Conditions: Malignant Neoplasm of Pancreas Metastatic to Peritoneal Surface Malignant Peritoneal Mesothelioma Peritoneal Carcinomatosis
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 64
Healthy volunteers: no

Brief summary:
This trial is to determine the safest dose of a triple combination (chemokine modulatory regimen or CKM) of celecoxib, interferon alfa (IFN), and rintatolimod that can be given with a DC vaccine as treatment of peritoneal surface malignancies after standard of care surgery.

The first phase of this study will determine the safest dose of IFN that can be given in combination with celecoxib and rintatolimod along with a DC vaccine. The doses of celecoxib (400 mg) and rintatolimod (200 mg) will be consistent while the dose of IFN will be increased (5, 10, or 20 MU/m2) as participants are enrolled to the trial. The high dose of IFN in combination with celecoxib and rintatolimod will be used for the next phase of the clinical trial. After surgery, participants will receive 2 cycles of the investigational treatment.

The second phase of this study will test if the investigational treatment has any effects on peritoneal surface malignancies. The doses of the combination determined in the first phase will be used in this phase of the clinical trial. After surgery, participants will receive 2 cycles of the investigational treatment, followed by standard chemotherapy as determined by their oncologist, and then 2 more cycles of the investigational treatment.

Detailed description:
This trial will evaluate the safety and effectiveness of autologous alpha-type-1 polarized dendritic cell (alpha-DC1) vaccines (patients' autologous alpha-DC1s loaded with autologous tumor material), combined with a systemic chemokine modulation regimen \[CKM; intravenous rintatolimod (TLR3 ligand, a derivative of Poly-I:C) + intravenous interferon-alfa + oral celecoxib\] as adjuvant therapy, after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), in patients with peritoneal surface malignancies (PSM), including but not limited to malignant peritoneal mesothelioma and peritoneal carcinomatosis (PC) of appendiceal and colorectal origin.

All patients judged to have peritoneal surface malignancy and considered able to be cytoreduced to Peritoneal Cancer Index (PCI) Completeness of Cytoreduction (CC) score of 1 or less will undergo CRS + HIPEC. Postoperative immunotherapy will start at least 4 weeks after CRS + HIPEC.

Immunotherapy regimen will include four cycles of intranodal (3M cells) and intradermal (3M cells) αDC1 vaccines. Each booster αDC1 vaccine dose (treatment cycles 2-4) will be followed by 4-days of systemic CKM, starting the day after vaccination (IFNα \[dose-escalation: 5-20 MU/m2\], intravenous \[IV\], once a day for 4 days; rintatolimod \[short-half-life TLR3 ligand\] 200 mg intravenous \[IV\], on Wednesday and Friday only of the CKM regimen; and celecoxib 200 mg, orally, twice a day for 4 days). In order to avoid overlap between experimental immunotherapy and potential adjuvant chemotherapy (which can be clinically indicated as a part of standard care in the subset of patients), the experimental treatments will be interrupted after cycles 1 and 2, to allow adjuvant chemotherapy that is done for each patient's clinical care, and is not a part of this research study. Whenever clinically indicated as a part of standard care, adjuvant chemotherapy may start at least 5 days after completion of the 2nd cycle of immunotherapy (first booster vaccine plus the first CKM). The 3rd cycle of immunotherapy may start at least 5 days after the completion of chemotherapy.

Arms:
arm 1: Week 1 (at recovery from surgery; ≥ 6 weeks post-surgery)-Priming Vaccine dose; no chemokine modulation; 1 day: αDC1 vaccine; Oral celecoxib, 200 mg, before \& after treatment on day of vaccination; Weeks 2-3 -Rest; Week 4 (target) - Booster C1; Mon: αDC1 vaccine;Tues - Fri: Systemic Chemokine Modulation Regimen. Oral celecoxib, 200 mg, BID on vaccination days \& CKM. Celecoxib will be dced after CKM on Fri. Rintatolimod only administered on Wed \& Fri.; Week 5-7 -Rest; Week 8 (target) -Booster C2; Monday: αDC1 vaccine. Oral celecoxib, 200 mg, BID on days of vaccination and CKM. Tues - Fri:Systemic Chemokine Modulation Regimen. Rintatolimod only administered on Wed \& Fri. Celecoxib will be dced after CKM on Fri.; Week 9-11 -Rest; Week 12 (target) -Booster C3; Monday: αDC1 vaccine. Tues-Fri: Systemic Chemokine Modulation Regimen. Rintatolimod only administered on Wed \& Fri. Oral celecoxib, 200 mg, BID, given on days of vaccination and CKM. Celecoxib will be discontinued after CKM on Fri.

Interventions: intervention 1: DC vaccine intervention 2: Celecoxib intervention 3: Interferon Alfa-2b intervention 4: rintatolimod
Intervention descriptions: intervention 1: Administered on Monday of each cycle: 1 intranodal ultrasound-guided injection (target dose of 3 x 10e6 cells in 0.5 mL) + 1 intradermal injection (target dose of 3 x 10e6 cells in 0.5 mL) intervention 2: Administered at 200 mg, once a day orally, starting the day of the first DC vaccine through week 4/cycle 2. Participants will not take celecoxib while receiving standard of care chemotherapy as instructed by their local oncologist. Celecoxib will continue starting week 20/cycle 3 and continue until the Friday of the last day of the CKM administration, cycle 4. Administered at 400 mg, 200 mg twice a day orally, on days participants receive vaccine and CKM. intervention 3: Intravenous infusion over 20 minutes: doses tested in Phase 1 portion (5, 10, or 20 MU/m2) will determine the Phase 2 dose. Administered on the Tuesday of each CKM cycle. intervention 4: Intravenous infusion of 200 mg on Wednesday and Friday only of the CKM regimen. The protocol allows for de-escalation to 100 mg if attributable adverse effects are observed.

Protocol document:
Prot_SAP_000.pdf: 
 
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HCC #: 12-110 
 
Old Protocol Date: 03-18-2016 New Protocol Date: 02-23-2018 
 
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TITLE: A Phase 1/2 Trial Evaluating DC1 Vaccines Combined with Tumor-Selective 
Chemokine Modulation as Adjuvant Therapy after Surgical Resection of Peritoneal Surface 
Malignancies 
 
UPCI #: 
12-110 
BB-IND#: 
15871 
Phase: 
1/2 
Version: 
8 
Version Date: 
02-23-2018 
Investigational Agent: 
Alpha-type-1 Dendritic Cell Vaccine and Rintatolimod 
Commercial Agent: 
Interferon-alpha and Celecoxib 
 
Sponsor: 
David L. Bartlett, MD 
 
Professor of Surgery 
 
Chair, Gastrointestinal and Surgical Oncology Services 
 
Director, Koch Center for Regional Therapy 
 
University of Pittsburgh 
 
UPMC Health System 
 
5150 Centre Ave, Pittsburgh, PA  15232 
 
Phone: (412) 692-2852 
 
bartdl@upmc.edu: 
 
 
Investigator: 
David L. Bartlett, MD 
 
Professor of Surgery 
 
Chair, Gastrointestinal and Surgical Oncology Services 
 
Director, Koch Center for Regional Therapy 
 
University of Pittsburgh 
 
UPMC Health System 
 
5150 Centre Ave, Pittsburgh, PA  15232 
 
Phone: (412) 692-2852 
 
bartdl@upmc.edu 
 
Source(s) of Support: 
Koch Fund and Immunotransplantation Center 
 
UPCI Monitor: 
Education and Compliance Office for Human Subject Research 
 
Research Conduct and Compliance Office 
 
University of Pittsburgh 
 
3500 Fifth Avenue, Suite 205 
 
Pittsburgh, PA 15213 
 


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Version Date: 03-18-2016 
 
2 
SCHEMA 
 
This trial will evaluate the effectiveness of autologous alpha-type-1 polarized dendritic cell 
(DC1) vaccines (patients’ autologous DC1s loaded with autologous tumor material), 
combined with a systemic chemokine modulation regimen [CKM; intravenous rintatolimod 
(TLR3 ligand, a derivative of Poly-I:C) + intravenous interferon-alpha + oral celecoxib] as 
adjuvant therapy, after cytoreductive surgery (CRS) and hyperthermic intraperitoneal 
chemotherapy (HIPEC), in patients with peritoneal surface malignancies (PSM), including but 
not limited to malignant peritoneal mesothelioma and peritoneal carcinomatosis (PC) of 
appendiceal and colorectal origin. 
 
All patients judged to have peritoneal surface malignancy and considered able to be cytoreduced 
to Peritoneal Cancer Index (PCI) Completeness of Cytoreduction (CC) score of 1 or less will 
undergo CRS + HIPEC. Postoperative immunotherapy will start upon recovery from surgery but 
no sooner than 4 weeks post CRS + HIPEC. 
 
The Phase 2 immunotherapy regimen will include 1 priming dose of the DC1 vaccine and 3 
booster doses of the DC1 vaccine combined with  CKM. Each dose of vaccine, whether 
priming or booster, will include 1 intranodal (3M cells) and 1 intradermal (3M cells) injection. 
Phase 1 includes only the priming vaccine dose and 1 cycle of a booster dose + CKM. 
 
Each booster vaccine dose (booster cycles 1-3) will be followed by 4-days of systemic CKM 
which is comprised of intravenous (IV) IFNα (dose-escalation in Phase 1 only: 5-20 MU/m2) 
once a day for 4 days; IV rintatolimod (short-half-life TLR3 ligand) 200 mg on Wednesday and 
Friday only of the CKM regimen; and oral celecoxib 200 mg twice a day for all 5 days. 
 
In order to avoid overlap between experimental immunotherapy and potential adjuvant 
chemotherapy (which can be clinically indicated as a part of standard care in a subset of 
patients), the experimental treatment may be interrupted after each cycle to allow adjuvant 
chemotherapy that may be done for each patient’s clinical care, not as part of this research study. 
If clinically indicated any cycle of adjuvant chemotherapy may start a minimum of 5 days after 
completion) of a cycle of immunotherapy and recovery form any potential side effects. The 
following cycle of immunotherapy may start at least 5 days after the completion of 
chemotherapy and after recovery from acute side effects of chemotherapy. 
 
Timing of the experimental treatment: 
• Priming cycle (vaccine alone): 6 to 16 weeks after surgery (target: 8 weeks) 
• Booster cycle 1 (vaccine plus CKM): 4 to 12 weeks after priming cycle (target: 4 weeks) 
• Booster cycle 2 (vaccine plus CKM):: 4 to 12 weeks after booster cycle 1 (target: 4 
weeks) 
• Booster cycle 3 (vaccine plus CKM):: 4 to 12 weeks after booster cycle 2 (target: 4 
weeks) 
 
The primary endpoint will be time to tumor progression/recurrence on CT or MR imaging. 
Secondary endpoints will be immunologic response markers. 
 


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The schemas for the trial are located in Sections 5.1 and 5.2. 


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4 
TABLE OF CONTENTS 
SCHEMA .........................................................................................................................................2 
LIST OF ABBREVIATIONS ..........................................................................................................6 
1. 
OBJECTIVES ......................................................................................................................8 
1.1 
Primary Objectives...................................................................................................8 
1.2 
Secondary Objectives...............................................................................................8 
2. 
BACKGROUND .................................................................................................................8 
2.1 
Tumor Immunogenicity in Malignant Peritoneal Mesothelioma .............................8 
2.2 
Tumor Immunogenicity in Colorectal Adenocarcinoma with Peritoneal 
Carcinomatosis .......................................................................................................10 
2.3 
Tumor Immunogenicity in Appendiceal Adenocarcinoma with Peritoneal 
Carcinomatosis .......................................................................................................11 
2.4 
Dendritic cells in tumor immunology ....................................................................11 
2.5 
Type-1 polarized DC (DC1) ................................................................................12 
2.6 
Chemokine Modulatory Regimen ..........................................................................13 
2.7 
Rationale ................................................................................................................15 
3. 
PATIENT SELECTION ....................................................................................................17 
3.1 
Pre-surgery Eligibility ............................................................................................17 
3.2 
Post-surgery Screening ..........................................................................................17 
3.3 
Participation of children .........................................................................................18 
3.4 
Women and pregnancy ..........................................................................................18 
3.5 
Minority enrollment ...............................................................................................18 
4. 
REGISTRATION PROCEDURES ...................................................................................19 
5. 
TREATMENT PLAN ........................................................................................................19 
5.1 
Phase 1: Dose assessment of αDC1 vaccine chemokine-modulatory 
regimen (CKM) ......................................................................................................19 
5.2 
Phase 2: Efficacy assessment of αDC1 vaccine followed by the 
chemokine-modulatory regimen (CKM) ...............................................................22 
5.3 
Leukapheresis ........................................................................................................23 
5.4 
Agent Administration.............................................................................................23 
5.5 
Continuation of Booster Vaccines Administration ................................................25 
5.6 
Safety evaluation and monitoring ..........................................................................25 
5.7 
Duration of Study Treatment .................................................................................25 
5.8 
Off Study Treatment Visit .....................................................................................26 
5.9 
Duration of Follow Up ...........................................................................................26 
5.10 
Duration of Study ...................................................................................................26 
6. 
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................26 
6.1 
Phase 1 ...................................................................................................................26 
6.2 
Phase 2 ...................................................................................................................26 
6.3 
Gastrointestinal Toxicity ........................................................................................27 


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6.4 
Hypersensitivity Reactions ....................................................................................27 
7. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS .............................28 
7.1 
Adverse Events and Risks List(s) ..........................................................................28 
7.2 
Definitions..............................................................................................................31 
7.3 
Recording/Reporting requirements ........................................................................32 
7.4 
Reporting of Suspected Adverse Reactions ...........................................................33 
7.5 
Review of Safety Information: Sponsor Responsibilities ......................................33 
7.6 
Review of Safety Information: Investigator Responsibilities ................................34 
7.7 
Reporting of Adverse Reactions to the FDA .........................................................34 
7.8 
Reporting Adverse Events to the Responsible IRB ...............................................35 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................35 
8.1 
DC Vaccine ............................................................................................................35 
8.2 
Celecoxib ...............................................................................................................37 
8.3 
Interferon-2b ........................................................................................................37 
8.4 
Rintatolimod (poly IC analog) ...............................................................................38 
9. 
CORRELATIVE STUDIES ..............................................................................................39 
10. 
STUDY CALENDAR .......................................................................................................40 
11. 
MEASUREMENT OF EFFECT........................................................................................42 
11.1 
Disease Parameters (May be used as a guideline for scan review prior to 
Cycle 2) ..................................................................................................................42 
11.2 
CT or MR-Imaging Response Criteria  ..................................................................42 
11.3 
Duration of Response .............................................................................................42 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS ...........................................42 
12.1 
Data Safety Monitoring Plan .................................................................................42 
12.2 
Quality Control and Quality Assurance .................................................................44 
12.3 
Data Handling and Record-Keeping ......................................................................44 
12.4 
Institutional Review Board (IRB) Approval ..........................................................44 
12.5 
Ethical and Scientific Conduct of the Clinical Study ............................................45 
12.6 
Informed Consent...................................................................................................45 
13. 
STATISTICAL CONSIDERATIONS...............................................................................45 
13.1 
Study Design/Endpoints.........................................................................................45 
13.2 
Power and Sample Size for the Study of Efficacy .................................................46 
13.3 
Data Analysis .........................................................................................................46 
13.4 
Continuous Safety Monitoring During the Efficacy Phase ....................................46 
REFERENCES ..............................................................................................................................49 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ..................................................55 
 
