stem cells (if available) will be considered.  Patients who 
have not engrafted by day +45 will be removed from study and not receive vaccination.
Graft versus Host Disease (GVHD)- The principal target organs of acute GVHD are 
skin, gastrointestinal tract, and liver.  Treatment in most cases will consist of increased 
doses of prednisone with or without the addition of other immune suppressive agents.  
Acute GVHD will be graded according to the modified Glucksberg score.16  Chronic 
GVHD can also affect skin, gut, and liver, but in addition, can affect mucosal membranes 
(dry eyes, dry mouth, vaginal dryness), joints (stiffness), and lungs (dry cough, dyspnea).  
Chronic GVHD will be graded as limited or extensive based on the original Seattle 
criteria.17
6.2 Toxicity Management
6.2.1 Vaccine site reaction- Local vaccine site reactions are generally transient and self limiting.  
Local management may include cold compress, moisturizing lotions.  Topical steroids and/or 
topical antihistamines should be avoided if possible so as to not potentially blunt the 


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immunologic response to the vaccine.  If the reaction persists more than 1 week, or the area of 
erythema and induration persists, a skin biopsy of the area will be considered.  
6.2.2
Severe Eosinophilia- If increased absolute eosinophil count to > 5.0 x10^9/L (5000/ul) occurs 
during the vaccination period, further vaccines will be delayed (see section 5.3.4).  In the event 
that the absolute eosinophil count remains >5.0 x10^9/L for more than 2 weeks despite being off 
vaccination, no further vaccinations will be given.  Since mild eosinophilia is common after 
allogeneic HSCT, and is also a well recognized and expected response to vaccine, a transient 
increase in absolute eosinophil count is not an automatic cause for halting all future vaccinations.  
6.3 Dose Modifications/Delays
There will be no vaccine dose adjustments for this study.
Guidelines for delays or discontinuation of vaccination are described in sections 5.3.3 and 5.3.4, 
respectively.
6.4 Unblinding
There are no plans for unblinding while patient are on treatment.. Should an event occur where unblinding 
is believed to be necessary for the care of the patient, the case will be discussed with the study PI and 
Robert Soiffer, M.D., the IND holder. After the study is closed to accrual and the last patient has 
completed the GVAX/placebo vaccinations, the study may be unblinded for data analysis.
7.0  DRUG FORMULATION AND ADMINISTRATION 
7.1 GVAX/Placebo
7.1.1 Description
GVAX is a GM-CSF secreting autologous leukemia cell vaccination.
The vaccine is produced through adenoviral vector mediated GM-CSF gene transfer into 
myeloblasts harvested from study subjects prior to admission for HSCT.  The placebo vaccine will 
consist of a sterile normal saline solution.
7.1.2
Form
Cells for vaccine will be thawed in a dedicated laminar flow biosafety cabinet in the CMCF and 
washed. Cells will be resuspended in a volume of 1 ml. for administration. 
7.1.3
Storage and Stability
Tumor cells for vaccination and immunologic evaluation will be cryopreserved and stored in 
liquid nitrogen. Six individual vaccine aliquots will be prepared for each patient. Cell dose per 
aliquot will be fixed for an individual patient and will range from a minimum of 1x106 cells per 
aliquot to 1x107 cells per aliquot. The dosage will be determined by dividing the total cell yield 
following transduction into six aliquots. Thus, a minimum of 6x106 cells will be required to 


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prepare six aliquots of 1x106 cells. For total cell yields greater than 6x107, individual aliquots 
will remain at 1x107 cells per dose.
7.1.4
Handling
Qualified personnel, familiar with procedures that minimize undue exposure to themselves and 
the environment, should undertake the preparation, handling, and safe disposal of the 
chemotherapeutic agent in a self-contained and protective environment.
7.1.5
Availability
GVAX/Placebo is an investigational agent and will be supplied free-of-charge from CMCF.
7.1.6
Preparation
7.1.6.1  GVAX
Harvested autologous myeloblasts will be transferred to the Cell Manipulation Core Facility 
(CMCF) at the Dana Farber Cancer Institute. The autologous myeloblasts will be introduced into 
short-term tumor culture in the presence of G-CSF, and transduced with a replication defective 
adenoviral vector encoding human GM-CSF.  
After transduction, the tumor cells will be washed extensively and irradiated with 10,000 cGy.  A 
radiation indicator tag that changes color from red to black after radiation will be appended to the 
bag containing the cells to assure that radiation is completed.  In addition, the completion of 
radiation will recorded by 2 qualified members of the laboratory, who will also verify that the 
appropriate radiation dose of 10,000 cGy is delivered.
A small aliquot of the transduced cells will be placed into culture and GM-CSF secretion will be 
determined by ELISA. The target level for GM-CSF production will be at least 40 ng/106 
cells/24 hours, although achieving this secretion will not be required for vaccine administration. 
Routine sterility cultures and testing for endotoxin and mycoplasma contamination will be 
performed.
Tumor cells for vaccination and immunologic evaluation will be cryopreserved and stored in liquid 
nitrogen.  Six individual vaccine aliquots will be prepared for each patient.  Cell dose per aliquot 
will be fixed for an individual patient and will range from about 1x106 cells per aliquot to 1x107 
cells per aliquot.  The exact vaccine cell dose in each patient will vary depending on the total yield 
of myeloblasts harvested. Vaccine dose will be calculated based on the myeloblast count 
performed on a post-ficoll sample assessed in the Hematology Laboratory at DFCI. Following 
transduction, the final product will be divided equally into six aliquots to yield 6 vaccines of the 
same dose.  For total cell yields greater than 6x107, individual aliquots will remain at a maximum 
of 1x107 cells per dose. 
On the day of vaccination, cells will be thawed in a dedicated laminar flow biosafety cabinet in 
the CMCF and washed.  Cells will be re-suspended in a volume of 1 ml. in a syringe for 
administration.  The syringe will be masked with special tape to prevent administrating personnel 
from distinguishing cellular vaccines from placebo.
7.1.6.2 Placebo


