Conditions: Metastatic Melanoma
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 26
Healthy volunteers: no

Brief summary:
Assess the safety and tumor response of utilizing an autologous tumor lysate, particle-loaded, dendritic cell (TLPLDC) vaccine given in combination with standard of care (SoC) checkpoint inhibitors (CPI) in patients with stage IV melanoma with measurable disease.

Detailed description:
Metastatic melanoma patients eligible for (or currently on) CPI therapy per SoC will be identified and screened for inclusion/exclusion criteria. Eligible patients will be counseled and consented for tissue procurement. They will undergo excisional or core needle biopsy as clinically indicated and this tissue will be shipped in liquid nitrogen shippers through FedEx to our central facility in Greenville, SC.The tumor will be stored frozen until vaccine preparation. Vaccine development requires 48 hours for preparation. Upon verification that adequate tissue was obtained, these patients will then be counseled and consented for participation in the trial.

The patients who qualify for participation in this trial will continue their treatment of CPI. Once consented, patients will receive a single injection of Neupogen (G-CSF) 300 μg SQ 24-48 hrs prior to having 70 mL of blood collected and sent to our central facility for DC isolation and preparation. Those who cannot tolerate Neupogen or refuse it will have 120 mL of blood drawn and sent. Additional blood may be drawn if additional vaccine doses need to be made or re-made for any reason. Vaccines will be prepared by producing TL through freeze/thaw cycling and then loaded into pre-prepared YCWP. The TL-loaded YCWP will be introduced to the DC for phagocytosis thus creating the TLPLDC vaccine, which will be frozen in single dose vials. Each vial will contain 1 x 106 TLPLDC and will be labeled with the patient's unique study number.

The frozen autologous TLPLDC will be sent back to the site with a total of 6 single dose vials after the vaccine has completed QA/QC testing and lot-release (usually 3 weeks). The primary vaccination series will include monthly inoculations at 0, 1, 2, 3 months followed by boosters at 6 and 9 months in the same lymph node draining area (preferably the anterior thigh). Once received, the first inoculation should occur within 4 weeks.

Safety data will be collected on local and systemic toxicities and graded and reported per the Common Terminology Criteria for Adverse Events (CTCAE) v4.03.

Patients will follow-up at their respective sites for evaluation of metastatic disease per SoC. They will under imaging, CT/PET-CT, to meet Response Evaluation Criteria in Solid Tumors (RECIST) criteria version 1.1 and iRECIST to monitor disease.

Blood (50 mL) will be collected from all patients prior to each inoculation and at 12 months from enrollment for a total of 7 time points or a total of 350 mL of blood over 1 year. The collected blood will be sent to our central facility for immunologic testing of T-cell responses.

Arms:
arm 1: No clinical response (PD de novo) after a minimum of 3 months on CPI monotherapy arm 2: Develop PD after initial clinical response to CPI monotherapy arm 3: Stable disease for at least 6 months on CPI monotherapy

Interventions: intervention 1: TLPLDC Vaccine
Intervention descriptions: intervention 1: Tumor Lysate, Particle Loaded, Dendritic Cell Vaccine

Protocol document:
Prot_SAP_000.pdf: 
Phase I/IIa Metastatic Melanoma vaccine trial     Confidential 
Version 2.0/23 Jun 2017 
 
  
Protocol Title:  
Multi-center phase I/IIa trial of an autologous 
tumor lysate (TL) + yeast cell wall particles 
(YCWP) + dendritic cells (DC) vaccine in 
addition to standard of care checkpoint inhibitor 
of choice in metastatic melanoma patients with 
measurable disease.  
 
Study Drugs: 
 
 
Autologous TLPLDC vaccine (tumor lysate,  
 
 
 
 
 
particle-loaded, dendritic cells) 
 
 
 
 
Sponsor: 
 
 
 
Elios Therapeutics, LLC 
 
Director: 
 
 
 
George E. Peoples, MD, FACS 
 
 
 
 
 
Cancer Insight, LLC 
 
 
 
 
 
110 East Houston Street, Floor #7 
 
 
 
 
 
 
San Antonio, TX  78205 
 
IND:  
 
 
 
IND 16101 
 
Principal Investigator:  
 
Steven J. O’Day, MD 
Director of Immuno-Oncology and Clinical 
Research 
 
 
 
 
 
Director of Medical Oncology 
 
John Wayne Cancer Institute 
2200 Santa Monica Blvd 
Santa Monica, CA 90404 
 
Medical Monitor:   
 
Garth Herbert, MD  
 
 
 
 
 
 
 
 
Department of Surgery 
 
 
 
 
 
Brooke Army Medical Center 
 
 
 
 
 
3551 Roger Brooke Drive 
 
 
 
 
 
Fort Sam Houston, TX 78234 
 
Protocol Version/Date: 
 