 
 


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6 
LIST OF ABBREVIATIONS 
 
ACE inhibitor 
angiotensin-converting-enzyme inhibitor 
AE 
Adverse event 
ALP 
Alkaline phosphatase 
ALT (SGPT) 
Alanine aminotransferase 
ANC 
Absolute neutrophil count 
AST (SGOT) 
Aspartate aminotransferase 
BUN 
Blood urea nitrogen 
cc 
cubic centimeters 
CC score 
Completeness of Cytoreduction score 
CEA 
Carcinoembryonic antigen 
cGMP 
current good manufacturing practice 
CKM 
chemokine modulation 
CRS 
Clinical Research Services 
CT 
Computed tomography 
CTCAE 
Common Toxicity Criteria for Adverse Events 
CTLs 
Cytotoxic T-Lymphocyte 
CTRC 
Clinical & Translational Research Center 
DLT 
Dose-limiting toxicity 
DSMB/DSMC 
Data Safety Monitoring Board/ Data Safety Monitoring Committee 
ECG 
Electrocardiogram 
FDA 
Food and Drug Administration 
GM-CSF 
granulocyte-macrophage colony stimulating factor 
HSA 
human serum albumin 
IB 
Investigator’s brochure 
IFNα 
interferon alpha 
ILCI 
intensive locoregional chemotherapy and immunotherapy 
IN 
intranodal 
IND 
Investigational new drug 
IP 
intraperitoneal 
IRB 
Institutional Review Board 
ITC 
Immunotransplantation Center 
IV 
intravenous 
MDSC 
myeloid-derived suppressor cells 
Mg 
milligrams 
mL 
milliliter 
MRI 
Magnetic resonance imaging 
MTD 
maximum tolerated dose 
MU 
million units 


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7 
NCI 
National Cancer Institute 
NK cells 
natural killer cells 
NSAID 
non-steroidal anti-inflammatory drug 
OS 
Overall survival 
OvCa 
ovarian cancer 
PBMC 
Peripheral blood mononuclear cell 
PET 
Positron emission tomography 
PFI 
progression free interval 
RP2D 
Recommended Phase 2 dose 
PS 
Performance status 
PTT 
partial thromboplastin time 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RNA 
Ribonucleic acid 
SAE 
Serious adverse event 
SOC 
Standard of care 
TILs 
tumor infiltrating lymphocytes 
TLR 
toll-like receptor 
TTP 
Time to progression 
ULN 
Upper limit of normal 
UPCI 
University of Pittsburgh Cancer Institute 
USP 
United States Pharmacopeia 
UV 
ultraviolet 
αDC 
alpha dendritic cell 
 
 


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Version Date: 03-18-2016 
 
8 
1. 
OBJECTIVES 
 
1.1 
Primary Objectives 
 
Preliminary data from our laboratory indicate that autologous antigen-loaded DC1 vaccines 
induce highly-effective tumor-specific CD8+ CTLs that express defined chemokine receptors, 
CCR5 and CXCR3.1-3 We have also demonstrated that IFN and poly-I:C enhance local 
production of relevant chemokines CCL5/RANTES and CXCL10/IP10 that are able to attract the 
CCR5- and CXCR3-expressing CTLs selectively to tumor lesions, rather than in marginal 
healthy tissues. Furthermore, the above factors suppress local production of undesirable 
chemokines (CCL22) that attract immunosuppressive Treg cells.4 In addition, studies have 
demonstrated a correlation between the density of infiltrating effector T cells and long-term 
outcomes in malignant peritoneal mesothelioma5,6 and colorectal cancer7,8. 
 
In this Phase 1/2 clinical trial, we will test the effectiveness of the treatment of patients with 
peritoneal surface malignancies, including but not limited to malignant peritoneal mesothelioma 
(MPM) and peritoneal carcinomatosis (PC) from appendiceal and colorectal primary tumors, 
using autologous DC1 vaccines combined with a systemic chemokine modulation regimen, 
consisting of celecoxib, IFN and TLR3 ligand as a component of adjuvant therapy. We 
anticipate that the resulting tumor-selective modulation of the peritoneal chemokine environment 
will promote the entry of spontaneously-occurring and αDC1-induced effector-type T (eff) cells 
into tumor, and limit the influx of undesirable regulatory-type T (reg) cells. 
 
Our primary objective is to test whether our combined immunotherapy regimen (DC1 vaccines 
+ CKM) is safe and whether it can prolong time-to-progression (TTP) in patients with peritoneal 
surface malignancies after optimal CRS + HIPEC with or without adjuvant chemotherapy. 
 
1.2 
Secondary Objectives 
 
• To estimate overall survival (OS). 
• Perform correlative studies to characterize sequential immune response changes by 
quantitative measures of immune cellular phenotypes and chemokine patterns in peripheral 
blood. These results will be correlated with TTP, PFS, and OS in attempt to predictive 
markers of the clinical benefit. 
 
2. 
BACKGROUND 
 
2.1 
Tumor Immunogenicity in Malignant Peritoneal Mesothelioma 
 
Malignant mesothelioma is a rare but aggressive primary malignancy that almost exclusively 
develops from the serosal lining of the pleural (incidence ~ 2000 cases/year) or peritoneal 
cavities (incidence ~ 250-500 cases per year).9 Malignant peritoneal mesothelioma is an 
aggressive loco-regionally invasive disease that rarely involves lymph nodes (5-10%) or 
metastasizes extra-abdominally (3-5%). Compressive symptoms occur due to progressive 
accumulation of tumor and ascites in the abdomen, which leads to organ-dysfunction, morbidity, 
and eventual mortality.10 Prognostic factors for improved overall and disease-free survival 


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9 
include epithelioid histology, lack of lymph node disease, small nuclear size (I/II), adequate CRS 
(CC-0/CC-1), low mitotic count ≤ 5 mitoses/50 HPF, age ≤ 60 years, female gender, prior 
surgical debulking, lack of deep tissue invasion, hyperthermic intraperitoneal chemoperfusion 
(HIPEC), and early stage of disease (Stage I/II).11,12 
 
Traditional systemic chemotherapy and palliative surgical procedures provide minimal benefit 
over the natural history of untreated disease, with median survival of 12 months and rare long-
term survivors. The most effective systemic chemotherapy regimen available for unresectable 
disease, combination cisplatin with 3rd generation antifolates pemetrexed and raltitrexed, 
demonstrates best response rates of up to 40%, mortality risk reduction of 10% at 1 year and 
corresponding improvement in survival of 6-8 weeks.13 Recent experience with aggressive 
cytoreductive surgery in combination with HIPEC has demonstrated median survival of 36 to 92 
months and 29% to 59% 5 year survival in retrospective analyses.14 However, disease recurrence 
is common and survival remains especially poor for high-risk patients with non-epithelioid 
histology, high mitotic index and incompletely resected tumors, despite mulimodality therapeutic 
strategies including neoadjuvant or adjuvant chemotherapy protocols in addition to cytoreductive 
surgery and intraperitoneal chemotherapy. This underscores the need for more effective targeted 
therapies, especially in patients with high-risk recurrent malignant peritoneal mesothelioma. 
 
Studies have shown that patients with malignant pleural mesothelioma who demonstrate robust 
anti-tumor immune responses survive longer. Increased CD8+ tumor-infiltrating lymphocytes 
(TILs) are associated with lower incidence/burden of mediastinal lymphadenopathy, higher 
numbers of apoptotic tumor cells in tumor tissue, as well as improved progression-free and 
overall survival after surgical resection, with or without neoadjuvant chemotherapy. This 
suggests that stimulation of CD8+ TILs is a potential therapeutic strategy. In fact, patients 
receiving neoadjuvant chemotherapy with cisplatin/pemetrexed combination demonstrate higher 
CD8+ TILs than those receiving other chemotherapy regimens, lending credence to this being 
the most efficacious regimen in randomized trials.5,6 However, the immune cell population of 
mesothelioma strongly favors a suppressive environment, with heavy infiltration of 
CD4+CD25+Foxp3 regulatory T cells (Tregs), and an absence of CD1α+ DCs, which might 
explain the lack of tumor kill despite high levels of effector T cells. This immunosuppressive 
environment must be modulated to improve immunotherapeutic efficacy.15 
 
Intra-peritoneal delivery of tumor-lysate pulsed DCs prior to intra-peritoneal tumor implantation 
of mouse mesothelioma cell line AB1 prevents tumor engraftment, halts mesothelioma 
progression and provides long-term protection against tumor re-challenge. In an adjuvant setting, 
this immunotherapy demonstrates a better outcome when delivered early after AB1 tumor 
implantation, when tumor burden is less. Mice receiving DC vaccine have higher AB1 cell lysis 
(chromium release assay) and higher IFNγ production from splenocytes (ELISPOT assay), 
suggesting an overall increased CTL activity. Adoptive transfer of CD8+ T cells, isolated from 
splenocytes of immunized mice, into non-immunized AB1 tumor bearing mice improves 
survival.16 A small Phase 1 clinical trial (10 patients) in patients with mesothelioma was 
performed to assess toxicity and feasibility of clinical grade DC vaccine immunotherapy and 
tumor response to immunotherapy. DCs were pulsed with autologous tumor lysate, matured ex-
vivo, and then administered intradermally and intravenously to select malignant pleural 
mesothelioma patients with epithelioid histology that demonstrated partial response or stable 
disease following CRS + cisplatin chemotherapy. DC immunotherapy was well tolerated and 


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10 
appeared to elicit an immunologic response (positive DTH skin test, increased inflammatory 
cells in skin biopsies at site of vaccination, increased antitumor T cells in blood) and some 
clinical response by RECIST (of 10 patients, 6 had progression, 1 had stable and 3 had partial 
response), however no survival benefit was noted.17 Recent evidence indicates that 
chemotherapeutic agents can induce specific immune responses, thereby improving therapeutic 
outcomes. Chemotherapy induced dead tumor cells may release “danger signals” that induce DC 
maturation with subsequent CTL activation. In a murine model of mesothelioma, gemcitabine 
has been shown to increase antigen presentation to CD8+ T cells. Vaccination of these tumor-
bearing mice following gemcitabine therapy resulted in a marked decrease in tumor growth and 
increased survival compared with vaccination without gemcitabine.18 Similarly, certain cytotoxic 
drugs like cisplatin have been shown to increase the sensitivity of tumor cells to immune-
mediated attack.19 
 
2.2 
Tumor Immunogenicity in Colorectal Adenocarcinoma with Peritoneal 
Carcinomatosis 
 
Cancer of the colon and rectum (colorectal cancer) is the third leading site of cancer diagnosed 
annually in the United States and the most common form of gastrointestinal malignancy. It 
accounts for approximately 150,000 new cases annually. Isolated peritoneal carcinomatosis in 
the setting of colorectal adenocarcinoma occurs synchronously in 8% and metachronously in 
25% of patients. Median survival without therapy is 6 months, while systemic chemotherapy 
improves median survival in unresectable patients to 12.6 months, with rare 5 year survivors.20 
Aggressive CRS + PIC has demonstrated median survival of 30-60 months and 20-50% 5 year 
overall survival rates, with particular benefit seen in patients undergoing complete CRS (CC-
0/CC-1) for low volume disease (low peritoneal carcinomatosis index; PCI).21 
 
Signs of an immune response, including increased mRNA levels for products of TH1 effector 
cells, markers of T cell migration, activation and differentiation, and CD8+ T cell infiltration 
within colorectal cancers are associated with the absence of early metastasis; increased density of 
CD45RO+ memory T cells and improved OS.8 Similarly, the type, location and density of TILs 
in colorectal cancer patients are strong predictors of survival. Co-expression of genes for 
cytotoxicity and TH1 adaptive immunity predicts patient survival independent of metastatic 
status.7 A meta-analysis of studies involving active specific immunotherapy (ASI) in patients 
with minimal residual colorectal cancer after R0 resection (6 studies, 1375 patients) and patients 
with advanced unresectable colorectal cancer (43 studies, 656 patients) was recently published. 
ASI included autologous tumor cell vaccines, defined tumor-protein vaccines, monoclonal 
antibodies, peptide vaccines, viral vector vaccines, DC vaccine and naked DNA vaccines. The 
authors demonstrated improved disease-free survival for stage II disease and improved disease-
free/overall survival for stage III disease in the setting of minimal residual colorectal cancer, 
while objective response rate (complete response + partial response; 1.6%) and clinical benefit 
rate (complete response + partial response + stable disease; 26%) were low in the setting of 
advanced unresectable colorectal cancer. They hypothesized that ASI may target cancer stem 
cells or micrometastases that are responsible for cancer recurrence/metastasis and are resistant to 
conventional chemotherapy.22 Autologous tumor lysate-pulsed DC vaccine administered 
intranodally to patients with colorectal metastasis after complete surgical resection induced 
tumor-specific T-cell proliferation or IFNγ secretory response in 63% of patients and a DTH 
response to autologous tumor cells in 61% of patients, with subsequent improved recurrence-free 


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11 
survival at 5 years in these patients.23 A pilot study evaluating the immunogenic effect of 
chemotherapy by concurrent CEA-peptide pulsed DCs vaccination and systemic 
oxaliplatin/capecitabine as adjuvant therapy in stage III colorectal cancer patients after complete 
resection demonstrated stable levels of peripheral blood mononuclear cells during chemotherapy, 
CEA-peptide-specific T-cell responses and higher production of IFNγ and IL-2 upon co-culture 
with CEA-loaded target cells.24 In a Phase 1/2 trial using DCs transfected with RNA encoding 
CEA to vaccinate patients after complete resection of colorectal liver metastasis, evidence of 
immune response in skin biopsies of DC injection sites and CEA-specific T-cell activity in 
peripheral blood was demonstrated.25 
 
2.3 
Tumor Immunogenicity in Appendiceal Adenocarcinoma with Peritoneal 
Carcinomatosis 
 
Appendiceal neoplasms are predominantly mucinous and frequently lead to peritoneal 
carcinomatosis. Classically, they are clinically characterized by progressive, intra-peritoneal 
dissemination of mucin, referred to as pseudomyxoma peritonei. These tumors comprise 1% of 
all colorectal cancers, with an annual incidence of 1500 cases in the United States. Their clinical 
course is primarily determined by the compressive effects of mucin accumulation and tissue 
invasion by neoplastic epithelial cells. Aggressive cytoreductive surgery with perioperative intra-
peritoneal chemotherapy is considered the standard of care for managing these tumors.26 
Multiple large retrospective studies have demonstrated markedly improved patient survival, 
decreased tumor recurrence, longer time to disease progression and less frequent re-operative 
interventions with this radical approach, when compared to historical serial debulking procedures 
or palliative systemic chemotherapy. Unfortunately, these tumors frequently recur, traditional 
systemic chemotherapy agents show minimal benefit, and targeted therapies are lacking. 
Multivariate Cox-regression analyses have consistently demonstrated incomplete cytoreductive 
surgery (CC-2/3) and non-DPAM histology to be the most consistent negative predictors of 
survival in patients undergoing CRS and PIC.27 This underscores the need for more effective 
targeted therapies, especially in patients with high-risk appendiceal cancers with peritoneal 
carcinomatosis/pseudomyxoma peritonei. 
 