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The placebo vaccine will be prepared by the CMCF staff on the day of vaccination.  The vaccine 
will consist of 1 ml. sterile normal saline.  The syringe will be masked with special tape to prevent 
administrating personnel from distinguishing cellular vaccines from placebo.
7.1.7
Administration
GVAX/Placebo vaccinations will be administered weekly x 3 weeks, then q2weeks x 6 weeks for 
a total of 6 vaccines.  The weekly scheduling of vaccination can be +/- 2 days for scheduling 
flexibility.  
A study team physician, physician assistant, nurse practitioner, registered nurse, or research 
registered nurse can administer the injections in either an inpatient or outpatient clinic. Injections 
will be administered according to standard nursing procedure in the patient’s arms and thighs on a 
rotating basis.  Injections must be performed without the prior application of EMLA or other 
topical or local anesthetics, as such compounds both could obscure local reactions to the 
vaccination and could cause reactions that might be interpreted as vaccine reactions. 
Approximately 1/2 of the vaccine dose should be administered subcutaneously, and remaining half 
the vaccine dose intradermally.  It is recommended that about half of the vaccine be given first 
intradermally, and the rest subcutaneously by changing the angle of the needle. 
Information regarding the number and location of the injections, the date and time of vaccination, 
route of administration, total volume of vaccine administered and vaccine site injection reactions 
will be collected for each vaccination and recorded in the patient’s chart.
7.1.8
Ordering
Orders for the collection of cells, manufacturing of vaccine/placebo, and release of the 
vaccine/placebo will be done through the electronic Biologic Order Entry system, as is 
standard for all cellular therapy order entry at the DFCI.  The GVAX/placebo vaccine will be 
manufactured at the Cell Manipulation Core Facility(CMCF). Once an order for processing has 
been received by CMCF, GVAX cells will be thawed or the placebo vaccine will be prepared for 
administration accordingly.  
7.1.9
Accountability
GVAX/placebo accountability is maintained by the Cell Manipulation Core Facility (CMCF). 
7.1.10 Destruction and Return
CMCF will receive reagents, if they are not used the reagents will be held for future use until 
they are out of date at which point they will be destroyed according to institutional policies. 
Destruction will be documented in the Drug Accountability Record Form.
8.0
CORRELATIVE/SPECIAL STUDIES 


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Biologic responses to vaccination following allogeneic stem cell transplant will be assessed by laboratory and 
histologic analyses of blood before and after vaccination, and skin biopsy samples at vaccination.  Bone marrow 
aspirates will also be cryopreserved, if sufficient material is available.  We anticipate that vaccination will elicit 
robust infiltrates composed of dendritic cells, macrophages, granulocytes, and lymphocytes.  The numbers and 
proportions of CD4+ and CD8+ T effectors and FoxP3+ Tregs will be evaluated.  The local production of relevant 
cytokines and chemokines will also be examined using real-time PCR and commercially available RNase 
protection assays.
Serum and circulating mononuclear cells will be frozen prior to beginning vaccination and at regular intervals 
thereafter.  These longitudinal samples will be analyzed for immune cell numbers and subsets.  We will use multi-
color flow cytometry methods (5 or 9 color), already established in the Cancer Vaccine Center Immune 
Assessment Core, to investigate immune cell subsets. These phenotypic measurements will be complemented 
with functional studies. An evaluation of T cell proliferation, cytokine production, and cytotoxicity will be 
undertaken, employing autologous tumors as targets, when available. The samples will also be used in research 
studies aimed at identifying the target antigens of vaccination, characterizing NK, T and B cell responses to these 
targets, and delineating the mechanisms involved in protective immunity.  These research tests may include 
evaluation of reactivity to targets identified in earlier vaccine studies; these may include ATP6S1, melanoma-
inhibitor of apoptosis protein (ML-IAP), opioid growth factor receptor (OGFr), CML28, CML66, PDI, ERp5, 
L1CAM, angiopoietin-1/2, MIF, progranulin, and MICA.  
9.0  STUDY CALENDAR
 
Tests/Evaluations
Enrollment 
Pre-SCT
Leukemia 
Cell 
Harvest
Day 20-30 
post SCT
Vaccine 1 
Day30-609  
post SCT
During 
vaccination
1 month* 
after last 
vaccine
6 months* 
post SCT
9months* 
post SCT
12 & 18 month*
post SCT 
Informed Consent
X
Physical Exam
X
X
X
Qwk
X
X
X
X
Adverse Event assessment
X
X
X
Qwk
X
X
X
X
GVHD assessment
X
X
Qwk
X
X
X
X
Pre-transplant testing1
X
CBC with differential
X
X
X
Qwk
X
X
X
X
Bun/Cr, LFTs, LDH
X
X
X
Qwk
X
X
X
X
CMCF/Immune Bloods2 
X
X
X
Qmonth
X
X
X
X
Marrow Asp/BX
X4
X5,6
X5
X5
X5
Peripheral blood leukemia cell 
harvest
X7
Vaccine specific toxicity 
Assessment (Appendix I)
X
Qwk
X
Skin bx of vaccination 3
X
Vaccine 5
cGVHD Form (Appendix II)
X8
X8
X8
X8