2.0/23 June 2017 
 
 


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Table of Contents 
 
1.0 PROTOCOL SYNOPSIS .......................................................................................... 4 
2.0 INTRODUCTION ............................................................................................... 8 
3.0 OBJECTIVES .................................................................................................... 13 
3.1 
Primary Objectives ..................................................................................................................................... 13 
3.2 
Secondary Objectives ................................................................................................................................. 13 
3.3 
Exploratory Objectives ............................................................................................................................. 13 
4.0 STUDY DESIGN ............................................................................................... 13 
4.1 
Description of Study ................................................................................................................................... 13 
4.2 
Rationale for Study Design ...................................................................................................................... 15 
4.3 
Outcome Measures ..................................................................................................................................... 16 
4.3.1 
Primary outcome measures ................................................................................................................. 16 
4.3.3 
Exploratory outcome measures ......................................................................................................... 17 
4.4   
Safety Considerations .............................................................................................................................. 17 
4.5   
Compliance with Laws and Regulations ......................................................................................... 18 
5.0   MATERIALS AND METHODS ........................................................................ 18 
5.1 
Subjects ............................................................................................................................................................ 18 
5.1.1 Subject selection ............................................................................................................................................ 19 
5.2 
Study Treatment .......................................................................................................................................... 21 
5.2.1 
Vaccine production .................................................................................................................................. 21 
5.2.3 
Inoculation series – administration ................................................................................................. 22 
5.3 
Study Assessments ..................................................................................................................................... 23 
5.3.1 
Pretreatment assessments ..................................................................................................................... 23 
5.3.2 
Assessments during treatment ........................................................................................................... 23 
5.3.3 
Follow-up assessments ........................................................................................................................... 24 
5.3.4  
Blood collection and processing ....................................................................................................... 24 
5.3.5  
Phenotypic assays ................................................................................................................................... 25 
5.3.6  
Functional assay  ..................................................................................................................................... 25 
5.4 
Discontinuation of Protocol-Specific Therapy ................................................................................ 25 
5.5 
Subject Discontinuation ........................................................................................................................... 26 
5.6 
Study Discontinuation ............................................................................................................................... 27 
5.7 
Data Collection .............................................................................................................................................. 27 
5.8 
Statistical Methods ..................................................................................................................................... 28 
5.8.1  
Rationale for study design .................................................................................................................. 28 
5.8.2  Sample size determination ...................................................................................................................... 28 
5.8.3  Data analysis ................................................................................................................................................. 29 
5.8.4 Withdrawal ..................................................................................................................................................... 30 
5.8.5 
Missing data ............................................................................................................................................... 31 
6.0 ADVERSE EVENTS .......................................................................................... 31 
6.1 
Adverse Event and Reporting Definitions ........................................................................................ 31 
6.2  
Reporting of Serious Adverse Events Associated with This Study ....................................... 32 
6.2.1  
MedWatch 3500A reporting guidelines ........................................................................................ 33 
6.3 
Reporting Requirements for IND Sponsor ....................................................................................... 34 


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7.0 INVESTIGATOR REQUIREMENTS .................................................................. 34 
7.1  
Study Initiation ............................................................................................................................................ 34 
7.2  
Study Completion ....................................................................................................................................... 35 
7.3  
Informed Consent ...................................................................................................................................... 35 
7.4 
Institutional Review Board or Ethics Committee Approval ..................................................... 35 
7.5 
Study Monitoring Requirements .......................................................................................................... 36 
7.6 
Data Safety Monitoring Plan ................................................................................................................... 37 
7.7  
Study Medication Accountability ........................................................................................................ 37 
7.8  
Disclosure of Data ...................................................................................................................................... 37 
7.9  
Retention of Records ................................................................................................................................ 37 
7.10  
Publications ................................................................................................................................................ 38 
7.11  
Changes to Protocol ................................................................................................................................ 38 
REFERENCES ........................................................................................................... 39 
Appendix A ................................................................................................................ 41 
Appendix B ................................................................................................................ 42 
Appendix C ................................................................................................................ 47 
Appendix D ................................................................................................................ 48 
Appendix E  ............................................................................................................... 49 
Appendix F ................................................................................................................ 50 
Appendix G ................................................................................................................ 51 
Appendix H ................................................................................................................ 52 
Appendix I ................................................................................................................. 53 
 
 
 
 
 
 
 
 
 
 
 
 
 