Research related to the immunogenicity of these tumors and the application of immunotherapy 
alone or in conjunction with systemic chemotherapy is lacking for this malignancy, but is 
expected to be similar to colorectal cancer, based on the tissue of tumor origin and similar 
location of the disease. 
 
2.4 
Dendritic cells in tumor immunology 
 
Several lines of evidence derived from both murine studies and human clinical trials suggest that 
cancer can be susceptible to immune-based therapies. Studies using dendritic cells to stimulate 
tumor-specific immune responses have been particularly encouraging.28-30 DCs are the most 
potent antigen presenting cells (APCs), capable of efficiently internalizing and presenting 
antigen in the context of co-stimulatory signals and cytokines essential to the induction of 
effective long-lasting T-cell mediated immunity. Animal models have demonstrated that DCs, 
pulsed ex vivo with defined tumor antigens or material derived from tumor cells, can induce 
protective tumor-specific immune responses and are capable of mediating the regression of 
established disease.31 Human clinical trials, including our own, demonstrate that DCs pulsed 


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with defined tumor-relevant antigenic peptides, or, alternatively, with tumor cell lysates or 
apoptotic bodies, can induce tumor-specific immune responses and even occasional complete 
tumor regression in late stage cancer patients.29 
 
Several competing approaches to DC therapy are currently being evaluated in clinical trials. In 
this context, two emerging issues appear to be critical for the development of “optimal” DC-
based immunization strategies. First, defining a strategy for the delivery of tumor antigens that 
facilitates efficient DC presentation of a broad range of class I- and class II-restricted epitopes 
appears to be critical to the induction of effective antigen-specific T-cell immunity. Second, 
recent results suggest that in order to induce tumor regression and promote long-term disease-
free status, DC-based strategies need to drive in vivo expansion and maintenance of Th1/Tc1-
type T cells (both CD8+ and CD4+) effector function. 
 
Human DCs may be readily obtained in large numbers from peripheral blood by short term in 
vitro culture in media containing interleukin-4 (IL-4) and granulocyte-macrophage colony 
stimulating factor (GM-CSF).32 In particular, for the purposes of this protocol, we can anticipate 
a yield of above 5 x 106 DCs per 200 mL of patient peripheral blood after 7 days of in vitro 
culture, where a single vaccination would consist of 3 x 105, or 3 x 106 antigen-loaded DCs, and 
the remaining cells will be used for vaccine testing, quality control, immunomonitoring, and the 
development of in vitro correlates of the in vivo (immunologic and potentially therapeutic) 
efficacy of DC. 
 
2.5 
Type-1 polarized DC (DC1) 
 
Two functions of dendritic cells are believed to be important for the ability of DCs to induce Th1 
cells and cytotoxic T-lymphocytes (CTLs), (the types of immune cells most desirable in cancer 
immunotherapy): high co-stimulatory activity and high production levels of anticancer cytokines, 
especially IL-12.31,33-35 Clinical trials to date have relied on the use of either fully matured DCs 
exhibiting high stimulatory function, but low IL-12 secretion, or immature DCs that display low 
stimulator/high IL-12 secretion functions. We have recently developed a novel culture method to 
generate mature DCs that are both highly stimulatory and produce exceedingly high levels of IL-
12.36 Such DCs will be referred to as type-1 polarized DC or αDC1. We have recently succeeded 
in adapting our original αDC1 protocols based on fetal bovine serum-supplemented cultures to 
allow αDC1 generation in serum free media, allowing for the application of αDC1s in clinical 
trials of cancer immunotherapy. Our in vitro observations show that such type-1-polarized DCs 
(αDC1s) induce up to 50-fold higher frequencies of tumor-specific CTLs during in vitro 
sensitizations when compared to conventionally matured DCs. Furthermore, these same αDC1s 
are highly effective inducers of tumor-specific Th1-type CD4+ T cell responses. 
 
Beyond merely exhibiting the unique combination of high immunostimulatory function and high 
production capacity for cytokines, αDC1s exhibit a stable phenotype that is resistant to PGE2, 
the suppressive factor over-expressed in colorectal cancer. αDC1s can produce IL-12p70 upon 
interaction with CD4+ T cells that are unable to produce IFN or other IL-12 co-inducing 
factors.36,37 This suggests the possibility of using αDC1s to boost the clinical efficacy of cancer 
vaccines, despite the presumed immunosuppressive environment of immunocompromised (Th2-, 
Th3- or Tr1-dominated) cancer patients. 
 


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αDC1s, the new type of dendritic cell vaccine developed by our group, are the serum-free, 
clinically-applicable version of type-1 polarized DCs, combining a fully-mature phenotype and 
high expression of co-stimulatory molecules with an elevated, rather than exhausted ability to 
produce IL-12p70.38 In addition to their elevated ability to induce high numbers of IFNγ-
producing CD8+ T cells recognizing MHC class-I restricted tumor-related antigens, αDC1s (in 
contrast to standard mature DCs) have been shown to convert non-cytolytic CD8+ T cells into 
high perforin- and granzyme B-expressing effector cells with high killer activity and tumor-
homing potential.39 Our clinical trials of αDC1 vaccines used as a single agent in end-stage 
cutaneus T cell lymphoma (CTCL) and metastatic melanoma showed preliminary evidence of 
the ability of αDC1s loaded with autologous tumor (CTCL) or antigenic peptides (melanoma) to 
induce disease stabilizations and clinical responses.1 However, the most promising data so far 
results from our recently published Phase 1/2 study in patients with high-grade malignant 
glioma, showing that the combination of intranodal immunization with αDC1-vaccines with 
systemic intramuscular (IM) administration of poly-ICLC, capable of enhancing tumor 
production of CXCR3 ligands (such as CXCL10) in preclinical models, is capable of inducing 
long-term stabilization of this aggressive disease and objective clinical responses. Within the 
cohort of 22 patients with recurrent high-grade gliomas (expected progression-free survival of 2-
4 months), nine patients achieved the PFS of at least 12 months, with two patients achieving 
complete radiologic responses and two additional patients undergoing partial (and sustained) 
responses (2PR and 1CR occurred after the publication of our JCO 2011 report). As expected, 
the ability of αDC1s from the individual patients to produce IL-12, the functional hallmark of 
polarized αDC1s and the predictive factor of in vitro potency of different types of DC vaccines 
was the best predictive factor of the ability of αDC1s + poly-ICLC therapy in promoting the 
progression-free survival of the treated patients.40 
 
Interferons, Toll-like receptor (TLR)-ligands, and prostanoid inhibitors, increase the production 
of effector (Teff)-attracting chemokines, and reduce the production of Treg-attracting chemokines. 
Our recently-published data and data from others, demonstrated that DCs developing in different 
inflammatory conditions can preferentially attract either effector-type immune cells (CTLs, Th1, 
and NK cells), desirable in the setting of cancer immunotherapy, or undesirable Tregs cells.4,41 Our 
data demonstrated the key role of IFNα, poly-I:C (TLR3-ligand), and prostanoid inhibitors 
(celecoxib), in suppressing the ability of DCs and colorectal cancer tissues to attract Tregs and 
promoting Teff attraction.4,42 Since αDC1-induced CD8+ T cells express particularly high CTL 
activity and express the typical Teff-associated chemokine receptors (CCR5 and CXCR5) 39, such 
chemokine-modulating therapies are likely to be particularly effective when combined with 
αDC1 vaccination. Our latest data from ovarian cancer patients demonstrates that the 
combination of 3 clinically-applicable factors, IFNα, TLR3 ligand, and celebrex, allows not only 
a further enhancement of the production of Teff-attracting chemokines, but can also suppress the 
overproduction of CCL22 a Treg-recruiting chemokine, which has been previously implicated in 
accelerated progression of ovarian cancer.43 
 
2.6 
Chemokine Modulatory Regimen 
 
2.6.1 Critical role of chemokine-driven T cell migration in cancers 
 
The numbers of effector T cells in malignant peritoneal mesothelioma and CRC tissues have 
been shown to be an independent prognostic marker, with high numbers predicting a delayed 


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time to cancer recurrence.5-8 In contrast, regulatory T cells in CRC patients are associated with 
poor tumor response.44-46 Chemokines and their respective receptors are critical for T cell 
migration and homing into tissues during homeostasis and inflammation.47,48 Several studies 
have shown that CXCR3 and CCR5 are critical for T cell entry into tumors, which is guided by 
intra-tumoral expression of respective chemokines. High levels of the chemokine ligands for 
CCR5 (CCL5/RANTES and CXCR3/IP10) in tumor tissue have been associated with infiltration 
of CD8 T cells with respective receptors in CRC,49 as well as melanoma50 and gastric cancer.51 
High CXCR3+ T cells in peripheral circulation has been associated with increased survival of 
stage III melanoma patients 52. In contrast, high levels of CCL22 (ligand for CCR4) expression 
by DC or macrophages in ovarian ascites recruit regulatory T cells and is associated with 
decreased patient survival43. But most tumors do not have T cell infiltration, or express the 
correct chemokines for effector T cell (Teff) entry. Colon tumors frequently show elevated 
CCL22 levels induced by a PGE2 rich tumor microenvironment 53,54 permitting regulatory T cells 
(Treg) rather than Teff cells, leading to highly biased Treg/Teff ratio in tumors. The current study 
attempts to correct the above mentioned chemokine bias in the tumor microenvironment using a 
chemokine modulation regimen and analyze whether such modulation can help Teff, entry and 
prevent Tregs influx into tumors. 
 
2.6.2 Past experience with chemokine modulation agents TLR3 ligands, IFN, and celecoxib 
 
In our preclinical ex vivo studies performed using explants of resected metastatic CRC, the 
combination of IFNwith nonselective or COX-2 selective inhibitors of prostaglandin synthesis 
resulted in strong elevation of production of the effector T cell-attracting chemokines CXCL10 
and CCL5 with the concomitant suppression of the intratumoral expression of CCL22, a Treg-
attracting chemokine. However, in a subset of patients, the optimal results, particularly with 
regard to CCL5 induction, required additional stimulation by TLR ligand, poly-I:C. Therefore, 
we propose to incorporate in this study a combination of the above 3 factors (IFNα; COX-2 
selective inhibitor, celecoxib; and a TLR3 ligand, rintatolimod, a short half-life derivative of 
Poly-I:C). 
 
Interferon–alpha (IFNα, Intron A, Interferon alfa-2b) is currently FDA approved for the adjuvant 
treatment of stage III melanoma. It has been examined by multiple investigators as an immune 
modulator in the setting of vaccine therapy with demonstrated safety. It has been extensively 
evaluated in the setting of metastatic CRC (as a single agent or in combination with 
chemotherapy or IL-2) and was shown to be largely ineffective at daily doses ranging from 3-20 
MU/m2, administered subcutaneously or intravenously.55-72 Vaishampayan et al administered 
IFNα (5 MU subcutaneously three times a week) following vaccination with a melanoma vaccine 
which was well tolerated (Melacine).73 Mitchell et al recently completed a large trial examining 
IFNα (5 MU subcutaneously three times a week) for one year74. In a small study by Astsaturov 
and colleagues, administration of IFNα in previously vaccinated melanoma patients 
demonstrated objective clinical responses, suggesting its ability to amplify the effectiveness of 
local T cells infiltration and/or function at the tumor site.75 
 
Celecoxib (Celebrex) has been extensively studied in long term clinical trials in patients 
predisposed to development of colorectal cancer.76,77 However, there is to our knowledge, no 
clinical data examining its use as a short term immune modulator in the setting of vaccine 
therapy. Several studies in murine models have suggested improved efficacy of anti-tumor 


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15 
vaccination with Cox-2 inhibition.78-80 Recent literature has suggested increased risk of adverse 
cardiovascular events associated with the administration of some selective Cox -2 inhibitors.81-83 
The literature regarding the precise risk with celecoxib remains controversial, with the reported 
cardiovascular side effects observed in its long-term users. This trial will involve a short course 
of celecoxib; given at an oral dose of 200 mg daily starting on the day of discharge from surgery 
and continuing until the off-study treatment visit. The dose will be 200 mg, twice a day, the day 
of vaccination (Monday) and over the 4 days of chemokine modulation regimen (Tuesday- 
Friday). It has been suggested that lower doses and shorter length of administration decrease the 
risk of adverse cardiovascular events associated with administration of celecoxib. 
 
Poly-I:C (polyinosinic-polycytidylic acid) is a small molecule ligand (mimicking double-
stranded RNA ligand of Toll-Like Receptor 3 [TLR3],84,85 extensively tested as a single drug in 
the setting of infectious diseases and cancer. It has been shown that TLR3 is involved in the 
recognition of viral components, such as poly-I:C and dsRNA. In contrast, TLR7 and TLR8 
appear to recognize ssRNA viruses and ssRNA, respectively.86 It is also noted that IFN-,  
and/or  treatment of cells results in the remarkable enhancement of TLR3 expression levels, and 
that poly-I:C is capable of inducing the production of pro-inflammatory cytokines (IL-6 and 
TNF) and chemokines (CCL2/MCP-1, CCL5/RANTES, CCL20/MIP-3, and CXCL10/IP-10). 
Other TLR ligands, such as LPS, lipoteichoic acid, peptidoglycan, flagellin, and CpG, failed to 
exert similar effects. These reports, in addition to our preclinical data, provide strong rationale 
for the combined use of poly-IC and IFN. With regard to clinical use of poly-I:C in cancer 
patients, it has been shown that low dose of poly-I:C is more efficacious than a high dose for 
enhancing immune effects, and that higher doses actually inhibit a number of cell-associated 
immune functions. Rintatolimod (Ampligen) is a poly-IC derivative with reduced half-life in 
vivo and increased selectivity of binding to TLR3. 
 
2.6.3 Clinical experience with chemokine modulating regimen (CKM) 
 
In 2012, we completed an Expanded Access - single patient IND (BB-IND 14, 934) protocol 
utilizing the CKM regimen of IFN intravenously at 5 MU/m2, rintatolimod intravenously at 200 
mg, and celecoxib orally at 200 mg twice a day. This regimen was well tolerated in this patient 
with grade 3 flushing and hypotension that resolved with slowing of the rintatolimod 
administration rate on the first cycle. 
 
Similar CKM treatment is currently being evaluated in a Phase 1/2 clinical trial, UPCI 10-131 
(IND 112532), open for patients with resectable, metastatic, colon cancer. In that trial, 
rintatolimod is administered daily and not every second day, as in the current trial. This trial 
evaluates the CKM regimen of IFN intravenously (dose escalation of 5, 10, and 20 MU/m2), 
rintatolimod intravenously at 200 mg, and celecoxib orally at 200 mg twice a day. Treatment on 
phase I has been completed without any regimen limiting toxicities and current enrollment is to 
Phase 2 portion of the clinical trial, using the dose of IFN of 20 MU/M2. 
 
2.7 
Rationale 
 
The current trial tests the safety and clinical effectiveness of the inclusion of personalized 
patient-specific immunotherapy in the clinical management of peritoneal surface malignancies 


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16 
(including but not limited to peritoneal carcinomatosis of colorectal-appendiceal and 
mesothelioma origin), the disease characterized by a uniformly poor overall prognosis and 
managed with the combination of surgical cytoreduction, local and systemic chemotherapy, 
similar in all subtypes. 
 
The tested combination immunotherapy will simultaneously target a) each patients’ lymphocytes 
specific to unique tumor-associated antigens overexpressed on each patient tumors, and b) tumor 
microenvironment (tumor stroma and infiltrating cells) in order to mobilize host’s immune 
responses against their own tumors and to counteract local immune suppression typical of the 
peritoneal cavity. 
 