Phase II GVAX Following HSCT for AML/MDS
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1
Standard pre-transplant testing per institution guidelines
2
Approximately 60cc blood
3
Skin biopsies of vaccine site(2-3 days after injection) are strongly encouraged, but not required for study participation.
4
Should be performed  28 prior to enrollment if the patient has received intervening therapy
5
Also sent for flow cytometry, FISH/cytogenetics, chimerism (if post SCT), molecular studies (if applicable). An additional marrow aspirate 
sample is encouraged, but not required to be drawn during protocol bone marrows, and should only be collected if there is excess marrow 
aspirate available and a sufficient number of cells for banking by the CMCF. 
6
Optional if patient qualifies for peripheral blood leukemia cell harvest or at treating physician’s discretion if previous restaging marrow 
aspirate/biopsy was within two weeks of collection. 
7
If the patient has blasts in peripheral blood, tumor cells may be collected by blood draw.  The amount of blood required may vary depending 
on calculations of blood volume needed to yield a desired target of 2 x 107 leukemia cells.  If the calculated volume of blood draw exceeds 
50 ml, it is recommended that bone marrow aspiration be used as the method for tumor cell harvest.
8
Participants will have cGVHD assessed with the cGVHD form at every protocol visit once the participant has developed cGHVD. 
9
Day 60 or next business day, if day 60 occurs on a weekend or holiday
*    +/- 2 weeks to allow for scheduling flexibility. Please refer to Section 5.3.5 and 5.3.6 to determine off treatment criteria with continued study 
visits and those with survival follow-up only.
 
Because this is a gene transfer study, all participants who received at least one vaccination will be followed for safety for up to 
15 years after removal from study, or until death, whichever occurs first (see Section 5.6 for additional information).


Phase II GVAX Following HSCT for AML/MDS
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10.0 ADVERSE EVENT REPORTING REQUIREMENTS
10.1Definitions
10.1.1
Adverse Event (AE)
An adverse event (AE) is any undesirable sign, symptom or medical condition or experience that 
develops or worsens in severity after starting the first dose of study treatment or any procedure 
specified in the protocol, even if the event is not considered to be related to the study. 
Abnormal laboratory values or diagnostic test results constitute adverse events only if they 
induce clinical signs or symptoms or require treatment or further diagnostic tests. 
10.1.2 Expectedness
Adverse events can be 'Expected' or 'Unexpected.' 
Expected adverse events are those that have been previously identified as resulting from 
administration of the GVAX/placebo vaccine. For the purposes of this study, an adverse event is 
considered expected when it is a known risk associated with the GVAX/placebo vaccination, or 
is included in the informed consent document as a potential risk.  
Refer to Section 6.1 for a listing of expected adverse events associated with GVAX/placebo 
vaccination.
For the purposes of this study, an adverse event is considered unexpected when it varies in 
nature, intensity or frequency from side effects that are expected after the GVAX/placebo 
vaccination. Refer to section 6.1 for a listing of expected adverse events associated with 
GVAX/placebo vaccination.
Adverse events occurring during vaccination or within 1 month of the last GVAX/placebo 
vaccination will be reported to the DFCI IRB according to DF/HCC policy. 
10.1.3 Attribution
Attribution is the relationship between an adverse event or serious adverse event and the study 
treatment. Attribution will be assigned as follows:
Definite – The AE is clearly related to the study treatment.
Probable – The AE is likely related to the study treatment.
Possible – The AE may be related to the study treatment. 
Unlikely - The AE is doubtfully related to the study treatment.
Unrelated - The AE is clearly NOT related to the study treatment.
10.2 Procedures for AE and SAE Recording and Reporting
Participating investigators will record and assess the occurrence of AEs at all participant evaluation 
time points during the study. Refer to section 9.0 for the evaluation time points.


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As with all transplant patients, regardless of being on study, all grade  3 non-hematologic AEs and 
grade  4 hematologic AEs will be recorded in the participant’s medical record and DFCI BMT data 
repository.
In addition, during and at 1 month after the last vaccination, adverse effects commonly associated with 
vaccination, as specified on the Vaccine Specific Toxicity Form (See Appendix I), will be recorded 
regularly regardless of grade. 
The descriptions and grading scales found in the revised NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. All appropriate treatment 
areas should have access to a copy of the CTCAE version 5.0.
A copy of the CTCAE version 5.0 can be downloaded from the CTEP website at:
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quick_Refere
nce_5x7.pdf
10.3 AE Reporting Period and Requirements
Because transplant is standard of care for this patient population, adverse events and deaths occurring 
before GVAX/placebo administration will not be reported. The first day of adverse event reporting will 
coincide with the day the first vaccination is administered. Adverse event reporting for this study ends 
at the final study visit (18 months post SCT). Adverse events occurring in a participant after the study 
period should be reported to the Overall PI if the participating investigator becomes aware of them.
It is the responsibility of each participating investigator to report adverse events to the Overall
PI as described below. The Overall PI or representative personnel will ensure the report is forwarded to 
the proper parties.
Notification Requirement