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1.0 PROTOCOL SYNOPSIS 
Brief Title 
Multi-center phase I/IIa trial of an autologous tumor lysate (TL) + yeast cell wall 
particles (YCWP) + dendritic cells (DC) vaccine in addition to standard of care 
checkpoint inhibitor of choice in metastatic melanoma patients with measurable 
disease. 
Test Article 
Name 
Autologous TLPLDC vaccine (tumor lysate, particle loaded, dendritic 
cells) 
Activity 
Induction of anti-cancer cell-mediated immune response 
Dosage form 
Intradermal injection of 1x106 autologous tumor lysate-loaded dendritic 
cells monthly x 4 followed by boosters at 6 and 9 months. 
Development 
Phase 
Phase I/IIa 
Indication 
To prevent disease progression in metastatic melanoma patients 
Rationale 
Setting:  
Responsible for approximately 5% of all skin cancers, melanoma is the cause of 80% of skin cancer 
related deaths according to the World Health Organization1.  The 5-year median survival rate for 
purely local disease is 98% versus a rapid decline to approximately 10-15% in patients with 
metastatic disease1, 2.  Surgical excision plays a major role in loco-regional treatment for melanoma; 
regarding metastatic disease, there exists a 20-40% 5-year survival benefit with metastectomies, 
although truly limited to surgically accessible tumors. Radiation has a limited role in treatment of 
melanoma, as this cancer is considered to be radio-resistant.  Despite multi-modal treatment 
regimens, the population continuing to experience suboptimal treatment outcomes involves stage IV 
disease.  Until recently, most treatments for metastatic melanoma were considered palliative 
treatments, and patients were encouraged to enroll into clinical trials once they reached this stage. 
Checkpoint inhibitors (CPI) are now approved for use in metastatic melanoma (MM), and a small 
proportion of treated pts will achieve a clinical complete response (CR) and another substantial 
portion will achieve durable partial responses (PR) and stable disease (SD).  However, the majority 
of pts will demonstrate progressive disease (PD).  One hypothesis is that these patients lack 
sufficient numbers/types of tumor reactive T cells to mount an endogenous, protective, anti-tumor 
immune response.   
Compared to the fusion technology, our new technology is more efficient and utilizes a yeast cell 
wall particle (YCWP) loading system to deliver tumor lysate (TL) to the cytoplasm of DC and 
requires only 120 mL of blood (for DC isolation) and as little as 1 mg of autologous tumor.  The TL, 
particle-loaded, DC (TLPLDC) vaccine can be produced in 48 hrs.  This new technology has been 
tested in preclinical animal models with superior results compared to the prior fusion technology, 
which showed clinical benefit (SITC 2015).  These results led to a phase I/IIa (n=20) clinical trial of 
the TLPLDC vaccine in multiple solid tumors demonstrating minimal toxicity and a 60% clinically 
beneficial (CR+PR+SD) response rate and a 30% objective tumor response rate (ICIC 2015).   
T cell-eliciting vaccines like our TLPLDC vaccine could be used in combination with CPI to 
theoretically improve the clinical efficacy of standard of care (SoC) CPI in MM.      
Vaccine:    
The majority of melanoma vaccines tested to date have been antigen-specific vaccines targeting 
melanoma-specific or associated antigens and utilizing a variety of delivery systems and immune-
adjuvants.  As opposed to testing an “off the shelf” vaccine that might be able to treat a subset of 
patients, our approach has been personalized to the patient and applicable to all patients.  Our 
vaccine approach consists of harnessing the most potent antigen presenting cell in the body – the 
dendritic cell (DC) – together with the full repertoire of tumor antigens from an individual’s cancer.  
We have conducted phase I and II studies using an autologous DC-tumor cell fusion technique that 
has now been simplified into a DC-tumor cell lysate vaccine.  The autologous tumor lysate (TL) is 
loaded into yeast cell wall particles (YCWP) that are naturally and efficiently taken up into the 
patient’s DC.  These autologous tumor lysate, particle-loaded, DC (TLPLDC) are injected 
intradermally (ID) monthly x4 followed by boosters at 6 and 9 months. 


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Rationale 
(continued) 
Prior Results: 
To date, we have vaccinated a total of 36 patients with varying malignancies with the 
dendritoma fusion technology, and 25 of these have been late-stage melanoma patients.  
These personalized vaccines have a very favorable toxicity profile with only flu-like 
symptoms immediately after inoculations, and no related serious adverse events have been 
observed in any patient vaccinated to date.  In the completed phase I/IIa melanoma trial of 
the dendritoma fusion technology, 25 stage IV patients were vaccinated.  The median 
overall survival (OS) was 16.1 months (compared to a historic rate of 8-10 months), and 
there was a 29.3% OS at 5 years.  There was a dose response with an OS improvement in 
patients receiving ≥3 inoculations compared to patients receiving less (log rank p=0.02). 
The fusion technology has now been replaced by the TLPLDC vaccine technology to 
create personalized autologous tumor/DC vaccines.  To date, 20 pts have been enrolled to 
the TLPLDC trial with a median follow-up of 7 mos. The study population is 60% male, 
90% Caucasian, 95% stage III/ IV disease, with a median age of 58 years. Thirteen 
different tumor types have been treated.  Of the 20 pts, 17 had measurable disease on 
initiation of treatment, and 3 were vaccinated adjuvantly. Twelve patients have completed 
treatment, 6 are in treatment, and 2 are consented but not initiated.  The 12 pts who have 
completed treatment received a median of 4 inoculations, and no grade ≥3 toxicities have 
been noted. Flu-like symptoms have been seen in 20%.  Of the 17 pts with measurable 
disease, 10 have completed treatment with 6 demonstrating clinical benefit (1 CR, 2 PR, 3 
SD). In the 3 adjuvant pts, 2 have completed treatment, and all 3 remain disease-free at a 
median follow- up of 11 months.  
 