We expect to uniformly achieve this goal by: 
a) Immunizing each patient with his/her own polarized dendritic cells (αDC1s) loaded with 
their tumor material as the source of unique patient/tumor-specific antigens (rather than 
using a pre-determined synthetic antigen), in order to induce the most relevant pattern of 
immunity in each patient; 
b) Utilizing our recently-developed triple CKM regimen which targets peritoneal stromal 
cells and local inflammatory infiltrate (rather than tumor cells themselves) in order to 
condition the peritoneal environment and promote selective attraction of the desirable 
effector cells (CTLs, TH1 and NK cells), while eliminating the local attraction and 
suppressive functions of the undesirable immune cells (Tregs and MDSCs). 
 
We anticipate that such personalized immune therapy will provide a complementary, indirect, 
and therapeutic synergy with chemotherapy (which directly targets tumor cells), jointly resulting 
in delayed time to disease progression. 
 
2.7.1 Rationale for intranodal and intradermal administration of DC1 vaccines 
 
The optimal route of DC administration has not been determined. Our recently completed trial in 
glioma patients used an intranodal (IN) route of vaccine delivery.40 In the current trial, we would 
like to administer a portion of the vaccine via an intradermal (ID) route in order to facilitate 
additional prolonged stimulation of the immune system by slowly migrating DCs. 
 
2.7.2 Rationale for the combination of DC1 vaccine and the proposed chemokine-modulating 
regimen 
 
Based on our preclinical observations that DC1 vaccine induce high levels of two chemokine 
receptors, CCR5 and CXCR3 on tumor-specific CTLs39 and the proposed combination of IFN, 
TLR3 ligand and COX2 inhibitor selectively increase the tumor production of the chemokine 
ligands for these receptors CCR5 ligand: CCL5; and CXCR3 ligands: CXCL9 and CXCL10)42, 
we expect that the proposed combination will be able to promote tumor immune 
surveillance by a) inducing high numbers of tumor-specific CTLs (DC1 component of 
treatment) and b) directing them to the tumor tissues (CKM component), thus establishing 
local immune surveillance within the peritoneal cavity and prolonging the time to disease 
recurrence. 
 


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3. 
PATIENT SELECTION 
 
Consent will be obtained for this study on all eligible patients by the investigator or 
sub-investigators. No patient will be entered into this clinical trial without having signed a 
consent form. The research nurse coordinator or designee will screen the patients further, as per 
investigator/sub-investigator orders, to determine if they meet all the inclusion/exclusion criteria. 
If a recruited patient is excluded or resigns for any reason during the course of study, a new 
patient will be enrolled. However, such patients may continue to be followed and/or receive any 
available vaccine doses. 
 
Candidates for this trial will have peritoneal surface malignancies and CRS + HIPEC is clinically 
indicated as the first line treatment. Due to the autologous nature of the vaccine, tumor tissue and 
the cells obtained from the leukapheresis procedure are required. Without those the vaccine 
cannot be manufactured and the patients are not eligible for this clinical study. 
 
Surgical outcome of must be deemed able to undergo optimal CRS defined as CC-score of 0 or 1 
based on post-surgical imaging. Cytoreduction is defined as the burden of residual disease 
nodules left at the end of surgery (CC-0: no visible disease; CC-1: residual tumor nodules ≤ 2.5 
mm in size; CC-2: residual tumor nodules 2.5 mm – 2.5 cm in size; CC-3: residual tumor 
nodules > 2.5 cm in size). 
 
Screening will occur after recovery from surgery to ensure they meet criteria for treatment. 
 
3.1 
Pre-surgery Eligibility 
 
1. Histologically confirmed peritoneal surface malignancies, including but not limited to 
malignant peritoneal mesothelioma and peritoneal carcinomatosis (PC) from presumed 
appendiceal and colorectal primary tumors. 
2. The following malignancies are ineligible for this study: low grade appendiceal and 
pseudomyxoma peritonei. 
3. Clinically indicated for optimal CRS+HIPEC 
4. At least 18 years of age 
5. Able to understand and willing to sign a written informed consent document 
 
3.2 
Post-surgery Screening 
 
3.2.1 Inclusion Criteria 
 
1. Must have had HIPEC during surgery 
2. Must have a CC score of 0 
3. ECOG performance status of 0, 1 or 2 
4. Able to swallow pills 
5. Platelet ≥ 75,000/µL 
6. Hemoglobin ≥ 9.0 g/dL 
7. Hematocrit ≥ 27.0% 
8. WBC >2000/mm3 
9. Creatinine < 1.5 x institutional upper limit of normal (ULN), OR Creatinine clearance ≥ 50 


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mL/min/1.73 m2 for patients with creatinine levels greater than 1.5 x ULN 
10. Total bilirubin ≤ 1.5 x ULN 
11. AST(SGOT) and ALT(SGPT) ≤ 2.5 X ULN 
12. Must be eligible for pheresis within 8 weeks of surgery 
13. Availability of sufficient number of tumor cells for cryopreservation and subsequent vaccine 
production 
 
3.2.2 Exclusion Criteria 
 
1. Infection of tumor tissue with pathogens resistant to radiation and fungizone 
2. Patients on systemic immunosuppressive agents, including steroids. Patients who are able to 
be removed from immunosuppressives at least 5 days prior to the first vaccine will be 
considered eligible 
3. Patients with active autoimmune disease or history of transplantation. Patients with indolent 
or chronic autoimmune disease not requiring steroid treatment are considered eligible. 
4. Patients who are pregnant or nursing 
5. Patients experiencing a cardiac events (acute coronary syndrome, myocardial infarction, or 
ischemia) within the 3 months prior to accrual 
6. Patients with a New York Heart Association classification of III or IV 
7. Prior allergic reaction or hypersensitivity to celecoxib or NSAIDs 
 
3.3 
Participation of children 
 
Children under the age of 18 years will not be considered as potential candidates because the 
incidence of peritoneal surface malignancies in the pediatric age group is extremely low and the 
fact that we do not have data to show that the proposed experimental treatment is feasible and 
safe to give to children under the age 18 years of age. If new information becomes available to 
show the proposed treatment has minimal risks when compared to the benefits and is feasible in 
pediatric patients, the protocol will be amended to include them. 
 
3.4 
Women and pregnancy 
 
Because the effect of the proposed investigational treatment was not studied in pregnant women 
the potential risks to the fetus cannot be assessed, pregnant females will not be included in the 
study. However, no female of childbearing potential will be excluded from the study. An 
effective form of contraception of the woman’s choice will be required at all times during study. 
A pregnancy test will be performed on enrolled women of childbearing potential. Should a 
woman become pregnant or suspect she is pregnant while participating in this study, she should 
inform her treating physician immediately. 
 
3.5 
Minority enrollment 
 
The racial and ethnic characteristics of the proposed patient population will reflect the 
demographics of Pittsburgh and the surrounding area and/or the patient population of the UPMC 
Health Systems. We shall attempt to recruit patients in respective proportions to these 
demographics. No exclusion criteria will be based on race, ethnicity, gender, or socioeconomic 
status. Patients with immune deficiencies such as human immunodeficiency virus infection will 


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19 
be excluded. The numbers of enrolled male to female patients will be consistent with and 
reflective of the numbers of patients seen in the UPMC clinics and in approximate 50:50 
proportions. No minorities or their subpopulations will be excluded from the study. Every 
attempt will be made to encourage participation of minorities in these trials. 
 
4. 
REGISTRATION PROCEDURES 
 
N/A (Single-Institution Study) 
 
5. 
TREATMENT PLAN 
 
Prior to starting study treatment patients will undergo CRS + HIPEC surgery. A portion of the 
resected tumor, removed as part of the patient’s clinical care for their disease, will be evaluated 
for the number of cancer cells as a part of eligibility screening procedures. This tissue will be 
used to manufacture each patient’s autologous vaccine (autologous tumor loaded on the patients’ 
autologous dendritic cells). The beginning of postoperative immunotherapy (defined as week 1) 
will be based upon recovery from CRS + HIPEC, but no sooner than 6 weeks post-surgery, at the 
discretion of the investigator/sub-investigator, to allow for adequate recovery from surgery. 
 
Immunotherapy are intended to be administered in the UPCI-CTRC. However, based upon 
scheduling and logistics those procedures are not limited to UPCI-CTRC and may be 
administered in equivalent locations at UPMC Shadyside and/or the Hillman Cancer Center. 
 
5.1 
Phase 1: Dose assessment of αDC1 vaccine chemokine-modulatory regimen (CKM) 
 
The recommended Phase 2 dose of the combination of DC1 vaccine in combination with IFNα, 
rintatolimod, and celecoxib will be established by administering fixed doses of the vaccine, 
rintatolimod, and celecoxib in combination with escalating doses of IFNα. Patients will receive a 
priming dose of the vaccine which consists of 1 intranodal injection followed by 1 intradermal 
injection on the Monday of the first week. Patients will then receive a booster dose of the DC 
vaccine, which consists of 1 intranodal injection and 1 intradermal injection, on Monday 
followed by the CKM regimen on days Tuesday through Friday of the booster cycle. 
 
There will be 3 dose finding cohorts with one additional de-escalation cohort (designated -1) if 
needed, as shown in the table below: 
 
Phase 1 
Dose Tiers 
DC1 Vaccine 
(IN + ID)*** 
Components of CKM cycle 
IFNα 
(MU/M2 IV) 
Days T-F 
Rintatolimod* 
(mg, IV) 
Days W&F 
Celecoxib** 
(mg, orally, twice a day) 
Days T-F 
-1 
3+3 M cells 
5 
100 
200 
1 
3+3 M cells 
5 
200 
200 
2 
3+3 M cells 
10 
200 
200 
3 
3+3 M cells 
20 
200 
200 


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*Rintatolimod starting dose will be 200 mg unless dose escalation is from tier -1 in which case cohorts 2 and 3 will use 100 mg 
of rintatolimod. 
**Celecoxib will be administered orally, at a dose of 200 mg, once a day starting the day of the first vaccine (day 1 of week 1) 
and continue until Friday the last day of the CKM regimen. The dose will be increased to 200 mg, twice a day on the days of 
vaccination (Monday) and over the 4 days of chemokine modulation regimen (Tuesday - Friday). 
***In case of limited availability of vaccine, the treatment may proceed with reduced numbers of the cells (down to 0.5 M IN + 
0.5 M ID for each vaccination cycle). 
 
Dose escalation will start with dose tier 1 and proceed to dose tier 2 in the absence of RLTs. 
Otherwise the dose will be de-escalated to tier -1. The escalation/de-escalation schema uses the 
following table. Under this schema, more than one patient can be enrolled at the same time; 
however, within Phase 1, CKM cannot be started on the next patient until the previous patient 
completes the cycle of CKM and an additional one week of observation for potential RLTs 
(total of two week difference between the consecutive patients). Also, CKM cannot be started 
on the next dose until 2 patients on the lower dose complete the CKM regimen and additional 
one week of observation for potential RLTs. Similar rule will be applied during the escalation 
between different tiers and for the patients within the same dose tier, in order to allow time to 
evaluate any potential toxicities. 
 
The establishment of the RP2D will be based on an adaptive design for which the next dose 
will be set according the following rules: 
 
Dose Escalation/De-escalation Rules 
Observed Number of RLTs on a Dose Tier 
Decision Rule for the Next Subject 
There is at least 1 RLT among the last 2 subjects treated 
on this dose tier and the proportion of DLTs on this dose 
tier is > 0.30 
Assign to next lower dose 
There are no RLTs among the last 2 subjects treated on 
this dose tier and the proportion of RLTs among all 
subjects on this dose tier is ≤ 0.30 
Assign to next higher dose 
Neither of the above is satisfied 
Assign to the same dose 
 
If no RLTs are observed among the first 3 dose tiers, four additional patients will be added to tier 
3 for a total of 6 on tier 3. If, after treating 10 patients without RLT (2 + 2 + 6), dose tier 3 will 
be declared the RP2D. If an RLT is observed at any dose tier the adaptive up-and-down design 
will commence until 15 patients are observed after which the Phase 2 starting dose will be 
estimated by isotonic regression. 
 
Regimen limiting toxicities (RLTs) are defined as the following toxicities: 
 
Vaccine possibly, probably or definitely related RLTs 
• Grade 2 or more bronchospasm or generalized uticaria (hypersensitivity) 
• Grade 2 or more allergic reaction 
• Grade 3 injection site reaction due to vaccine 
• > Grade 3 toxicity of any kind related to the DC vaccine 
 
CKM possibly, probably or definitely related RLTs 


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• Grade > 3 leukopenia or neutropenia persisting > 4 days (96 hours) after treatment 
• Greater than or equal to grade 3 non-hematologic adverse events, except for the following 
grade 3 toxicities unless they last greater than one week: 
o Flu-like symptoms/constitutional symptoms (i.e., fever, chills, arthralgias, myalgias) 
o Depression, anxiety, restlessness, or insomnia 
o Manageable GI symptoms (i.e., nausea, diarrhea) 
 
The observation period for each patient in the Phase 1 portion of this study will be up to 5 weeks 
(i.e. up to and including the Friday 1 week after the end of the chemokine modulating regimen). 
 
Note: The last 2 patients in the Phase 1 cohort that determines the RP2D will continue on to the 
Phase 2 part of the trial and will receive the 2nd and 3rd booster/CKM cycles and follow-up per 
the Phase 2 portion of this protocol. All patients in the dose finding cohort will be followed for 
primary efficacy endpoints as well as have blood and serum drawn for corollary studies. 
 
Patients in the Phase 1 (safety) cohort will receive their study treatment and will be monitored 
for RLTs according to the following timeline: 
 
Eligibility 
ECOG performance status, blood work 
CRS + HIPEC 
Screening 
History and physical exam, ECOG performance status, blood 
work,  and evaluation of tumor material 
Post-surgery (after the 
discharge  from the 
hospital) 
Leukapheresis 
Week 1* 
(upon recovery from 
surgery; at least 4 weeks 
after surgery) 
Priming Vaccine dose; no chemokine modulation 
Monday: αDC1 vaccine 
Oral celecoxib, 200 mg, twice daily on the day of 
vaccination 
Tues – Sun: oral celecoxib 200mg, once daily 
Weeks 2-3 
Rest – continue oral celecoxib, 200 mg, once daily 
Week 4 
Cycle 1 (“booster cycle”) 
Monday: αDC1 vaccine  
Tues – Fri: Systemic Chemokine Modulation Regimen. Oral 
celecoxib, 200 mg, twice daily on the days of 
vaccination and CKM. Celecoxib will be discontinued 
after CKM on Friday. Rintatolimod is only 
administered on Wednesday and Friday. 
Off study treatment 
Follow-up for Time-to-Progression/occurrence (TTP) 
CRS: Cytoreductive surgery; HIPEC: Hyperthermic intraperitoneal chemoperfusion; TTP: Time-to-progression 
*Adjuvant immunotherapy may be delayed until full recovery at the discretion of the investigator/sub-investigator. The beginning 
of immunotherapy will be considered week 1 of the experimental treatment and the timing of all subsequent elements of 
treatment will be based upon the first vaccine. 
 