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10.3.1 Reporting to the IND-Holder and the FDA
Site Responsible Investigators (or their designee) will forward all reportable events to both 
the Overall PI and the IND-Holder (or IND-Holder’s designee) within 2 business days of 
knowledge of the event. 
The Overall Principal Investigator (or his designee) will forward all events occurring at the 
lead site to the IND-Holder, Dr. Robert Soiffer, or the IND-Holder’s designee, within 2 
business days of knowledge of the event. Additionally, the Overall Principal Investigator will 
ensure that all reportable events that are received from participating sites, which have not 
already been forwarded to the IND-Holder are sent to Dr. Soiffer (or his designee) within 2 
business days. 
Robert Soiffer, MD, as IND sponsor, will be responsible for all communication with the 
FDA. He will report to the FDA any adverse event that is serious, unexpected and reasonably 
related (i.e., possible, probable, definite) to the GVAX/placebo vaccination according to the 
FDA requirements.
10.4 Reporting to the NIH Office of Science Policy (OSP)
Toxicity
Known 
correlation
Attribution 
to study drug
Robert Soiffer, MD
(IND Sponsor)
Clinical Trials Office
Vincent Ho, MD 
(Principal Investigator)
DFCI IRB
Grade  3 non-
hematologic, 
Grade 
4 hematologic, 
and 
Grade 5.
Any
(Expected or
Unexpected)
Any
Within 2 working days from 
notificationa
Via Emailb
Use Medwatch 3500Ac
Submit directly if required 
per DFCI IRB AE reporting 
policy. Submit within IRB 
established reporting 
timelines. Dr. Ho must 
prospectively approve all 
submissions.. Ho must 
prospectively approve all 
submissions.
a.
In the event that the prticipating investigator does not become aware of the adverse event immediately (e.g., participant 
sought treatment elsewhere), the participating investigator is to report the event within 2 working days after learning of it 
and document the time of his or her first awareness of the adverse event. 
b.
Refer to the 12-217 Manual of Procedures. 
c.
Medwatch 3500A downloadable form at   http://www.fda.gov/medwatch/getforms.htm


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The IND Sponsor, Robert Soiffer, MD, will be responsible for all communication with OSP. Dr. 
Soiffer will report to OSP, regardless of the site of occurrence, any adverse event that is serious, 
unexpected and reasonably related (i.e., possible, probable, definite) to the GVAX/placebo vaccination 
according to the OBA requirements.
10.5 Reporting to the Institutional Biosafety Committee (IBC)
Any adverse event that is serious, unexpected and reasonably related (i.e., possible, probable, definite) 
to the GVAX/placebo vaccination GVAX/placebo vaccination according will be reported to the IBC 
according to each IBC’s requirements.
10.6 Reporting to Hospital Risk Management
Participating investigators will report to their local Risk Management office any subject safety reports 
or sentinel events that require reporting according to institutional policy.
11.0 DATA AND SAFETY MONITORING
11.1 Data Reporting
11.1.1 Method 
The Clinical Research Coordinator will work together with the QACT to collect, manage, 
and monitor data for this study. 
11.1.2 Data Submission 
Allogeneic transplantation data will be collected for all patients enrolled on this study.  These 
will include the allogeneic transplant data entered into the BMT repository via EDC-Inform.  In 
addition to the transplant-specific data, the following research specific forms are required for this 
study:
Form
Submission Timeline
Eligibility Checklist
Complete prior to registration with QACT
Vaccine Specific Toxicity 
Form
Within 45 days of the last vaccination 
Off Treatment/Off Study Form
Within 14 days of being taken off treatment or 
study.
11.2 Safety Meetings


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The DF/HCC Data and Safety Monitoring Board (DSMB) will review and monitor study progress, 
toxicity, safety and other data from this trial. The board is chaired by a medical oncologist from outside 
of DF/HCC and has external and internal representation. Information that raises any questions about 
participant safety or protocol performance will be addressed with the Principal Investigator, statistician 
and study team members.  Should any major concerns arise, the DSMB will offer recommendations 
regarding whether or not to suspend the trial.
The DSMB will meet twice a year to review accrual, toxicity, response and reporting information. 
Information to be provided to the DSMB may include: participant accrual, treatment regimen 
information, adverse events and serious adverse events reported by category, summary of any deaths 
on study, audit results, and a summary provided by the study team. Other information (e.g. scans, 
laboratory values) will be provided upon request. 
11.3 Monitoring 
Involvement in this study as a participating investigator implies acceptance of potential audits or 
inspections, including source data verification, by representatives designated by the DF/HCC Overall 
Principal Investigator or DF/HCC. The purpose of these audits or inspections is to examine study-
related activities and documents to determine whether these activities were conducted and data were 
recorded, analyzed, and accurately reported in accordance with the protocol, institutional policy, 
Good Clinical Practice (GCP), and any applicable regulatory requirements. 
All data will be monitored for timeliness of submission, completeness, and adherence to protocol 
requirements. Monitoring will begin at the time of participant registration and will continue during 
protocol performance and completion. 
12.0 STATISTICAL CONSIDERATIONS 
12.1
Endpoints
12.1.1
Primary Endpoint: The primary endpoint of this study is progression-free survival (PFS) 
at 18 months post-randomization. Progression-free survival is defined as time from 
randomization to progression of disease or death whichever occurs first. Patients with 
relapse/progressive disease who re-enter remission after vaccination or upon withdrawal of 
immune suppression alone will not be considered as having disease progression. The primary 
analysis will be performed using the modified intention-to-treat (ITT) principle, i.e., all 
transplanted and eligible patients who receive at least one vaccination will be included in the 
analysis according to the treatment arm they are randomized to.
12.1.2
Secondary Endpoints
12.1.2.1 Safety and toxicity of vaccination, as measured by the development of: 
Grade II-IV and III-IV acute GVHD
CTC grade  3 non-hematologic toxicity, or 