 Primary 
Endpoint 
1) To determine the safety of adding the TLPLDC vaccine to SoC CPI.   
2) To determine tumor response with the addition of the vaccine per RECIST and 
iRECIST criteria. 
Secondary 
Endpoints 
1) To compare combination therapy with currently known rates of AEs and ORR of CPI 
monotherapy. 
Exploratory 
Endpoints 
1) To document the immunologic response to the vaccine through T-cell assays 
recognizing known melanoma-specific antigens. 
2) To correlate vaccine immune response to clinical outcome. 
Patient 
Population 
Metastatic melanoma patients eligible for (or currently on) SoC CPI with measurable 
disease.   
Treatment  
Vaccinated group = autologous tumor cell lysate + yeast cell wall particles + autologous 
DC 
Number of 
Patients  
N= up to 45 
Sample Size 
Justification 
  45 patients will allow an 80% power of detecting an absolute 25% increase in the 
objective tumor response rate compared to current SoC CPI monotherapy with an alpha of 
0.05 (one sided).  
Number of Sites 
4-8 sites will be established. 


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Duration of Trial 
With 4-8 sites enrolling, we anticipate enrollment to be complete in 12 months.  With a 
primary endpoint of 1 year to monitor the safety of the vaccine and tumor response, the 
trial duration is expected to be 2 years. 
Trial Design and 
Conduct 
Metastatic melanoma patients eligible for (or currently on) CPI therapy per SoC will 
be identified and screened for inclusion/exclusion criteria.  Eligible patients will be 
counseled and consented for tissue procurement.  They will undergo excisional or 
core needle biopsy as clinically indicated and this tissue will be shipped in liquid 
nitrogen shippers through FedEx to our central facility in Greenville, SC.The tumor 
will be stored frozen until vaccine preparation. Vaccine development requires 48 
hours for preparation.  Upon verification that adequate tissue was obtained, these 
patients will then be counseled and consented for participation in the trial.    
The patients who qualify for participation in this trial will continue their treatment 
of CPI. Once consented, patients will receive a single injection of Neupogen (G-CSF) 
300 µg SQ 24-48 hrs prior to having 70 mL of blood collected and sent to our central 
facility for DC isolation and preparation.  Those who cannot tolerate Neupogen or 
refuse it will have 120 mL of blood drawn and sent.  Additional blood may be drawn 
if additional vaccine doses need to be made or re-made for any reason. Vaccines will 
be prepared by producing TL through freeze/thaw cycling and then loaded into pre-
prepared YCWP.  The TL-loaded YCWP will be introduced to the DC for phagocytosis 
thus creating the TLPLDC vaccine, which will be frozen in single dose vials.   Each 
vial will contain 1 x 106 TLPLDC and will be labeled with the patient’s unique study 
number.  
The frozen autologous TLPLDC will be sent back to the site with a total of 6 single 
dose vials after the vaccine has completed QA/QC testing and lot-release (usually 3 
weeks).  The primary vaccination series will include monthly inoculations at 0, 1, 2, 
3 months followed by boosters at 6 and 9 months in the same lymph node draining 
area (preferably the anterior thigh).  Once received, the first inoculation should 
occur within 4 weeks. 
Safety data will be collected on local and systemic toxicities and graded and reported 
per the Common Terminology Criteria for Adverse Events (CTCAE) v4.03. 
Patients will follow-up at their respective sites for evaluation of metastatic disease 
per SoC.  They will under imaging, CT/PET-CT, to meet Response Evaluation Criteria 
in Solid Tumors (RECIST) criteria version 1.1 and iRECIST to monitor disease. 
Blood (50 mL) will be collected from all patients prior to each inoculation and at 12 
months from enrollment for a total of 7 time points or a total of 350 mL of blood over 
1 year.  The collected blood will be sent to our central facility for immunologic 
testing of T-cell responses. 