 
 


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5.2 
Phase 2: Efficacy assessment of αDC1 vaccine followed by the chemokine-
modulatory regimen (CKM) 
 
Study treatment will consist of one priming dose of DC vaccination followed by 3 booster cycles 
of DC vaccine + chemokine modulation regimen (CKM), cycles 1-3. The booster vaccine is 
administered on Monday followed by 4 days of the CKM regimen (Tuesday – Friday).  
 
Timing of the experimental treatment: 
• Priming cycle: 6 to 16 weeks after surgery (target: 8 weeks) 
• Booster cycle 1: 4 to 12 weeks after priming cycle (target: 4 weeks) 
• Booster cycle 2: 4 to 12 weeks after booster cycle 1 (target: 4 weeks) 
• Booster cycle 3: 4 to 12 weeks after booster cycle 2 (target: 4 weeks) 
 
It is expected that a significant proportion of the patients will undergo adjuvant clinically 
indicated chemotherapy. Adjuvant chemotherapy can be administered between the courses of 
immunotherapy, but no sooner than 5 days after finishing any cycle of immunotherapy. The 
following cycle of immunotherapy will start no sooner than 5 days after the last day of a 
chemotherapy cycle and after recovery from acute side effect of chemotherapy. 
 
Patients who (for clinical or logistic reasons) will not be able to take any cycle of 
immunotherapy  within the above-indicated windows, can still receive the remaining courses of 
immunotherapy at later time points, but will not be included in the analysis of the primary 
efficacy endpoint, although they can be analyzed in an exploratory manner. 
 
Similarly, patients who (for clinical or logistic reasons) will not be able to receive the priming 
dose of vaccine within 3 months after surgery, can still receive immunotherapy at later time 
points, but will not be included in the analysis of the primary efficacy endpoint, although they 
can be analyzed in an exploratory manner. 
 
In the efficacy phase, patients will receive a priming dose of the DC1 vaccine followed by 3 
courses of the DC1 booster vaccine combined with CKM regimen as illustrated in the 
following table: 
Eligibility 
Informed Consent  
CRS + HIPEC 
Screening 
History and physical exam, ECOG performance status, blood 
work, evaluation of tumor material 
Post-surgery (within the 
first 8 weeks following 
surgery) 
Leukapheresis 
Week 1* 
(upon recovery from 
surgery; no sooner than 6 
weeks post-surgery) 
Priming Vaccine dose; no chemokine modulation) 
One day: αDC1 vaccine 
Oral celecoxib, 200 mg, before and after treatment on the 
day of vaccination 
Weeks 2-3 
Rest  
Week 4 (target)* 
Booster Cycle 1  
Monday: αDC1 vaccine  


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Tues – Fri: Systemic Chemokine Modulation Regimen. Oral 
celecoxib, 200 mg, twice daily on the days of 
vaccination and CKM. Celecoxib will be discontinued 
after CKM on Friday. Rintatolimod is only 
administered on Wednesday and Friday. 
Week 5-7 
Rest 
Week 8 (target)** 
Booster Cycle 2  
Monday: αDC1 vaccine. Reintroduce oral celecoxib, 200 mg, 
twice daily on the days of vaccination and CKM. 
Tues – Fri: Systemic Chemokine Modulation Regimen. 
Rintatolimod is only administered on Wednesday and 
Friday. Celecoxib will be discontinued after CKM on 
Friday. 
 
Week 9-11 
Rest  
Week 12 (target)** 
Booster Cycle 3  
Monday: αDC1 vaccine. 
Tues – Fri: Systemic Chemokine Modulation Regimen. 
Rintatolimod is only administered on Wednesday and 
Friday. 
Oral celecoxib, 200 mg, twice daily, will be given on the days of 
vaccination and CKM. Celecoxib will be discontinued after CKM 
on Friday. 
Off study treatment 
Follow-up for Time-to-Progression/occurrence (TTP) 
CRS: Cytoreductive surgery; HIPEC: Hyperthermic intraperitoneal chemoperfusion; TTP: Time-to-progression 
*Adjuvant immunotherapy may be delayed until recovery at the discretion of the investigator/sub-investigator. The beginning of 
immunotherapy will be considered week 1 of the experimental treatment and the timing of all subsequent elements of 
treatment will be based upon the first vaccine. 
**Patients may receive postoperative (standard of care, adjuvant) chemotherapy at the discretion of the treating oncologist. 
Adjuvant chemotherapy may start 5 days after the first full cycle of immunotherapy (first booster vaccine + CKM). Following 
completion of adjuvant chemotherapy, subsequent immunotherapy can start after 5 days post adjuvant chemotherapy. 
 
5.3 
Leukapheresis 
 
Prior to the procedure each patient’s venous access will be evaluated. If a patient does not have 
acceptable venous access a pheresis catheter will need to be inserted into a central vein by 
qualified personnel and removed directly after leukapheresis. A separate consent form for central 
venous access will be obtained for such a scenario. 
 
All selected patients will undergo leukaphersis after CRS + HIPEC surgery and screening but 
before the priming dose of vaccine. The product is delivered immediately to the University of 
Pittsburgh Cancer Institute Immunotransplantation Center (ITC). The leukapheresis product will 
be immediately processed as described in the Chemistry, Manufacturing, and Control section of 
the BB-IND affiliated with this protocol and will be cryopreserved as described. 
 
5.4 
Agent Administration 
 


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5.4.1 Celecoxib 
 
The drug will be administered orally, at a dose of 200 mg, twice daily on all study treatment days 
only.  
 
5.4.2 DC vaccine administration 
 
The intranodal and intradermal administration of the DC vaccine will be performed by the 
investigator/sub-investigator or their designee. 
 
5.4.2.1 
Intra-nodal administration 
 
The priming dose of vaccine may be administered on any day of the week since it is not followed 
by the CKM regime. The intranodal injection for the booster doses will be administered on 
Monday of cycles 1 through 3. 
 
Intranodal administration will consist of ultrasound-guided intranodal injections of the 
autologous tumor αDC1 vaccine at a target dose of 3 x 106 in 0.5 mL. Due to manufacturing 
limitations a minimum of 0.5 x 106 cells is acceptable. In order to avoid repetitive scarification of 
a single lymph node, the patients will have subsequent doses administered at 3 different sites, 
with the sites rotated as follows: (a) right inguinal lymph nodal group, (b) left inguinal lymph 
nodal group, (c) right axillary lymph nodal group, and (d) left axillary lymph nodal group. Only 
one lymph node will be injected at each visit with the dendritic cells. The size of the lymph node 
to be injected will be a minimum of 5 mm and a maximum size of 20 mm. 
 
5.4.2.2 
Intradermal route 
 
Intradermal injection will be used to complement the intranodal injections (provide a depot 
effect) and it can be used as the only route (for all DCs) in case intranodal injection is not 
feasible. Each portion of the vaccine will be administered using a 1 mL syringe and needle 
appropriate for intradermal injections and will hold 0.5 mL of the vaccine preparation. The 
intradermal DC vaccine should be injected in the vicinity of the major nodal basin of the thigh. 
The nodal basin must not have been previously dissected. 
 
5.4.3 Tumor-selective systemic chemokine modulation regimen (CKM) 
 
The chemokine modulating regimen will be administered over 4 consecutive days (Tuesday to 
Friday) in the following order: 
 
• Pretreatment: 500 mL Normal saline IV over approximately 60 minutes 
• Pre-meds: Acetaminophen (Tylenol) 650 mg x 1 dose; Prochlorperazine (Compazine) 10 mg 
x 1 dose – administered 30 minutes (±5 minutes) after starting pre-treatment hydration 
• Celecoxib: 200 mg orally, administered any time prior to IFN 
• IFN: IV over 20 minutes (±5 minutes) 
• Celecoxib: 200 mg orally followed at least 15 minutes later by rintatolimod 
• Rintatolimod: 200 mg (or 100 mg in case of de-escalation) IV, Wednesday and Friday only 


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of the CKM regimen, initial administration should begin at a slow rate of infusion (approx. 
20 cc/hour) and increase to 40cc/hour after approximately 30 minutes. Tubing should be 
flushed with 30 to 50 mL of normal saline solution upon completion, Administration will be 
followed by 1 hour of observation and vital signs at 30 (±5 minutes) and 60 minutes (±10 
minutes) 
 
Pretreatment and pre-meds listed above are recommendations and may be modified based upon 
institutional SOC requirements and at the discretion of the investigator/sub-investigator. 
 
5.5 
Continuation of Booster Vaccines Administration 
 
At the discretion of the treating physician, any patient who completes study treatment or is 
removed for reasons other than vaccine related AE/SAEs may continue to receive available 
vaccine. These vaccines may be administered 4-12 weeks apart. Subjects removed will continue 
to be evaluated for safety, but not be included in the analysis of formal efficacy objectives but 
may be evaluated in an exploratory manner. These subjects will be evaluated/followed based 
upon the conventional care evaluations outlined in the study calendar on days of vaccination 
(i.e., PE, vitals, AE evaluation). 
 
5.6 
Safety evaluation and monitoring 
 
The recommended starting dose of the combination of vaccine and chemokine modulation will 
be determined in the Phase 1 portion of the trial. In order to refine the estimate of the RLT rate 
during the efficacy phase we will apply continual Bayesian monitoring of treatment-related 
regimen limiting toxicities and, if needed, impose a stopping rule that permits suspension of the 
trial by the investigator for review by the Data Safety and Monitoring Committee (DSMC). 
Details and a monitoring table are in section 13. 
 
5.7 
Duration of Study Treatment 
 
In the absence of treatment delays due to adverse event(s), treatment may continue until one of 
the following criteria applies: 
 
• Disease progression (excluding disease progression during the time between surgery and the 
CKM regimen, these patients will be allow to continue with study treatment). See also 
Section 5.5. 
• Patient withdraws consent but allows continued follow-up for survival 
• Patient non-compliance 
• Unacceptable agent specific adverse event(s). 
• General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator/sub-investigator. 
• Pregnancy in patient 
 
The reason and date a patient was removed from study treatment must be documented. 
 


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5.8 
Off Study Treatment Visit 
 
Within 1-2 weeks after the last day of study treatment, patients will have their last study specific 
clinical visit. At the discretion of the treating physician, the tests/procedures due to be performed 
at the Off Study Treatment visit may be performed on the last day of the CKM treatment for 
scheduling purposes.  
 
AEs and conmeds will be collected for up to 5 days post last dose of treatment. Any patient 
experiencing study related SAE will be followed until resolution to Grade 1 or baseline. 
 
5.9 
Duration of Follow Up 
 
Patients will be followed until death and the follow-up information for trial reporting will be 
obtained either from the patient’s medical records or through direct contact with the patient (i.e. 
clinic visit or phone call). The timing of these will be based on scheduling of clinical care for the 
treatment of the patient’s cancer (i.e. clinic visits every 3 months, 6 months, yearly). Patients will 
be followed specifically for evidence of progression/recurrence based on imaging and survival. 
 
5.10 
Duration of Study 
 
Patients will be removed from study if any of the criteria below applies. 
 
• Patient decides to withdraw from the study. 
• Patient removed due to non-compliance. 
• The investigator decides to prematurely close the trial. 
 
The reason for study removal and the date the patient was removed must be documented. 
 
6. 
DOSING DELAYS/DOSE MODIFICATIONS 
 
Each vaccination and/or chemokine-modulation regimen may be delayed for up to 8 weeks and 
all subsequent cycles will be adjusted accordingly. 
 
6.1 
Phase 1 
 
Any patient who experiences a RLT will be removed from study treatment and followed until the 
RLT resolves to Grade 1 or baseline. 
 
6.2 
Phase 2 
 
After cycle 1, any AE experienced by a patient must resolve to Grade 1 or baseline prior to 
receiving adjuvant chemotherapy. 
 
6.2.1 DC vaccine 
 
Any patient who experiences the following, and is attributable to the DC vaccine, will be 
removed from study treatment: 


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• Grade 2 or more bronchospasm or generalized uticaria (hypersensitivity) 
• Grade 2 or more allergic reaction 
• Grade 3 injection site reaction due to vaccine 
• > Grade 3 toxicity of any kind related to the DC vaccine 
 
6.2.2 CKM 
 
For grade 3 toxicities: 
1st episode: dose will be held (until the toxicity is reduced to ≤ grade 1 or baseline) and 
restarted at the next study visit at a dose reduction of 33% (dose reduction for IFN and 
rintatolimod, celecoxib will not be dose reduced). The dose can be re-escalated at the 
next study cycle. 
2nd episode: dose will be held and restarted (if toxicity is resolved to ≤ grade 1 or baseline) at 
the next study visit at a dose reduction of 33%. The dose cannot be re-escalated. 
For grade 4 toxicities: 
1st episode: dose will be held (until the toxicity is reduced to ≤ grade 1 or baseline) and 
restarted at the next study visit at a dose reduction of 33% (dose reduction for IFN and 
rintatolimod, celecoxib will not be dose reduced). The dose can be re-escalated at the 
next study cycle. 
2nd episode: Eliminate the CKM regimen 
 
Patients who are discontinued from the CKM treatment may still receive the DC vaccine. 
 
6.3 
Gastrointestinal Toxicity 
 
Nausea and/or vomiting should be controlled with adequate anti-emetic therapy. Prophylactic 
anti-emetic therapy can be used at the discretion of the treating physician. Patients are 
encouraged to take plenty of oral fluids. If symptoms persist despite maximal anti-emetic 
therapy, protocol drugs should be withheld until recovery to ≤ grade 1. 
 
Diarrhea should be managed with appropriate anti-diarrheal therapy. Patients should be 
encouraged to take plenty of oral fluids. If symptoms do not decrease to grade 1 or less with 
adequate anti-diarrheal therapy, all protocol drugs should be held until resolved to ≤ grade 1. 
 
6.4 
Hypersensitivity Reactions 
 
Caution: patients who had a mild to moderate hypersensitivity reaction have been successfully 
re-challenged, but careful attention to prophylaxis and bedside monitoring of vital signs is 
recommended. 
 
Hypersensitivity reactions to IFNα and/or TLR3 ligand will be managed as follows: 
 
Mild symptoms (e.g., mild flushing, rash, pruritus) - complete infusion, supervise at bedside, no 
treatment required. 


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Moderate symptoms (e.g., moderate rash, flushing, mild dyspnea, chest discomfort) - stop 
infusion, give intravenous diphenhydramine 25 mg and intravenous dexamethasone 10 mg, 
resume the infusion at a low rate after recovery of symptoms, then, if no further symptoms, at 
full dose rate until infusion is complete. If symptoms recur, stop the infusion and the patient 
should receive no additional INFα or TLR3 ligand for that cycle, but may be retreated after 
discussion with the Investigator. Keep a record of the toxicity. 
 
Severe life threatening symptoms (e.g., hypotension requiring pressor therapy, angioedema, 
respiratory distress requiring bronchodilation therapy, generalized urticaria) - stop infusion, give 
intravenous diphenhydramine and dexamethasone as above, add epinephrine or bronchodialtors 
if indicated. If wheezing is present, that is not responsive to bronchodilators, epinephrine is 
recommended. Patient should be removed from further protocol therapy. Report it as an adverse 
event. 
 
7. 
ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The 
following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will 
determine whether the event requires expedited reporting in addition to routine reporting. 
 