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Grade  4 hematologic toxicity attributable to vaccination 
12.1.2.2 Biologic responses to vaccination following allogeneic stem cell transplant, as assessed 
by laboratory and histologic analyses of blood before and after vaccination, and skin 
biopsy samples at vaccination sites (Section 8.0). Serum and circulating mononuclear 
cells will be frozen prior to beginning vaccination and at regular intervals 
thereafter.  Bone marrow aspirates will also be cryopreserved, if sufficient material is 
available.
12.2 Study Design and Objectives  
This is a randomized placebo controlled Phase II study of GVAX versus placebo vaccination given 
early after allogeneic HSCT in high risk AML/MDS patients. The premise is that GVAX vaccination 
early after HSCT will increase progression-free survival (PFS) in this patient population. The target 
accrual goal is 106 eligible patients for vaccination, 53 per each arm, over a 3.8 year period and 
followed for an additional 18 months. This design will give approximately 80% power to detect a 75% 
increase in 18 month PFS in the GVAX arm (Arm A) compared to the placebo arm (Arm B) as 
graphically illustrated in Figure 1. 
12.3 Accrual
Based on the accrual of the DFCI transplant group between 2006 and 2011, the projected accrual rate 
will be approximately 40 high risk AML/MDS patients with active disease who meet the eligibility 
criteria per year.  Of these 40 eligible patients, we anticipate that about 30% will not meet the criteria 
for starting GVAX/Placebo administration outlined in Section 5.3.1.  Based on this projection, it is 
anticipated that approximately 3.8 years of accrual will be necessary to enroll the targeted sample size 
of 106 eligible patients for vaccination.  Accounting for the 30% attrition, we anticipate that about 152 
patients will be enrolled on the study to obtain 106 patients eligible to start vaccination.
12.4 Randomization 
After enrollment, patients will be randomized at a ratio of 1:1 between two arms using permuted block 
algorithm within strata. Randomization will be stratified by center (DFCI, BIDMC, MGH), disease 
(AML vs. MDS), age 
 vs. <50), and conditioning intensity (myeloablative Fly/Bu4 vs. RIC 
Flu/Bu2). 
12.5 Sample Size and Power Calculations 
In our previous study10, the 2-year progression-free survival for 15 patients who received at least one 
vaccination was 46%. This estimate compared to 18% 2-year PFS from our contemporaneous control 
cohort that was most similar to those patients in the GVAX trial. Extrapolating this information, we 
hypothesize that the PFS will be increased by 75% at 18 months post randomization in Arm A 
(GVAX) compared to Arm B (placebo). A retrospective analysis of high risk AML/MDS patients who 
underwent myeloablative or RIC HSCT between 2004 and 2008 at DFCI shows that a small portion of 
patients are cured from the underlying disease after allogeneic HSCT and the distribution of PFS 
follows a two-component exponential cure rate model (Figure 1). Basing the fitted curve in Figure 1 as 
the null hypothesis, we hypothesize that the PFS will be increased by 75% from 26% to 46% by 18 
months post HCT in Arm A. More specifically, the proposed alternative hypothesis is HA: SA > SB, 


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where SA and SB denote the distributions of PFS in Arms A and B, as shown in (1) and (2), 
respectively
SA = 0.45+0.45*exp(-t*(log(2)/2.5))+ 0.1*exp(-t*(log(2)/4.5)) (1)
SB = 0.24+ 0.76*exp(-t*(log(2)/3.5))
(2)
This projection incorporates approximately 30-45 days of wait time from randomization to the start of 
GVAX/Placebo vaccination and additional ~40 days for the administration of a serial of 6 
vaccinations.  During this period, we expect little difference in PFS between two arms. Figure 4 
depicts (1) and (2) graphically. With this design, 106 eligible patients with 69 events will be required 
to achieve approximately 80% power with one-sided significance level of 0.15. Since this is a direct 
but nondefinitive randomized comparison to a standard treatment control, we follow recommendations 
made by Rubinstein et al. 18, 19 and use a one-sided type I error rate of 0.15 with 80% power 18-20. The 
power calculation is calculated using the R program, Powlgrnk (developed by Dr. Robert Gray at 
DFCI), which computes power of the two-group log-rank test for arbitrary failure time distributions 
and has been used for  non-proportional hazards alternative.21
Figure 4. Target PFS. Blue line represents the projected PFS distribution in Arm A (GVAX) and red 
line represents the projected PFS distribution in Arm B (Placebo). The solid black line is the Kaplan-
Meier curve from the historical control
12.6 Interim Analyses 
The study will be monitored using standard procedures and processes by an independent Data and 
Safety Monitoring Committee (DSMC) of the Dana-Farber Harvard Cancer Center (DF/HCC). Interim 
analysis for efficacy will occur annually starting at 33% information time, which is anticipated to 
occur approximately 2.8 years after the start of the trial. The interim results will be reported to the 
DF/HCC DSMB annually. However, these interim inspections will not have an effect in terms of 