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Inclusion 
Criteria 
1) 18 years or older 
2) Eastern Cooperative Oncology Group (ECOG) performance status 0 or1 
(Appendix A) 
3) Metastatic melanoma eligible for (or currently on) standard of care CPI 
therapy (treating physician’s choice) with measurable disease.   
4) Approximately 1  cm3 preferred but 1 mg minimum of accessible and 
dispensable tumor (minimum of 3 passes with a core needle) 
5) Able to tolerate CPI treatment regimen (if already started) 
6) Adequate organ function as determined by the following laboratory 
values: 
• 
ANC ≥ 1,000/μL 
• 
Platelets ≥ 75,000/μL 
• 
Hgb ≥ 9 g/dL 
• 
Creatinine ≤ 1.5 x upper limit of normal (ULN) or Creatinine 
clearance ≥ 50% of lower limit of normal (LLN) 
• 
Total bilirubin ≤ 1.5 x ULN 
• 
ALT and AST ≤ 1.5 x ULN 
7) For women of child-bearing potential, agreement to use adequate birth 
control (abstinence, hysterectomy, bilateral oophorectomy, bilateral 
tubal ligation, oral contraception, IUD, or use of condoms or 
diaphragms) 
8) Signed informed consent 
 
Exclusion 
Criteria 
1) Inability to tolerate CPI therapy (if already started) 
2) Rapidly progressive, multi-focal metastatic disease 
3) Insufficient tumor available to produce vaccine  
4) ECOG ≥2 
5) Immune deficiency disease or HIV, active HBV, or active HCV 
6) Receiving immunosuppressive therapy including chronic steroids (except 
physiologic maintenance doses), methotrexate or other known immunosuppressive 
agents. 
7) Pregnancy (assessed by urine HCG) 
8) Breast feeding 
  9) Active pulmonary disease requiring medication to include multiple inhalers (>2 
inhalers and one containing steroids) 
10) Involved in other experimental protocols (except with permission of the other 
study PI) 
 


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Statistical 
Analysis 
Toxicities will be monitored and categorized according to CTCAE v.4.03 
continuously.  Each patient’s tumor response will be assessed per RECIST criteria 
version 1.1 and iRECIST at multiple time points.  Overall objective tumor response 
rates will be analyzed among all patients and compared to expected response rates 
to CPI monotherapy. 
Planned 
Analyses 
1) Safety will be monitored continuously. 
2) Objective tumor response rates will be assessed in real time. 
3) The interim analysis of response rates and comparisons will be completed 12 
months after initiation of this trial to assess the vaccine safety profile and tumor 
response trends. 
4) The final analysis will be completed after 12 months follow-up from the last 
enrolled patient.  
 
 
2.0 
INTRODUCTION  
Responsible for approximately 5% of all skin cancers, melanoma is the cause of 80% 
of skin cancer related deaths according to the World Health Organization1. The 5-
year median survival rate for purely local disease is 98% versus a rapid decline to 
approximately 10-15% in patients with metastatic disease1, 2.  Surgical excision 
plays a major role in loco-regional treatment for melanoma; regarding metastatic 
disease, there exits at 20-40% 5-year survival benefit with metastectomies, 
although truly limited to surgically accessible tumors. Radiation has a limited role in 
treatment of melanoma, as it is considered to be radio-resistant. For resections with 
inadequate margins, positive nodal disease status post lymphadenectomy, and brain 
metastases are instances in which radiation can be used for further loco-regional 
control of disease2, 3.   
The addition of radiation has been associated with a 10% rate of local recurrence 
compared to a 40.6% rate in those who did not receive radiation in high risk node 
positive patients.  These results are associated with the risk of development of 
lymphedema2.  The risk of recurrence is the highest within the first 5 years of 
diagnosis.  Despite multimodal treatment regimens, the population continuing to 
experience poor treatment outcomes involves stage IV disease.  To date, most 
treatments for metastatic melanoma are considered palliative treatments, and 
patients are encouraged to enroll into clinical trials once they have reached this 
stage.    
 
The mainstay of treatment for metastatic melanoma is systemic therapy.  The only 
FDA approved chemotherapeutic medication is dacarbazine, and its oral 
preparation temozolomide.  These medications have shown minimal overall 
survival (OS) benefit, median OS 6.4 and 7.7 months, respectively with a 12% and 
14% objective response rate (ORR), respectively4.  Despite poor outcomes with 
monotherapy, all other chemotherapeutic drugs, such as taxanes and vinca 
alkaloids, have similar poor results. Cytokine therapy is another modality, which has 
showed notable shifts in management of metastatic melanoma. Interleukin-2 (IL-2), 
known to stimulate T-cell proliferation and further release of cytokines, when used 