Note that Phase 2 of this study will include two periods of immunotherapy, administered before 
and after adjuvant chemotherapy (minimum 5 day wash-out periods), in order to separate 
potential toxicities of the chemokine modulatory regimen (all three factors are short-acting), 
from the anticipated toxicities of adjuvant chemotherapy. For this reason, we will only collect the 
toxicity data from the periods of immunotherapy. All toxicities related to the vaccine or CKM 
must be followed until resolution to grade 1 or baseline. 
 
7.1 
Adverse Events and Risks List(s) 
 
7.1.1 DC Vaccine 
 
Dendritic cell vaccines have been investigated extensively in a number of centers and to date, 
have not been reported to be associated with limiting toxicities or adverse side effects. DC 
vaccines carry a potential risk of development of autoimmune disease (such as lupus, or vitiligo). 
Whereas development of vitiligo has been reported with similar vaccines administered to 
melanoma patients (and correlated with positive response to vaccination), other side effects have 
not been reported. Although, based on previous trials with DC-based vaccines, the possibility of 
developing an allergic reaction to DC-based vaccines is rare there is a chance that patients could 
have an allergic reaction to the vaccine. 
 
While other classes of immunotherapueutic drugs, particularly the currently approved immune 
checkpoint blocker, Yervoy [Ipilimumab] can produce significant toxicity, such as enterocolitis, 
hepatitis, dermatitis (including toxic epidermal necrolysis), neuropathy, and endocrinopathy, due 
to its ability to promote polyclonal T-cell activation and proliferation, such effects have not been 
described following application of DC cancer vaccines, including previously-administered alpha-
DC1-based vaccines, their combinations with a long acting TLR3 ligand poly-ICLC (Okada, 


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Kalinski, Bartlett, J. Clin. Onc. 29 (3):330-336, 2011) or their combinations with the proposed 
CKM regimen in our patients treated on compassionate-use protocols. 
 
7.1.2 Celecoxib 
 
Long term use of celecoxib may cause dyspepsia, headaches (including migraines) and 
borderline elevated liver function tests (which could indicate liver damage). Recently, 
information from three long-term studies of celecoxib has become available. In the first study, a 
cancer prevention study, an increased risk of heart attacks, strokes, and/or deaths resulting from 
heart or blood vessel disease was reported among people taking celecoxib. Approximately 1 in 
100 patients enrolled in this study receiving the placebo treatment had one of these serious 
events. In contrast, between 2 and 3 in 100 patients taking celecoxib (between 400 and 800 mg 
daily) had one of these serious events. Another clinical cancer prevention study found no 
increased risks in patients taking celecoxib 400 mg daily. The third study, an Alzheimer's disease 
prevention study, did not find increased risks with celecoxib. Dosing has been suspended in all 
three of these studies based on the findings of the first cancer prevention study. As a result, the 
FDA is now evaluating the possibility that celecoxib increases the risk of heart attack, stroke, 
and or death resulting from heart or blood vessel disease. Known infrequent side effects of 
celecoxib include nausea and/or vomiting, diarrhea, flatulence, abdominal and stomach pain, 
bleeding ulcer, upper respiratory tract infection, pharyngitis, rhinitis, sinusitis, peripheral edema, 
back pain, dizziness, insomnia, and skin rash. Rare risks include sudden death (unexpected or 
instant death that occurs within minutes or hours from any cause other than violence), vasculitis, 
hepatitis, liver failure, kidney failure, blood dyscrasia, hypoglycemia, hyponatremia, viral 
meningitis, severe allergic reaction, visual changes, and transient ischemic attack.  
 
Warnings/Precautions: Stomach problems may be more likely to occur if patients drink alcoholic 
beverages while taking this medicine. Taking two or more of the nonsteroidal anti-inflammatory 
drugs together on a regular basis may increase the chance of unwanted effects. Also, taking 
acetaminophen, aspirin or other salicylates, or ketorolac (e.g., Toradol) regularly while taking a 
nonsteroidal anti-inflammatory drug may increase the chance of unwanted effects. The risk will 
depend on how much of each medicine is taken every day and how long the medicines are taken 
together. Therefore, patients should not take acetaminophen or aspirin or other salicylates or 
ketorolac (e.g., Toradol). Clinical studies with celecoxib have identified potentially significant 
interactions with fluconazole and lithium. Experience with nonsteroidal anti-inflammatory drugs 
(NSAIDs) suggests the potential for interactions with furosemide and ACE inhibitors. Celecoxib 
is contraindicated in patients with known hypersensitivity to celecoxib. Celecoxib should not be 
given to patients who have demonstrated allergic-type reactions to sulfonamides. Celecoxib 
should not be given to patients who have experienced asthma, urticaria, or allergic-type reactions 
after taking aspirin or other NSAIDs. Severe, rarely fatal, anaphylactic-like reactions to NSAIDs 
have been reported in such patients. 
 
For more risk information reference the Investigator’s Brochure or package insert. 
 
7.1.3 Interferon-2b 
 
IFNα may cause fever, chills and flu-like symptoms; loss of appetite; nausea; vomiting, diarrhea 
and abdominal pain; fatigue; lowered white blood count may increase risk of infection; lowered 


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platelets may lead to an increase in bruising or bleeding; hair loss. Other risks which may be 
common in cases of prolonged administration include drowsiness; temporary confusion; anxiety, 
amnesia, irritability, confusion, delusions and depression which can be severe; numbness and/or 
tingling in the hands and/or feet, skin rashes and inflammation of the pancreas. Inflammation of 
the pancreas is swelling or irritation of the pancreas which may result in tenderness or pain in the 
stomach and/or back. When the pancreas is inflamed, the body is not able to absorb all the 
nutrients it needs. 
 
For more risk information reference the Investigator’s Brochure or package insert. 
 
7.1.4 Rintatolimod (poly IC analog) 
 
Clinical experience with rintatolimod totals over 800 patients with more than 400 patients 
receiving Ampligen® for at least six (6) months, greater than 200 patients for one (1) year, over 
50 patients up to two (2) years, and with 20 or more patients over two (2) years at doses as high 
as 1200 mg i.v. twice weekly. No evidence of dose-limiting organ toxicity, including 
hematologic, liver, or renal toxicity, has been observed. 
 
Adverse events related to infusion such as mild flu-like symptoms, transient headache, fever, 
myalgia, arthralgia, and fatigue/malaise which were seen, usually occur during the initial weeks 
of treatment and tend to subside on repeated administration. These side events were seen in 
Chronic Fatigue Syndrome patients, cancer patients, chronic hepatitis B infected patients and 
individuals infected with HIV at doses of 200 and 400 mg and higher. Patients that experience 
these minor side effects can continue on Ampligen® and as noted, these signs and sympotms 
typically subside after several weeks of continued treatment. Specific symptoms of note include 
a flushing reaction, characterized by at least one occurrence of erythema of the face, neck and 
chest, which has been observed in approximately 10% of patients treated in various studies. 
Usually the flushing is both mild and transient and disappears with repeated dosing. 
Occasionally, it can be accompanied by a tightness of the chest, tachycardia, anxiety, shortness 
of breath, subjective reports of "feeling hot", diaphoresis and nausea. The reaction is usually 
infusion-rate dependent and may generally be controlled by slowing the infusion rate. An 
antihistamine (diphenhydramine hydrochloride) can be helpful in controlling and reducing the 
response in the occasional patient for whom the symptom persists. Other less frequently 
occurring adverse effects include nausea, diarrhea, itching, urticaria, bronchospasm, transient 
hypotension, photophobia, rash, bradycardia and transient visual disturbances. A severe 
unexpected local reaction to extravasation of rintatolimod (Ampligen®, Poly I:Poly C12U) at the 
infusion site in the dorsum of the left hand was reported in a Chronic Fatigue Syndrome patient 
with chilblains. Several patients experienced liver enzyme level elevations while receiving 
Ampligen® associated with chronic dosing over many weeks. 
 
Rintatolimod has been dosed in combination with alpha interferon in investigator initiated 
studies under investigator IND applications during the period between December 1985 and April 
1994. A total of 24 patients received combination treatments. Clinical conditions included renal 
cell carcinoma, chronic myelogenous leukemia, melanoma, and ovarian cancer. Rintatolimod 
was given as an IV infusion at a dose of 300 mg BIW. The starting dose was sometimes as low 
as 1-10 mg. The interferons were administered at a dose of 3 million Units daily, with some 
doses of 0.75 mU at the low side and up to 6 mU at the higher side. 


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The therapy with rintatolimod in combination with alpha interferon was generally well tolerated 
without evidence of dose-limiting or cumulative toxicities. The most frequent adverse reactions 
were considered minor in severity and duration. Most of them were flu-like symptoms such as 
chills, cold feeling, fatigue, decreased appetite, fever, muscular aches. Also shortness of breath 
has been seen as well as hypotension, nausea, anemia, dyspnea, numbness, itching and blurred 
vision. These adverse events were judged possibly related to the condition of the patients, but 
also possibly related to the administration of rintatolimod or interferon. In some cases worsening 
of the patient’s condition has been seen due to tumor progression, but in general favorable 
clinical patterns were observed in these patients with advanced disease. Such combinations were 
not intended to be immune modulating and were evaluated in the context of clinical cancer care. 
 
For more risk information reference the Investigator’s Brochure. 
 
7.2 
Definitions 
 
Adverse event (AE) means any untoward medical occurrence associated with the use of a drug in 
humans, whether or not considered drug related. 
 
Adverse reaction means any adverse event caused by a drug. 
 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility 
that the drug caused the adverse event. Suspected adverse reaction implies a lesser degree of 
certainty about causality than “adverse reaction”. 
 
Reasonable possibility, for the purpose of IND safety reporting, means there is evidence to 
suggest a causal relationship between the drug and the adverse event. 
 
Life-threatening, suspected adverse reaction is considered "life-threatening" if, in the view of 
either the investigator (i.e., study site principal investigator) or sponsor, its occurrence places the 
patient or subject at immediate risk of death. It does not include a suspected adverse reaction 
that, had it occurred in a more severe form, might have caused death. 
 
Serious, suspected adverse reaction is considered "serious" if, in the view of either the 
investigator (i.e., study site principal investigator) or sponsor, it results in any of the following 
outcomes: death, a life-threatening adverse reaction, inpatient hospitalization or prolongation of 
existing hospitalization, a persistent or significant incapacity or substantial disruption of the 
ability to conduct normal life functions, or a congenital anomaly/birth defect. 
 
Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the patient or subject and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. Examples of such medical events 
include allergic bronchospasm requiring intensive treatment in the emergency room or at 
home, blood dyscrasias or convulsions that do not result in inpatient hospitalization, or the 
development of drug dependency or drug abuse. 


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Unexpected, suspected adverse reaction is considered "unexpected" if it is not listed in the 
general investigational plan, clinical protocol, or elsewhere in the current IND application; or is 
not listed at the specificity or severity that has been previously observed and/or specified. 
 
7.3 
Recording/Reporting requirements 
 
7.3.1 Eliciting AE Information 
 
Research subjects will be routinely questioned about AEs at study visits. 
 
7.3.2 Recording Requirements 
 
All observed or volunteered adverse events (serious or non-serious) and abnormal test findings, 
regardless of study group or suspected causal relationship to the study drug(s) will be recorded in 
the subjects’ case histories. For all adverse events, sufficient information will be pursued and/or 
obtained so as to permit 1) an adequate determination of the outcome of the event (i.e., whether 
the event should be classified as a serious adverse event) and; 2) an assessment of the casual 
relationship between the adverse event and the study drug(s). 
 
AEs or abnormal test findings felt to be associated with the investigational drug or study 
treatment(s) will be followed until the event (or its sequelae) or the abnormal test finding 
resolves or stabilizes at a level acceptable to the investigator (i.e., study site principal 
investigator) or sponsor. 
 
7.3.3 Abnormal Test Findings 
 
An abnormal test finding will be classified as an adverse event if one or more of the following 
criteria are met: 
• 
The test finding is accompanied by clinical symptoms. 
• 
The test finding necessitates additional diagnostic evaluation(s) or medical/surgical 
intervention; including significant additional concomitant drug treatment or other 
therapy. 
Note: simply repeating a test finding, in the absence of any of the other listed criteria, 
does not constitute an AE. 
• 
The test finding leads to a change in study drug dosing or discontinuation of subject 
participation in the clinical study. 
• 
The test finding is considered an AE by the investigator (i.e., study site principal 
investigator) or sponsor of the IND application. 
7.3.4 Causality and severity assessment 
 
The investigator (i.e., study site principal investigator) or sponsor of the IND application will 
promptly review documented adverse events and abnormal test findings to determine 1) if the 
abnormal test finding should be classified as an adverse event; 2) if there is a reasonable 


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possibility that the adverse event was caused by the study drug(s); and 3) if the adverse event 
meets the criteria for a serious adverse event. 
 
If the investigator (i.e., study site principal investigator) or sponsor’s final determination of 
causality is “unknown and of questionable relationship to the study drug(s)”, the adverse event 
will be classified as associated with the use of the study drug(s) for reporting purposes. If the 
investigator (i.e., study site principal investigator) or sponsor’s final determination of causality is 
“unknown but not related to the study drug(s)”, this determination and the rationale for the 
determination will be documented in the respective subject’s case history. 
 
7.4 
Reporting of Suspected Adverse Reactions 
 
All events meeting the definition of a serious adverse event should be recorded on a MedWatch 
3500A Form 
(http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Forms/UCM048334.pdf) or 
departmental SAE form. Copies should be sent to the Sponsor, Investigator, 
crssafetysubmissions@upmc.edu, and the local Institutional Review Board per institutional 
reporting requirements. 
 
In addition to completing appropriate patient demographic and suspect medication information, 
the report should include as applicable the following information that is available at the time of 
report within the Event Description (section 5) of the MedWatch 3500A form: 
 
• CTCAE term(s) and grade(s) 
• current status of study drug 
• all interventions to address the AE (testing and result, treatment and response) 
• hospitalization and/or discharge dates 
• event relationship to study drug 
 
Follow-up reports: 
Additional information may be added to a previously submitted report by adding to the original 
MedWatch 3500A report and submitting it as follow-up or creating supplemental summary 
information and submitting it as follow-up with the original MedWatch 3500A form. 
 
7.5 
Review of Safety Information: Sponsor Responsibilities1 
 
The sponsor must promptly review all information relevant to the safety of the drug obtained or 
otherwise received by the sponsor from foreign or domestic sources, including information 
derived from any clinical or epidemiological investigations, animal or in vitro studies, reports in 
the scientific literature, and unpublished scientific papers, as well as reports from foreign 
regulatory authorities and reports of foreign commercial marketing experience for drugs that are 
not marketed in the United States. 
 
                                                 
1 21 CFR Sec. 312.50 
 


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7.6 
Review of Safety Information: Investigator Responsibilities2 
 
An investigator shall promptly report to the sponsor of the IND application any adverse effect 
that may reasonably be regarded as caused by, or probably caused by, the drug. If the adverse 
effect is alarming, the investigator shall report the adverse effect immediately. An investigator 
shall provide the sponsor with an adequate report shortly after completion of the investigator's 
participation in the investigation. 
 
7.7 
Reporting of Adverse Reactions to the FDA 
 
Reporting of serious adverse events to the FDA will follow 21 CFR 312.32. 
 
7.7.1 Written IND safety reports 
 
The Sponsor will submit a written IND Safety Report (i.e., completed FDA Form 3500 A) to the 
responsible new drug review division of the FDA for any observed or volunteered adverse event 
that is determined to be a serious and unexpected, suspected adverse reaction. Each IND Safety 
Report will be prominently labeled, “IND Safety Report”, and a copy will be provided to all 
participating investigators (if applicable) and sub-investigators. 
 