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stopping accrual to the study and terminate the study early in favor of alternative (superiority) or null 
hypothesis (futility). This is because i) due to a small sample size at each interim look, stopping early 
for futility would result in substantially wide confidence intervals, larger Type II error, and thus 
leading to greater uncertainty about the magnitude of the PFS difference, ii) even if the PFS difference 
is not as large as targeted, investigators are interested in learning the magnitude of the PFS difference 
for further investigation, iii) stopping early for superiority would provide less safety data than planned 
and potential difficulty with the efficacy analysis and its interpretation. 
12.7 Guidelines for Grade III-IV acute GVHD and serious toxicity 
Monitoring of key safety endpoints (grade 3 or higher treatment related toxicity, grade III-IV acute 
GVHD) will be conducted in accordance with the DF/HCC DSMB meeting. GVAX was well tolerated 
in the previous trial (DFCI#04023). For the entire cohort of 24 patients that included 9 patients without 
vaccination, the incidence rate of grade III-IV acute GVHD was 4%, which is comparable to 9% in a 
historical control cohort of patients whose patients and transplant characteristics were most similar to 
those in the GVAX trial. Based on this information, we do not anticipate that GVAX will be 
associated with an increased risk of grade III-IV aGVHD nor severe toxicity. However, we will 
compare the grade III-IV aGVHD rate and grade 3 or higher treatment related toxicity rate between 
two arms at each interim look. If, at any interim look, this difference is significant at the two-sided 
level of 0.05, this would trigger a consultation with the DF/HCC DSMB for additional review. 
12.8 Statistical Analysis Plan 
The primary analysis will be the modified ITT analysis for the primary endpoint of PFS at 18 months 
after randomization. The primary analysis will be performed using the Kaplan-Meier estimates for PFS 
for each arm at 18 months along with 95% confidence intervals. Several secondary analyses of PFS 
will be conducted, depending on an assessment of the original assumption of non-proportional hazards 
assumed in the study design. First of all, graphical and analytical diagnostics will be used to assess the 
presence of non-proportional hazards between treatment arms.  If there is no evidence of non-
proportional hazards, a relative risk will be estimated from the Cox model both unadjusted and 
adjusted for other covariates. To assess the effect of GVAX, several approaches will be taken:  1) 
inclusion of the treatment arm as a fixed covariate in a model, 2) inclusion of the total number of 
GVAX vaccinations (0-6) as a fixed covariate in a model, 3) treating the number of GVAX/placebo 
vaccinations as a time dependent repeated measures and an interaction between the number of 
vaccinations and the treatment arm in a model, 4) exploring a joint model for survival and longitudinal 
data.26 If there appears to be non-proportional hazards, several analyses will be conducted: 1) a 
comparison of PFS at 18 months post randomization will be conducted using the linear combination 
test proposed by Logan et al.24, 28.29  This method directly compares the PFS curves starting at 18 
months, and accounts for patients enrolled early in the study having additional follow-up past 18 
months. 2) a pseudo value regression approach30, 3) PFS from the start of vaccination will be analyzed, 
4) multivariable cure rate model will be performed as described in Ibrahim et al.27
Secondary objectives include relapse and non-relapse mortality (NRM), acute and chronic GVHD, 
overall survival. For the comparison  of GVHD, NRM and relapse, we will perform competing risks 
data analysis using Gray test and competing risks regression analysis.25 All laboratory correlative 
studies will be analyzed using appropriate statistical methods. In particular, the effect of vaccination 
on infiltration of dendritic cells, macrophages, granulocytes, and lymphocytes as well as T cell 
reconstitution will be examined by comparing pre to post vaccination data and the GVAX to the 


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placebo arm. 
12.9 Analysis of Laboratory Correlative Studies
For the laboratory correlative studies, patients who receive at least one GVAX/placebo vaccination 
will be included. To identify and determine relevance of vaccine induced immune responses, we will 
compare the laboratory parameters described in Section 8.0 between the GVAX and placebo arm. The 
general overview of the analysis is that all longitudinal measurements will be graphically assessed and 
simple comparison will be made at each time point using either Fisher’s exact test for categorical 
variables or Wilcoxon-Rank-Sum test for continuous variables without considering multiple testing. 
For long term responders, repeated measures analysis will be performed to characterize the pattern of 
each immunologic/biologic response. If there appears to be association between these measurements 
and PFS, we will incorporate these measurements as time dependent repeated covariates in time-to-
event model and/or explore a joint model of longitudinal and survival data26. When data are available, 
we will first validate the previous finding of elevated shed MICA, a NKG2D ligand. In the previous 
report of GVAX (DFCI#04023), the median soluble MICA level (sMICA) among 7 long-term 
responders was 1,947 pg/ml before HCT, but fell to 383 pg/ml within 1 year post HCT. In contrast, no 
marked decrease was seen among 34 control patients. Conservatively extrapolating this result, if the 
average percent reduction in sMICA level from pre to 1 year post randomization in the GVAX arm is 
70% and 10% in the placebo arm, we will have 85% power to detect a 60% difference, assuming the 
standard deviation of the difference is 60% (i.e., effect size=1). This power calculation is based on 
asymptotic power of the Wilcoxon-Rank-Sum test and assumes a sample size of 25 in the GVAX arm 
and 16 in the placebo arm at 1-year post randomization. 
13.0 PUBLICATION PLAN 
This study is intended for publication, even if terminated prematurely. Publication may include any or all of the 
following: posting of a synopsis online, abstract and/or presentation at a scientific conference, or publication of 
a full manuscript. The Principal Investigator and authors may submit a manuscript describing study results 
within 24 months after the last data become available; which for vaccine trials, may take up to several months 
after the last patient visit. 