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in high doses was associated with a 16% objective response rate (complete 
response (CR) 6%, and partial response (PR) 10%)4, 5. This data was obtained via 
retrospective analysis of several trials from 1985-1993 where high dose IL-2 was 
given over a 5 day, as tolerated, with multiple cycles occurring every 6-12 weeks.  Of 
the patient’s whom experienced tumor response, there was no evidence of disease 
progression after 5-years5. Interferon-alpha (IFN-α), also involved in systemic 
inflammation, is the only FDA approved drug for adjuvant therapy with metastatic 
melanoma3, 4.  Four trials have studied this drug, the most significant by the 
European Organization for Research and Treatment of Cancer (EORTC) randomizing 
patients with resected stage III melanoma to 5 years of pegylated-IFNα, pegylated to 
increase the drugs half-life, versus observation.  After median follow-up of 7.6 years, 
the reduction in relative risk of recurrence was 39.1% versus 34.6% in the 
observation group3, 6. The results with these medications were not devoid of side 
effects.  Many include fever, chills, myalgias and malaise4. IL-2 has been associated 
with hypotension, arrhythmias and even systemic inflammatory response requiring 
close monitoring during treatment. Neither of these medications has shown a 
significant improvement in overall survival (OS).  In addition, combination therapy, 
termed biochemotherapy, also demonstrated significant toxicities with no survival 
benefit.  Interestingly, the use of IL-2 and IFN-α did reveal that stimulation of the 
immune system can effectively destroy tumors in metastatic melanoma patients.  
Creating an immune system capable of eradicating metastatic tumor burden and 
preventing recurrence; therein lies the ideology behind further immunotherapy 
development for the management of stage IV melanoma.  
 
Targeted therapies have been developed as further research has revealed specific 
mutations associated with melanoma.  Medications targeting B-RAF signal 
mutations in melanoma tumors include vemurafenib and dabrafenib.   
A phase III trial comparing vemurafenib to dacarbazine, in patients with metastatic 
melanoma with no prior treatments, revealed increase in progression free survival 
(PFS) 6.9 months versus 1.6 months and median OS 13.6 months versus 9.7 months 
(both p<0.001)7.  Dabrafenib was also evaluated in a phase III trial against 
dacarbazine revealing a PFS of 5.1 months versus 2.7 months (p<0.0001)2.  An 
additional drug trametinib, an oral medication which inhibits a downstream 
molecule, MEK1 and MEK2, has shown efficacy in a phase III trial versus 
chemotherapy revealing a PFS of 4.8 months versus 1.5 months2.  Toxicities for 
these medications include arthralgias, development of squamous cell carcinoma and 
photosensitivity.  Although effective, these medications can only be used in 
approximately 50% of patients with melanoma who have this mutation2, 7.  
 
The final group of developed drugs for treatment of metastatic melanoma includes 
the check point inhibitors (CPI).  These medications are human monoclonal 
antibodies used to prevent interaction of tumor cell surface molecules used to 
downregulate the immune system thus preventing activation of T-cells.  The initial 
CPI used for metastatic melanoma, ipilimumab, is an anti-cytotoxic T lymphocyte 
antigen-4 (anti-CTLA-4) antibody. This medication has been extensively studied, 
and received FDA approval in 2011.  A phase III trial was completed on patients 


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with stage III/IV melanoma, where patients were randomized into three groups, 
Ipilimumab alone, a peptide vaccine, gp100 alone, or ipilimumab and gp100.  
Median OS was noted to be 10.1 months, 6.4 months and 10 months, respectively. 
There were no statistically significant differences between the two groups involving 
ipilimumab1.  In addition, this medication was compared to dacarbazine in a phase 
III trial.  The two treatments included ipilimumab and dacarbazine versus 
dacarbazine alone in untreated metastatic melanoma patients.  The overall survival 
was 11.2 months versus 9 months, respectively. As evidenced in a CTLA-4 knock-out 
animal model, the animals all died from severe lymphoproliferative disease; it is not 
unexpected that significant autoimmune toxicities are associated with this 
medication1.  These are characterized mostly as skin and gastrointestinal (GI) 
toxicities, with 8-23% of patient’s experiencing grade III/IV GI toxicities.  
Specifically, patients may experience severe diarrhea/colitis, hypophysitis, uveitis, 
and hepatitis.  Although reported to be managed with corticosteroids and anti-
interferon gamma (anti-IFN-γ), these significant toxicities definitely reflect likely 
poor compliance with the medication1, 8. 
 