Written IND Safety Reports will be submitted to the FDA as soon as possible and, in no event, 
later than 15 calendar days following the Sponsor receipt of the respective adverse event 
information and determination that it meets the respective criteria for reporting. 
 
For each written IND Safety Report, the Sponsor will identify all previously submitted IND 
Safety Reports that addressed a similar suspected adverse reaction experience and will provide 
an analysis of the significance of newly reported, suspected adverse reaction in light of the 
previous, similar report(s) or any other relevant information. 
 
Relevant follow-up information to an IND Safety Report will be submitted to the applicable 
review division of the FDA as soon as the information is available and will be identified as such 
(i.e., “Follow-up IND Safety Report”). 
 
If the results of the Sponsor’s follow-up investigation show that an adverse event that was 
initially determined to not require a written IND Safety Report does, in fact, meet the 
requirements for reporting; the Sponsor will submit a written IND Safety Report as soon as 
possible, but in no event later than 15 calendar days, after the determination was made. 
 
7.7.2 Telephoned IND safety reports – fatal or life-threatening suspected adverse reactions 
 
In addition to the subsequent submission of a written IND Safety Report (i.e., completed FDA 
Form 3500A), the Sponsor will notify the responsible review division of the FDA by telephone 
or facsimile transmission of any unexpected, fatal or life-threatening suspected adverse reaction.  
 
The telephone or facsimile transmission of applicable IND Safety Reports will be made as soon 
                                                 
2 21 CFR Sec. 312.64 


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as possible but in no event later than 7 calendar days after the Sponsor’s receipt of the respective 
adverse event information and determination that it meets the respective criteria for reporting. 
 
7.8 
Reporting Adverse Events to the Responsible IRB 
 
In accordance with applicable policies of the University of Pittsburgh Institutional Review Board 
(IRB), the Investigator will report, to the IRB, any observed or volunteered adverse event that is 
determined to be 1) associated with the investigational drug or study treatment(s); 2) serious; 
and 3) unexpected. Adverse event reports will be submitted to the IRB in accordance with the 
respective IRB procedures. 
 
Applicable adverse events will be reported to the IRB as soon as possible and, in no event, later 
than 10 calendar days following the investigator’s receipt of the respective information. Adverse 
events which are 1) associated with the investigational drug or study treatment(s); 2) fatal or 
life-threatening; and 3) unexpected will be reported to the IRB within 24 hours of the 
Investigator’s receipt of the respective information. 
 
Follow-up information to a reported adverse event will be submitted to the IRB as soon as the 
relevant information is available. If the results of the Investigator’s follow-up investigation show 
that an adverse event that was initially determined to not require reporting to the IRB does, in 
fact, meet the requirements for reporting; the Investigator will report the adverse event to the 
IRB as soon as possible, but in no event later than 10 calendar days, after the determination was 
made. 
 
8. 
PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational and 
commercial agents administered in this study can be found in Section 7.1. 
 
This Phase 1/2 trial will evaluate the effectiveness of autologous αDC1 (alpha dendritic cell type 
1 loaded with autologous tumor material) vaccines, combined with a systemic chemokine 
modulation regimen [CKM; intravenous rintatolimod (TLR3 ligand, a derivative of Poly-I:C) + 
intravenous IFNα + oral celecoxib] as adjuvant therapy, after cytoreductive surgery (CRS) and 
locoregional hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with potentially 
resectable peritoneal surface malignancies (PSM), including but not limited to malignant 
peritoneal mesothelioma and peritoneal carcinomatosis (PC) of appendiceal and colorectal 
origin. The primary outcome measure will be recurrence free survival. 
 
8.1 
DC Vaccine 
 
Dendritic cells (DC) are derived from autologous (the patient’s own) adherent mononuclear cells 
(monocytes) in the peripheral blood by 5-day or 6- day culture in the presence of interleukin 4 
(IL-4) and granulocyte-macrophage colony stimulating factor (GM-CSF), followed by 1-2 days 
of maturation. The autologous tumor tissue needed for manufacturing of the vaccine is acquired 
from surgery that is performed as part of the patient’s standard of care for their cancer as 
determined by their treating physician. 
 


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8.1.1 Other names 
 
Alpha-type-1 polarized dendritic cells, alpha DC1, αDC1 
 
8.1.2 Formulation 
 
The DC Vaccine will be prepared in the cGMP facility of the University of Pittsburgh Cancer 
Institute, in a process analogous to the existing BB-IND 13,234 (colorectal cancer). The αDC1 
vaccines are prepared in the University of Pittsburgh Immunotransplantation Center (ITC) under 
cGMP conditions and the final product is vialed and cryopreserved. Labels placed on all tubes 
contain a unique vaccine lot. The vaccine release will follow the quality and safety testing 
performed by the ITC. The target dose of αDC1 vaccine is 3 x 106 cells in 0.5 mL for each 
injection, intranodal and intradermal, however, in case of manufacturing limitations; a minimum 
of 0.5 x 106 cells is acceptable per injection site (0.5 x 106 cells total). Patients can receive a 
lesser number of vaccine DCs, but any such patients will not be included in the analysis of the 
primary endpoint. 
 
8.1.3 Storage and preparation 
 
DCs used in the vaccine will be suspended in 5% human serum albumin (HSA) and delivered to 
the clinic for administration. For preparation of the vaccines, the labeled vials of cryopreserved 
αDC1 are removed from storage in liquid nitrogen and quickly thawed in a 37C water bath. 
After 3 washes in sterile medium, thawed αDC1 will be suspended in saline with 5% human 
serum albumin (HSA) and placed in sterile syringes for administration to the patient. Each 
syringe will be labeled with a custom-designed label, identifying the patient and the vaccine. 
 
Intranodal and intradermal vaccines will be delivered as single injections. 
 
8.1.4 Supplier 
 
The DC vaccine will be prepared by the cGMP facility of the University of Pittsburgh Cancer 
Institute, in a process analogous to the vaccine for colorectal cancer patients covered by the 
existing BB-IND 13,234. 
 
 
 


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8.2 
Celecoxib 
 
A sulfa non-steroidal anti-inflammatory drug (NSAID) used in the treatment of osteoarthritis, 
rheumatoid arthritis, acute pain, painful menstruation and menstrual symptoms, and to reduce 
numbers of colon and rectum polyps in patients with familial adenomatous polyposis. 
 
8.2.1 Other names 
 
Celebrex, Celebra, or Onsenal (commercially available) 
 
8.2.2 Formulation and packaging 
 
Celecoxib as capsules in the following dosages: 100 mg, 200 mg, and 400 mg. 
 
8.2.3 Preparing and dispensing 
 
Externally prepared and dispensed per treating physician prescription.Drug storage and 
accountability 
 
Store at room temperature at 77 °F (25 °C) away from light and moisture. Brief storage between 
59-86 °F (15-30 °C) is permitted. 
 
8.3 
Interferon-2b 
 
An antiviral drug approved around the world for the treatment of chronic hepatitis C, chronic 
hepatitis B, hairy cell leukemia, chronic myelogenous leukemia, multiple myeloma, follicular 
lymphoma, carcinoid tumor, and malignant melanoma. 
 
8.3.1 Other names 
 
Interferon-2b, Intron A, IFN-2b, IFN, IFN, NSC #377523 (commercially available) 
 
8.3.2 Formulation and packaging 
 
50 MU/mL, lyophilized powder, which must be reconstituted prior to administration. 
 
Vial size: 10 MU/vial 
 
Diluent: Compatible with normal saline, Ringer’s injection, lactated Ringer’s, and 5% sodium 
bicarbonate injection. IFN should be reconstituted with 1 mL to reach a final concentration of 
10:1. IV dose should be diluted in sodium chloride 0.9%/100 mL (100,000 U/mL) and given 
over 20 minutes. The final concentration of INTRON A should not be less than 10 million 
IU/100 mL 
 
Source: Schering Plough Corp. 
 


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8.3.3 Preparing and dispensing 
 
The lyophilized product is reconstituted as directed by the manufacturer. Investigational Drug 
Services will prepare and dispense. 
 
For IV injection, it is recommended that IFN be administered as a 100,000 U/mL solution to 
minimize adsorption of the drug to glass and plastic containers. 
 
8.3.4 Concomitant medications 
 
Interactions between IFN and other drugs have not been fully evaluated. Caution should be 
exercised when administering IFN therapy in combination with other potentially 
myelosuppressive agents such as zidovudine. Concomitant use of IFN and theophylline 
decreases theophylline clearance, resulting in a 100% increase in serum theophylline levels. 
Concomitant IFN and REBETOL (Ribavirin) use is contraindicated. 
 
For more information on concomitant medications reference the Investigator’s Brochure or 
package insert. 
 
8.4 
Rintatolimod (poly IC analog) 
 
A substituted double stranded polyribonucleic acid (polyI:polyC12U), rintatolimod preserves 
activity of polyIC with a much improved systemic toxicity profile. The product has been studied 
extensively for use as a vaccine adjuvant and for its direct antiviral activity, as well in several 
cancer studies as a monotherapy, but most extensively in chronic fatigue syndrome (CFS). 
 
8.4.1 Other names 
 
PolyIC12U, Ampligen®, poly I: polyC12U; Polyinosinic:polycytidylic-polyuridylic acid; 
polyriboinosinic/polyribocytidylic (uridylic) acid; supplied by Hemispherx Biopharma, Inc. 
 
8.4.2 Formulation and packaging 
 
Rintatolimod is supplied as a liquid solution in glass bottles containing 200 mg per 80 mL. 
Rintatolimod is a colorless solution containing 2.5 mg/mL in physiological salts (0.15 M NaCl, 
0.01 M phosphate, 0.001 M Mg++). The product does not contain preservatives or antioxidants. 
 
8.4.3 Preparing and dispensing 
 
A vial of rintatolimod is suitable for direct IV infusion. Investigational Drug Services will 
prepare and dispense. Each vial should be taken from the refrigerator and allowed to equilibrate 
to room temperature. 
 
8.4.4 Drug storage and accountability 
 
Rintatolimod should be stored at 2 to 8°C, but should be infused at room temperature. Used vials 


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should be accounted for and destroyed according to institutional procedure. 
 
9. 
CORRELATIVE STUDIES 
 
At indicated time points (see the study calendar, Section 10) up to 60 cc of peripheral blood will 
be collected and cryopreserved for potential correlative studies. For additional correlative 
studies, we may cryopreserve the available portions of the harvested tumors, not used for the 
preparation of autologous vaccines. The exact scope of the correlative studies will depend on the 
clinical outcomes and available funding, but may include: 
 
• Changes in circulating subsets of immune cells (flow cytometry). 
• Changes in serum immune mediators, cytokines, chemokines (Luminex, ELISAs). 
• Changes in gene expression of blood cells (mRNA/Taqman assays). 
• Changes in the frequencies and activity of tumor-reactive cells (ELISPOTs and ELISAs) 
 
TTP may be correlated with the changes in the blood samples from the treated subjects. For 
subjects who will need palliative surgery or will demonstrate clinical response and will have 
accessible tumor tissue, we may obtain tumor material to analyze tumor-infiltrating CD8+ T cells 
in the resected metastatic CRC lesions and local expression of chemokines and other 
inflammatory mediators. This is measured as the ratio between the CD8 (or other gene) mRNA 
message and the expression of the housekeeping gene HPRT, in situ hybridization [ISH], and 
Immunohistochemistry/immunofluorescence [ICH/IF]. Examples of additional relevant 
parameters include total numbers of infiltrating T cells, their CD4/CD8 ratios, frequencies of 
FoxP3 cells, and the expression of chemokine receptors on CD4+ and CD8+ T cells (CXCR3, 
CCR5, CCR4, CCR6, and CXCR4). Using ISH, IF, and Taqman, we may also evaluate the local 
expression of Teff-attracting chemokines: CCR5, CXCL9, and CXCL10 and CXCL11, and 
MDSC/Treg-attracting chemokines: CCL22 and CXCL12. Similar assays may also be performed 
on any available pre-treatment tumors (if such material will remain after preparation of 
vaccines). 
 
These potential correlative studies may allow us to determine if any blood- or tumor-associated 
markers are predictive of response to treatment and thus may be used as prospective inclusion 
criteria or assist us in prospective decisions regarding continuation of treatment in the individual 
patients. They may also facilitate development of additional therapies. 
 
Any biological samples (from tissue, leukapheresis, blood draws, etc.) not needed for this 
research study will be de-identified and may be used for additional cancer research outside of 
this clinical trial. 
 


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10. 
STUDY CALENDAR 
 
Baseline/screening evaluations will be conducted within 14 days and imaging will be conducted within 28 days of leukapheresis. 
 
There is a window of ±1 week available for scheduling treatment and/or procedures at the discretion of the Investigator/Sub-
investigator. This applies also if a course is missed or a subject's treatment and/or testing day(s) need to be rescheduled due to the 
subject’s inability to comply with the study calendar (i.e., hospitalizations, business, vacation plans, travel from long distances for 
study treatment, in advance of the scheduled date to allow ready access to the result(s), reduce financial burden on the subject [i.e. 
non-UPMC insurance coverage] or reduce travel inconvenience, illness, transportation issues, holidays, family emergencies, etc.). 
Parameter 
Eligibility 
Surgery 
Screening 
Week 1* 
(Priming) 
Week 4* 
(Booster 
Cycle 1) 
Week 8* 
(Booster 
Cycle 2) 
Week 12* 
(Booster 
Cycle 3) 
Off 
treatment 
visit9 
Informed Consent 
X 
 
 
 
 
 
 
 
History and Physical Exam1 
 
 
X 
X 
X 
X 
X 
 
Vital Signs2 
 
 
X 
X 
X 
X 
X 
 
Adverse Event/Con Meds10 
 
 
X 
X 
X 
X 
X 
X 
ECOG Performance Status 
 
 
X 
X 
X 
X 
X 
 
CEA 
 
 
X 
 
 
 
 
X 
Urine pregnancy test3 
 
 
X 
X3 
 
 
 
 
CT or MR imaging 
(scheduled as clinically indicated) 
 
 
X8 
 
 
X 
 
X 
CBC, platelets, differential7 
 
 
X 
X 
X 
X 
X 
 
Chemistries4,7 
 
 
X 
X 
X 
X 
X 
 
Leukapheresis 
 
 
X 
 
 
 
 
 
αDC1 vaccine 
 
 
 
X 
Monday 
Monday 
Monday 
 
Chemokine modulation 
 
 
 
 
Tues-Fri 
Tue-Fri 
Tue-Fri 
 
Celecoxib5 
 
 
 
X 
M-F 
M-F 
M-F 
 
Blood (60 cc) in vitro assays6 
 
 
 
X 
X 
X 
X 
 
Tissue collection 
 
X 
 
 
 
 
 
 
*. The indicated weeks represent “target weeks” In order to avoid conflict with chemotherapy, each cycle of immunotherapy can be 
delayed:  see the study schema). 