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14.0 REFERENCES 
1.
Collins RH, Jr., Shpilberg O, Drobyski WR, Porter DL, Giralt S, Champlin R et al. Donor leukocyte 
infusions in 140 patients with relapsed malignancy after allogeneic bone marrow transplantation [see 
comments]. J Clin Oncol 1997; 15(2): 433-44.
2.
Dranoff G, Jaffee E, Lazenby A, Golumbek P, Levitsky H, Brose K et al. Vaccination with irradiated 
tumor cells engineered to secrete murine granulocyte-macrophage colony-stimulating factor stimulates 
potent, specific, and long-lasting anti-tumor immunity. Proc Natl Acad Sci U S A 1993; 90(8): 3539-43.
3.
Dunussi-Joannopoulos K, Dranoff G, Weinstein HJ, Ferrara JL, Bierer BE, Croop JM. Gene 
immunotherapy in murine acute myeloid leukemia: granulocyte-macrophage colony-stimulating factor 
tumor cell vaccines elicit more potent antitumor immunity compared with B7 family and other cytokine 
vaccines. Blood 1998; 91(1): 222-30.
4.
Tani K, Azuma M, Nakazaki Y, Oyaizu N, Hase H, Ohata J et al. Phase I study of autologous tumor 
vaccines transduced with the GM-CSF gene in four patients with stage IV renal cell cancer in Japan: 
clinical and immunological findings. Mol Ther 2004; 10(4): 799-816.
5.
Salgia R, Lynch T, Skarin A, Lucca J, Lynch C, Jung K et al. Vaccination with irradiated autologous 
tumor cells engineered to secrete granulocyte-macrophage colony-stimulating factor augments antitumor 
immunity in some patients with metastatic non-small-cell lung carcinoma. J Clin Oncol 2003; 21(4): 
624-30.
6.
Soiffer R, Hodi FS, Haluska F, Jung K, Gillessen S, Singer S et al. Vaccination with irradiated, 
autologous melanoma cells engineered to secrete granulocyte-macrophage colony-stimulating factor by 
adenoviral-mediated gene transfer augments antitumor immunity in patients with metastatic melanoma. 
J Clin Oncol 2003; 21(17): 3343-50.
7.
Soiffer R, Lynch T, Mihm M, Jung K, Rhuda C, Schmollinger JC et al. Vaccination with irradiated 
autologous melanoma cells engineered to secrete human granulocyte-macrophage colony-stimulating 
factor generates potent antitumor immunity in patients with metastatic melanoma. Proc Natl Acad Sci U 
S A 1998; 95(22): 13141-6.
8.
Hodi FS, Schmollinger JC, Soiffer RJ, Salgia R, Lynch T, Ritz J et al. ATP6S1 elicits potent humoral 
responses associated with immune-mediated tumor destruction. Proc Natl Acad Sci U S A 2002; 99(10): 
6919-24.
9.
Schmollinger JC, Vonderheide RH, Hoar KM, Maecker B, Schultze JL, Hodi FS et al. Melanoma 
inhibitor of apoptosis protein (ML-IAP) is a target for immune-mediated tumor destruction. Proc Natl 
Acad Sci U S A 2003; 100(6): 3398-403.
10.
Ho VT, Vanneman M, Kim H, Sasada T, Kang YJ, Pasek M et al. Biologic activity of irradiated, 
autologous, GM-CSF-secreting leukemia cell vaccines early after allogeneic stem cell transplantation. 
Proc Natl Acad Sci U S A 2009; 106(37): 15825-30.
11.
Jinushi M, Hodi FS, Dranoff G. Therapy-induced antibodies to MHC class I chain-related protein A 
antagonize immune suppression and stimulate antitumor cytotoxicity. Proc Natl Acad Sci U S A 2006; 
103(24): 9190-5.


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12.
Gonzalez S, Groh V, Spies T. Immunobiology of human NKG2D and its ligands. Curr Top Microbiol 
Immunol 2006; 298: 121-38.
13.
Fonseca C, Soiffer R, Ho V, Vanneman M, Jinushi M, Ritz J et al. Protein disulfide isomerases are 
antibody targets during immune-mediated tumor destruction. Blood 2009; 113(8): 1681-8.
14.
Raveh S, Gavert N, Spiegel I, Ben-Ze'ev A. The cell adhesion nectin-like molecules (Necl) 1 and 4 
suppress the growth and tumorigenic ability of colon cancer cells. J Cell Biochem 2009; 108(1): 326-36.
15.
Arlt MJ, Novak-Hofer I, Gast D, Gschwend V, Moldenhauer G, Grunberg J et al. Efficient inhibition of 
intra-peritoneal tumor growth and dissemination of human ovarian carcinoma cells in nude mice by anti-
L1-cell adhesion molecule monoclonal antibody treatment. Cancer Res 2006; 66(2): 936-43.
16.
Przepiorka D, Weisdorf D, Martin P, Klingemann HG, Beatty P, Hows J et al. Consensus Conference on 
Acute GVHD Grading. Bone Marrow Transplant 1994; 15(6): 825-8.
17.
Sullivan KM, Shulman HM, Storb R, al e. Chronic graft versus host disease in 52 patients: adverse 
natural course and successful treatment with combination immunosuppression. Blood 1981; 57: 267.
18.
Rubinstein L, Crowley J, Ivy P, Leblanc M, Sargent D. Randomized phase II designs. Clin Cancer Res 
2009; 15(6): 1883-90.
19.
Rubinstein LV, Korn EL, Freidlin B, Hunsberger S, Ivy SP, Smith MA. Design issues of randomized 
phase II trials and a proposal for phase II screening trials. J Clin Oncol 2005; 23(28): 7199-206.
20.
Seymour L, Ivy SP, Sargent D, Spriggs D, Baker L, Rubinstein L et al. The design of phase II clinical 
trials testing cancer therapeutics: consensus recommendations from the clinical trial design task force of 
the national cancer institute investigational drug steering committee. Clin Cancer Res 2010; 16(6): 
1764-9.
21.
Kim HT, Gray R. Three-component cure rate model for nonproportional hazards alternative in the 
design of randomized clinical trials. Clin Trials. 2012;9(2):155-63. Epub 2012 Feb 21.
22.
Crowley J, Hu M. Covariance Analysis of Heart Transplant Survival Data. 
 . JASA 1977; 72: 27-36.
23.
Anderson JR, Cain KC, Gelber RD. Analysis of survival by tumor response. Journal of Clinical 
Oncology 1983; 1: 710-719.
24.
Logan BR, Klein JP, Zhang MJ. Comparing treatments in the presence of crossing survival curves: an 
application to bone marrow transplantation. Biometrics 2008; 64(3): 733-40.
25.
Kim HT. Cumulative incidence in competing risks data and competing risks regression analysis. Clin 
Cancer Res 2007; 13(2 Pt 1): 559-65.


Phase II GVAX Following HSCT for AML/MDS
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41
26.       Wulfsohn MS, Tsiatis, Anastasios A. A joint model for survival and longitudinal data measured with 
error. Biometrics 1997;  53:330-339
27.       Ibrahim, Joseph George, Chen, Ming-Hui and Sinha, Debajyoti (2001)  Bayesian survival analysis  
Springer-Verlag Inc (Berlin; New York)
28.       Zhang X, Loberiza FR, Klein JP, Zhang M-J. A SAS macro for estimation of direct adjusted survival 
curves based on a stratified Cox regression model. Computer methods and programs in biomedicine 
2007; 88: 95-101.
29.       Klein, J. P., Logan, B., Harhoff, M., and Andersen, P. K.(2007). Analyzing survival     
            curves at a fixed point in time.Statistics in Medicine 26, 4505–4519.
30.       Klein, J. P. and Andersen, P. K. (2005). Regression modeling of competing risks data  
            based on pseudo-values of the cumulative incidence function. Biometrics 61, 223–229. 