The second class of CPI drugs includes monoclonal anti-PD1 antibodies, again 
functioning 
to 
block 
suppression 
of 
T-cell 
activation, 
nivolumab 
and 
pembrolizumab.  Both drugs have been approved by the FDA for treatment of 
metastatic disease that has failed management with anti-CTLA-4 antibody or 
mutated BRAF inhibitor therapy if indicated.  Also extensively studied, a phase III 
trial comparing nivolumab to dacarbazine in stage III/IV unresectable melanoma 
without the BRAF mutation revealed significant differences; a total of 68% of the 
patient population were previously treated with chemotherapy prior to enrollment 
in the trial, evenly distributed between the two treatment arms.   
The 12 month OS was 72.9% versus 42.1% in the two arms, respectively, with an 
ORR of 40% with nivolumab (CR 7.6%) and 13.9% with dacarbazine (CR 1.0%) 
(p<0.001)9.  Another phase III trial revealed similar promising results when 
comparing two dosing regimens of pembrolizumab (10mg/kg every 2 weeks versus 
every 3 weeks) to ipilimumab.  This trial included unresectable stage III/IV 
melanoma patients.  Patients in the pembrolizumab treatment arms experienced 12 
month OS of 74.1% and 68.4% in the every 2 week versus every 3 week dosing 
regimens.    They were compared to a 58.6% 12 month OS associated with 
ipilimumab treatment (p=0.0005)10. Interestingly, the PD1 inhibitors appear to be 
superior to the CTLA-4 inhibitors in terms of toxicity. Although the patients treated 
with pembrolizumab did experience grade 3 toxicities (13.3% and 10.1% according 
to treatment dosing every 2 weeks versus 3 weeks), the anti-PD1 therapy compared 
favorably to the 19.9% with ipilimumab.  The majority of the toxicities were related 
to cutaneous toxicities, thyroid derangements and diarrhea11.   
 
In September 2015, the FDA approved a new treatment regimen using combination 
therapy with two CPI for metastatic melanoma, ipilimumab and nivolumab followed 
by nivolumab maintenance therapy. This new approval was obtained after a phase II 
double-blinded trial randomizing 142 patients with no prior treatment to 
combination therapy with ipilmumab plus nivolumab versus ipilimumab plus 


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placebo revealed a 61% ORR in the combination arm compared to 11% in the 
ipilimumab plus placebo arm12.  Approximately 39% patients had a partial response 
on combination therapy, with potentially 80% of those partial responses being 
durable. However, the combination did produce significant toxicities with 54% of 
patients experiencing grade 3 or 4 toxicities in the combination arm versus 24% 
with ipilimumab alone.  The most common cause for discontinuation of the trial was 
toxicity in the combination arm (45%) and disease progression12.   
 
During this same period of targeted therapy development, recognition of the high 
potential for dendritic cells (DC) to aid in the development of appropriate immune 
responses for management of solid tumors also occurred. These cells innately 
possess receptors necessary for T-cell stimulation. Initially introducing specific 
tumor associated antigens to dendritic cells in order to stimulate MHC Class I-
mediated cytotoxic T-cells (CTL) was evaluated.  Due to a system limited by the 
number of identifiable antigens, we have pursued DC fusion with tumor as a vaccine 
strategy.  Through the strong immunogenicity produced by DC, in addition to 
creating a vaccine with multiple antigens by utilizing a complete sample of the solid 
tumor, more effective vaccines were produced2. Pilot studies were conducted in 
stage IV melanoma and stage IV renal cell carcinoma patients testing the fusion of 
DC with tumor cells termed dendritoma and used with IL-22.  These pilot studies 
revealed the dendritomas to be immunogenic, leading to a significant increase in 
interferon-gamma (IFN-γ) producing T-cells.  Clinically, stabilization or partial 
responses were observed in 40% of stage IV RCC patients involved.  In the 
completed phase I/IIa melanoma trial of the dendritoma fusion technology, 25 stage 
IV patients were vaccinated.  The median overall survival (OS) was 16.1 months 
(compared to a historic rate of 8-10 months), and there was a 29.3% OS at 5 years.  
There was a dose response with an OS improvement in patients receiving ≥3 
inoculations compared to patients receiving less (log rank p=0.02)16. 
 
Multiple DC-based vaccines have now been studied along with a multitude of other 
vaccine strategies, but the only FDA approved cancer vaccine, Spileucel – T or 
Provenge, is a DC-based vaccine where DC are incubated with a fusion protein 
PA2024 (prostatic acid phosphatase and granulocyte macrophage colony-
stimulating factor).  The vaccine is approved for use in castration-resistant 
metastatic prostate cancer patients. Results from the phase III study of this vaccine 
versus placebo resulted in a median OS of 25.9 months versus 21.4months in the 
placebo group (p<0.02)8. Despite the efficacy, significant effort is required in order 
to produce these autologous cell-based vaccines.  The final vaccines are not 
available for several weeks due to long incubation periods, in addition to quality 
assurance protocols, and the requirement for a large volume of blood greatly affect 
the efficiency of production. 
 
Thus, we have developed a new highly efficient technique for introducing tumor 
lysate into the cytoplasm of DC using denatured yeast cell wall particles (YCWP).  
These tumor lysate-loaded particles are incubated and phagocytized by autologous 
DC forming the tumor lysate, particle-loaded, dendritic cell (TLPLDC) vaccine.  