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1. Physical examination will be performed by the investigator/sub-investigator or their designee. 
2. Vital signs (temperature, blood pressure, pulse rate, and respiratory rate) will be performed before (within 30 minutes) and after (within 30 minutes) intra-nodal vaccine doses. 
3. Pregnancy test is only for WOCBP who are sexually active. Test prior to cycle 1 is to be done on day 1 and must be resulted prior to vaccination. 
4. Glucose, BUN, creatinine, sodium, potassium, chloride, CO2, calcium, total protein, albumin, alkaline phosphatase, AST, ALT, total bilirubin, amylase, lipase. 
5. Celecoxib will be administered orally, at a dose of 200 mg, twice daily on vaccine and CKM study treatment days 
6. Peripheral blood for potential correlative studies will be collected at the following time points: once during the pre-screening, within 60 minutes before the vaccinations of the 
priming cycle,  and booster cycles 1 and 2; and within 60 minutes after completing  booster cycle 2 on Friday. Peripheral blood for potential correlative studies may 
additionally be drawn within 60 minutes before the vaccination of booster cycle 3 on Monday and within 60 minutes after completing booster cycles 1 and 3 on Friday. 
7. Performed within 2 weeks prior to the priming dose of vaccine and 5 business days prior to cycles 1, 2 and 3 vaccines. 
8. CT or MRI imaging should be performed prior to cycle 1 if the recovery period from surgery is greater than 6 weeks. 
9. At the discretion of the treating physician, the tests/procedures due to be performed at the Off Study Treatment visit may be performed on the last day of the CKM treatment for 
scheduling purposes. 
10. Performed as routine pre-operative evaluation. 
11. AEs /conmeds should be collected up to 5 days after treatment, unless considered clinically significant or serious in nature in which case they will be followed until resolution 
or Grade 1. 
 
 


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11. 
MEASUREMENT OF EFFECT 
 
All Patients will undergo CT or MR prior to returning for cycle 2 of the investigational treatment 
(approximately week  6 or 7), at the time of the off treatment visit at MD discretion, and 
subsequently based upon the timing the regular care for their cancer. Response or progression 
will primarily be evaluated by CT or MR imaging of tumor nodules using RECIST criteria v1.1, 
however tumor measurements are not required as patients must be completely surgically resected 
to be eligible. 
 
11.1 
Disease Parameters (May be used as a guideline for scan review prior to Cycle 2) 
 
Measurable disease: Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as ≥10 mm with CT or MR imaging 
(CT/MR slice thickness no greater than 5 mm). . Malignant lymph nodes may be considered 
measureable disease if they are ≥ 15 mm in short axis as measured by CT or MR imaging with 
no greater than 5 mm slice thickness. 
 
Non-measurable disease: All other lesions (longest diameter < 10 mm with CT or MR scan) are 
considered non-measurable disease. Bone lesions, ascites, leptomeningeal disease, 
pleural/pericardial effusions, lymphangitis cutis/pulmonis, inflammatory breast disease are all 
non-measurable. 
 
11.2 
CT or MR-Imaging Response Criteria  
 
CT or MR imaging will be performed with cuts of 5 mm or less in slice thickness contiguously. 
RECIST criteria v1.1 will primarily be used to assess tumor recurrence. 
 
Progressive Disease (PD): The appearance or recurrence of one or more new lesions is 
considered progression. 
 
11.3 
Duration of Response 
 
Time-to-Progression (TTP): Time-to-Progression is measured from the start of treatment until 
the criteria for progression are met 
 
Duration of overall response: The duration of overall response is measured from the time of 
surgical resection until the first date that progressive disease is objectively documented (taking 
as reference for progressive disease the smallest measurements recorded since the treatment 
started). 
 
 
 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS 
 
12.1 
Data Safety Monitoring Plan 
 


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Sponsor, Investigator, Sub-investigators, regulatory, CRS management, clinical research 
coordinators, clinical research associates, data managers, and clinic staff meet monthly in disease 
center Data Safety Monitoring Boards (DSMB) to review and discuss study data to include, but 
not limited to, the following: 
 
• serious adverse events 
• subject safety issues 
• recruitment issues 
• accrual 
• protocol deviations 
• unanticipated problems 
• breaches of confidentiality 
 
Minutes from the DSMB meetings are available to anyone unable to attend the center DSMB. 
 
All toxicities encountered during the study will be evaluated on an ongoing basis according to 
the NCI Common Toxicity Criteria version 4. All study treatment associated adverse events that 
are serious, at least possibly related and unexpected will be reported to the IRB. Any 
modifications necessary to ensure subject safety and decisions to continue, or close the trial to 
accrual are also discussed during these meetings. If any literature becomes available which 
changes the risk/benefit ratio or suggests that conducting the trial is no longer ethical, the IRB 
will be notified in the form of an Unanticipated Problem submission and the study may be 
terminated. 
 
All study data reviewed and discussed during these meetings will be kept confidential. Any 
breach in subject confidentiality will be reported to the IRB in the form of an Unanticipated 
Problem submission. The summaries of these meetings are forwarded to the UPCI DSMC which 
also meets monthly following a designated format. 
 
For all research protocols, there will be a commitment to comply with the IRB’s policies for 
reporting unanticipated problems involving risk to subjects or others (including adverse events). 
DSMC progress reports, to include a summary of all serious adverse events and modifications, 
and approval will be submitted to the IRB at the time of renewal. 
 
Protocols with subjects in long-term (survival) follow-up or protocols in data analysis only, will 
be reviewed twice a year rather than monthly by the disease center DSMB. 
 
Both the UPCI DSMC as well as the individual disease center DSMB have the authority to 
suspend accrual or further investigate treatment on any trial based on information discussed at 
these meetings. 
 
All records related to this research study will be stored in a locked environment. Only the 
researchers affiliated with the research study and their staff will have access to the research 
records. 
 


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12.2 
Quality Control and Quality Assurance 
 
Independent monitoring of the clinical study for protocol and Guidelines on Good Clinical 
Practice compliance will be conducted periodically (i.e., at a minimum of annually) by qualified 
staff of the Education and Compliance Office – Human Subject Research, Research Conduct and 
Compliance Office, University of Pittsburgh. 
 
The Investigator (i.e., the study site principal investigator) and the University of Pittsburgh and 
University of Pittsburgh Medical Center will permit direct access of the study monitors and 
appropriate regulatory authorities to the study data and to the corresponding source data and 
documents to verify the accuracy of this data. 
 
12.3 
Data Handling and Record-Keeping 
 
The Investigator (i.e., the study site principal investigator) will maintain records in accordance 
with Good Clinical Practice. 
 
The investigator will retain the specified records and reports for up to 2 years after the marketing 
application is approved for the investigational drug; or, if a marketing application is not 
submitted or approved for the investigational drug, until 2 years after investigations under the 
IND have been discontinued and the FDA so notified. 
 
12.4 
Institutional Review Board (IRB) Approval 
 
The investigator (i.e., the study site principal investigator) will obtain, from the University of 
Pittsburgh Institutional Review Board (IRB), prospective approval of the clinical protocol and 
corresponding informed consent form(s); modifications to the clinical protocol and 
corresponding informed consent forms, and advertisements (i.e., directed at potential research 
subjects) for study recruitment, if applicable. 
 
The only circumstance in which a deviation from the current IRB-approved clinical 
protocol/consent form(s) may be initiated in the absence of prospective IRB approval is to 
eliminate an apparent immediate hazard to the research subject(s). In such circumstances, the 
investigator will promptly notify the University of Pittsburgh IRB of the deviation. 
 
The University of Pittsburgh IRB operates in compliance with FDA regulations at 21 CFR Parts 
50 and 21 CFR 56, and in conformance with applicable International Conference on 
Harmonization (ICH) Guidelines on Good Clinical Practice. 
 
In the event that the University of Pittsburgh IRB requires, as a condition of approval, substantial 
changes to a clinical protocol submitted under an FDA-accepted IND application, or in the event 
of an sponsor’s decision to modify the previously accepted clinical protocol, the sponsor will 
submit (i.e., in advance of implementing the change) a Protocol Amendment to the IND 
describing any change that significantly affects the safety of subjects, the scope of the 
investigation, or the scientific quality of the study. Examples of protocol changes requiring the 
submission of a Protocol Amendment include: 


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• Any increase in drug dosage or duration of exposure of individual subjects to the 
investigational drug beyond that described in the current protocol, or any significant increase 
in the number of subjects under study. 
• Any significant change in the design of the protocol (such as the addition or deletion of a 
control group). 
• The addition of a new test or procedure that is intended to improve monitoring for, or reduce 
the risk of, a side effect or AE; or the dropping of a test intended to monitor the safety of the 
investigational drug. 
 
12.5 
Ethical and Scientific Conduct of the Clinical Study 
 
The clinical study will be conducted in accordance with the current IRB-approved clinical 
protocol; ICH Guidelines on Guidelines on Good Clinical Practice; and relevant policies, 
requirements, and regulations of the University of Pittsburgh IRB, University of Pittsburgh and 
University of Pittsburgh Medical Center, Commonwealth of Pennsylvania, and applicable federal 
agencies. 
 
12.6 
Informed Consent 
 
The investigator (i.e., the study site principal investigator) will make certain that an appropriate 
informed consent process is in place to ensure that potential research subjects, or their authorized 
representatives, are fully informed about the nature and objectives of the clinical study, the 
potential risks and benefits of study participation, and their rights as research subjects. The 
investigator, or a sub-investigator(s) designated by the sponsor, will obtain the written, signed 
informed consent of each subject, or the subject’s authorized representative, prior to performing 
any study-specific procedures on the subject. The date and time that the subject, or the subject’s 
authorized representative, signs the informed consent form and a narrative of the issues discussed 
during the informed consent process will be documented in the subject’s case history. The 
investigator or sub-investigator will retain the original copy of the signed informed consent form, 
and a copy will be provided to the subject, or to the subject’s authorized representative. 
 
The investigator will make certain that appropriate processes and procedures are in place to 
ensure that ongoing questions and concerns of enrolled subjects are adequately addressed and 
that the subjects are informed of any new information that may affect their decision to continue 
participation in the clinical study. In the event of substantial changes to the clinical study or the 
risk-to-benefit ratio of study participation, the investigator will obtain the informed consent of 
enrolled subjects for continued participation in the clinical study. 
 
13. 
STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
13.1.1 Primary endpoint 
 
• (For Phase 1) Define Recommended Phase 2 Dose (RP2D) 


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• To evaluate time-to-progression (TTP) in patients with peritoneal surface malignancies 
(PSM), including but not limited to malignant peritoneal mesothelioma and peritoneal 
carcinomatosis (PC) of appendiceal and colorectal primary tumors. For patients who will 
be completely resected, time-to-progression will be equal to recurrence. 
 
13.1.2 Secondary endpoints 
 
• To estimate overall survival (OS). 
• Correlative studies to characterize sequential immune response changes by quantitative 
measures of immune cellular phenotypes and chemokine patterns in peripheral blood (see 
Section 9). These results will be correlated with TTP, PFS, and OS. 
 
Note the additional discussion of the Phase 1 dose-finding studies described in Section 5.1. 
 
13.2 
Power and Sample Size for the Study of Efficacy 
 
Based on information from our prospective database at the University of Pittsburgh over the last 
10 years, we expect to treat ~ 115 patients per year (malignant peritoneal mesothelioma ~ 15 
cases/year; appendiceal peritoneal carcinomatosis ~ 40 cases/year; colorectal carcinomatosis ~ 
60 cases/year). We anticipate approximately 50% of treatment patients will participate in the 
clinical trial. A review of the literature demonstrates median time-to-progression of 20 months, 
20 months and 12 months for malignant peritoneal mesothelioma, appendiceal peritoneal 
carcinomatosis, and colorectal carcinomatosis, respectively. We aim to demonstrate a 25% 
improvement in time-to-progression (malignant peritoneal mesothelioma 25 months; appendiceal 
peritoneal carcinomatosis 25 months; and colorectal carcinomatosis 15 months). We will need 
168 patients over 3 years of accrual with an additional 1.5 years of follow-up after accrual 
ceases. This will provide 90% power to detect an overall improvement of 25% for an exponential 
test at alpha = 0.10. 
 
13.3 
Data Analysis 
 
At the completion of follow-up in evaluable patients, we will estimate progression-free survival 
by the Kaplan-Meier method with Greenwood 90% confidence intervals. We will conduct a 
formal test of the hypothesis that progression-free survival is improved with the experimental 
therapy. This test will be a one sided exponential test at α = .10 that the median progression-free 
survival is better than 25% compared to historical controls. If this test is significant we will 
conclude that the progression-free survival is improved compared to the historical control. 
Descriptive summaries will be prepared of all adverse events by grade, frequency and attribution. 
An assessment of the association between immune parameters and survival will be conducted. 
The panel of immune parameters will be tested for association with progression-free and overall 
survival with Cox proportional hazards regression. 
 
13.4 
Continuous Safety Monitoring During the Efficacy Phase 
 
We will use continual Bayesian monitoring of treatment-related regimen limiting toxicities with 
a stopping rule that permits suspension of the trial by the investigator for review by the Data 


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47 
Safety and Monitoring Committee (DSMC). We have selected a moderately vague prior 
probability of an RLT to conform to our prior beliefs that the probability of an RLT is unlikely to 
be greater than the 30% target of the dose finding phase and could be lower if no RLTs are found 
in Phase 1. Specifically we chose a beta prior distribution with parameters a = 1.93 and b = 4.74 
which yields a distribution with a mode of .2, a mean of .29. 
 
A stopping rule will be based on the updated posterior probability of an RLT. If the posterior 
probability exceeds .80 that 30% or more of the patients experience a treatment-related RLT, the 
study will be suspended pending review by the DMSC. In order to permit continuous monitoring 
of serious patient toxicities, the following table was prepared based upon cumulative observed 
AEs at any point in the trial and can be used to signal when either arm should be suspended and 
reviewed by the DSMC. Values are presented in the table in intervals of 5 or 10 patients 
 
 Number of RLTs needed to suspend the trial 
Number of Patients 
RLTs 
P(π|R > .30)* 
B(RLT)**. 
5 
4 
0.927 
0.031 
10 
5 
0.831 
0.15 
15 
7 
0.857 
0.131 
20 
9 
0.879 
0.113 
25 
10 
0.812 
0.189 
30 
12 
0.841 
0.159 
35 
14 
0.865 
0.135 
40 
15 
0.812 
0.193 
45 
17 
0.839 
0.164 
50 
19 
0.862 
0.141 
60 
22 
0.842 
0.162 
70 
25 
0.826 
0.18 
80 
28 
0.811 
0.195 
90 
32 
0.854 
0.15 
100 
35 
0.842 
0.163 
110 
38 
0.832 
0.174 
120 
41 
0.822 
0.184 
130 
44 
0.813 
0.194 
140 
47 
0.805 
0.202 
150 
51 
0.842 
0.163 
160 
54 
0.834 
0.171 
168 
56 
0.812 
0.194 
* P(π|R > .30) = Posterior probability of a treatment-related RLT exceeds 30% given R, the 
number of observed RLTs and the prior distribution. 
** B(RLT) is the binomial probability of observing at least the number of RLTs  in column 2 if 
the underlying rate of RLT is 30%. 
This table presents the minimum number of RLTs that dictate suspension of the trial in 
accordance with the stopping rule. For example, according to this table 5 RLTs among any of the 


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48 
first 10 enrolled patients on the efficacy phase will trigger suspension of the trial. 
 
 
 


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49 
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APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able 
to carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In bed <50% of the time. 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities. Up and about 
more than 50% of waking hours. 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated. Death not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly. 
5 
Dead. 
0 
Dead.