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15.0 APPENDIX 
I. Vaccine Specific Toxicity Form
Fill out weekly during vaccination period, and 1 month after last vaccination.
Patient Name:
MRN:
Appointment Date:
Clinician:
Sign/Symptom
Check if 
present
Grade
Length and 
Width (If 
Applicable)
Attribution to 
vaccine
0 = No relation
1 = Unlikely
2 = Possible
3 = Probable
4 = Definite
Comments
Vaccine Site specific
     induration
    erythema
    pruritus
Generalized 
Symptoms
     fever
     fatigue
     nausea
     rash
     pruritus
Other (fill-in below)


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II. cGVHD Survey
12-217 Chronic GVHD Provider Survey
Date of Visit:
Patient:
Study ID:
Your Name:
Instructions: 
Please score a symptom only if you know or suspect it be related to chronic GVHD. 
Subjective symptoms are acceptable.  For example, joint tightness can be scored based on 
subjective findings despite the absence of objective limitations.
Please score symptoms present in the last week.  Even if they may have resolved with 
treatment in the past week, if they were present recently and may possibly return, please score 
them.


Phase II GVAX Following HSCT for AML/MDS
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0
1
2
3
Skin 
Score
  No 
Symptoms
  <18% BSA with 
disease signs but NO 
sclerotic features
  19-50% BSA OR 
involvement with 
superficial sclerotic 
features “not 
hidebound” (able to 
pinch)
  >50% BSA OR deep 
sclerotic features 
“hidebound” (unable to 
pinch) OR impaired 
mobility, ulceration or 
severe pruritus
Mouth 
Score
  No 
symptoms
  Mild symptoms 
with disease signs but 
not limiting oral intake 
significantly
  Moderate symptoms 
with signs with partial 
limitation of oral intake
  Severe symptoms with 
disease signs on 
examination with major 
limitation of oral intake
GI Tract 
Score
  No 
symptoms
  Symptoms such as 
dysphagia, anorexia, 
nausea, vomiting, 
abdominal pain or 
diarrhea without 
significant weight loss 
(<5%)
  Symptoms associated 
with mild to moderate 
weight loss 
(5-15%)
  Symptoms associated 
with significant weight loss 
>15%, requires nutritional 
supplement for most calorie 
needs OR esophageal 
dilation
Eye Score
  No 
symptoms
  Mild dry eye 
symptoms not 
affecting ADL 
(requiring eye drops 
<3x per day) OR 
asymptomatic signs of 
kerato-conjunctivitis 
sicca
  Moderate dry eye 
symptoms partially 
affecting ADL (requiring 
eye drops >3x per day or 
punctual plugs) 
WITHOUT vision 
impairment
  Severe dry eye 
symptoms significantly 
affecting ADL (special 
eyewear to relieve pain) OR 
unable to work because of 
ocular symptoms OR loss 
of vision caused by kerato-
conjunctivitis sicca
Joint and 
Fascia 
Score
  No 
symptoms
  Mild tightness of 
arms or legs, normal or 
mild decreased range 
of motion (ROM) AND 
not affecting ADL
  Tightness of arms or 
legs OR joint 
contractures, erythema 
thought due to fasciitis, 
moderate decrease ROM 
AND mild to moderate 
limitation of ADL
  Contracture WITH 
significant decrease of ROM 
AND significant limitation 
of ADL (unable to tie shoes, 
button shirts, dress self etc.)
Genital 
Tract 
Score
(score even if no 
GYN exam, 
required for men 
too)
 No GYN 
Exam
  No 
symptoms
  Symptomatic with 
mild distinct signs on 
exam AND no effect 
on coitus and minimal 
discomfort with GYN 
exam
  Symptomatic with 
distinct signs on exam 
AND with mild 
dyspareunia or 
discomfort with GYN 
exam
  Symptomatic WITH 
advanced signs (stricture, 
labia agglutination or 
severe ulceration) AND 
severe pain with coitus or 
inability to insert vaginal 
spectrum
Lung 
Score
  No 
symptoms
  Mild symptoms 
(shortness of breath 
after climbing one 
flight of steps)
  Moderate symptoms 
(shortness of breath after 
walking on flat ground)
  Severe symptoms 
(shortness of breath at rest; 
requiring O2)


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Is an erythematous or maculopapular rash present?        
 Yes       
 No   
Does the patient have nausea, vomiting or diarrhea?       
 Yes       
 No   
Liver score to be completed using most recent LFTs from within +/- 2 weeks of the assessment
Date LFT sample obtained __________
PFT values from within one month of the assessment
% FEV1   _______%   Date of FEV1 __________
 
 Not done   
% DLCOc   ______%   Date of DLCOc _________
 
 Not done
’
Please rate the severity of this person s chronic GVHD
on this 
scale   
None (1)
Mild (2)
Moderate  (3)
Severe  (4)
 cGVHD
symptoms
are not at
all severe
cGVHD 
symptoms
are most
severe 
possible
and on 
this scale 
(circle one)
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
Liver Score
 Normal LFTs
  Elevated 
bilirubin, alkaline 
phosphatase, AST 
or ALT <2x ULN
  Bilirubin > 3 
mg/dl or bilirubin, 
AST or ALT 2-5x 
ULN
  Bilirubin, AST 
or ALT > 5x ULN