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These vaccines require less tissue, small quantities of blood, and are produced 
within 48 hours14.  This new method was used in a B16 metastatic melanoma 
murine model.  The TLPLDC vaccine was created with lysed tumor cells from B16F0 
melanoma and each mouse injected with 3 weekly doses for up to 4 weeks.  All mice 
were sacrificed at the end of the observation period, and lungs harvested to identify 
and count pulmonary metastasis.  All mice who received the TLPLDC vaccinations 
showed no evidence of metastatic disease compared to controls (p<0.01).  The 
median survival for mice in the control arm was 21 days compared to 29 days with 
TLPLDC and 41 days with TLPLDC with CpG adjuvant.  Additional preclinical data 
has demonstrated that the TLPLDC vaccine is actually superior to the fusion 
dendritoma technology in the same murine metastatic melanoma model14.  
Therefore, the fusion technology has now been replaced by the TLPLDC vaccine 
technology to create personalized autologous tumor/DC vaccines.  To date, 20 pts 
have been enrolled to the TLPLDC trial with a median follow-up of 7 mos. The study 
population is 60% male, 90% Caucasian, 95% stage III/ IV disease, with a median 
age of 58 years. Thirteen different tumor types have been treated.  Of the 20 pts, 17 
had measurable disease on initiation of treatment, and 3 were vaccinated 
adjuvantly. Twelve patients have completed treatment, 6 are in treatment, and 2 are 
consented but not initiated.  The 12 pts who have completed treatment received a 
median of 4 inoculations, and no grade ≥3 toxicities have been noted. Flu-like 
symptoms have been seen in 20%.  Of the 17 pts with measurable disease, 10 have 
completed treatment with 6 demonstrating clinical benefit (1 CR, 2 PR, 3 SD). In the 
3 adjuvant pts, 2 have completed treatment, and all 3 remain disease-free at a 
median follow- up of 11 months.    
 
Both the fusion dendritoma technology and the current TLPLDC vaccine technology, 
both autologous tumor/DC vaccines, have shown promise in patients with 
metastatic melanoma.  From these trials arose an on-going randomized phase IIb 
trial utilizing the TLPLDC vaccine in the adjuvant setting to prevent recurrence in 
high risk melanoma patients.  
 
Recognizing the utility of the CPI and the immunogenicity of the TLPLDC 
vaccination, merging these two treatment methods may lead to a more robust and 
effective anti-tumor immune response. The tumor-reactive T cells stimulated by the 
TLPLDC vaccine may become inactivated in the tumor microenvironment due to T-
cell downregulation by the tumor.  In fact, this may explain the failures of most 
cancer vaccines in general that have been tested in the metastatic setting.  CPI could 
aid in overcoming this mechanism of tumor cell evasion by blocking these inhibitory 
signals and allowing the T cells to attack the tumor.  Likewise, CPIs are limited in 
their effectiveness based on the availability of tumor-reactive T-cells.  Therefore, the 
use of CPI + vaccines makes intuitive sense.   
 
There may be some concern regarding the toxicity associated with the combination 
of these modalities; however, one could also argue that the combination could 
theoretically reduce the toxicity of the CPI.  First, the vaccines are inherently safe 
and have never been shown to produce autoimmunity; therefore, if toxicity were to 


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increase with the combination, it would likely be related to the increased activity of 
tumor destruction not autoimmunity.  On the other hand, since the vaccine will 
induce larger numbers of tumor-reactive T cells, the dose of the CPI may be 
decreased perhaps resulting in less toxicity.  Furthermore, the larger number of 
tumor-reactive T cells may bind a higher proportion of the CPI leaving less to bind 
to auto-reactive T cells.  Either mechanism may lead to lower, not higher, toxicity 
with the combination of CPI and TLPLDC vaccine.   
 
This prospective, open label, multicenter phase I/IIa trial will assess the effects of 
utilizing both a CPI and the TLPLDC vaccine in metastatic melanoma patients with 
measurable disease eligible for (or currently on) standard of care CPI therapy.  By 
developing an adaptive immunity to melanoma via the TLPLDC vaccine, and 
inhibiting the down regulation of T-cells via tumor-induced immunosuppression 
with the CPI, the tumor response rates would be expected to increase relative to the 
results experienced when these modalities are used individually.  
 
3.0 OBJECTIVES 
In this study, we intend to assess the safety and tumor response of utilizing an 
autologous tumor lysate, particle-loaded, dendritic cell (TLPLDC) vaccine given in 
combination with standard of care (SoC) checkpoint inhibitors (CPI) in patients with 
stage IV melanoma with measurable disease.    
3.1 
Primary Objectives 
• To determine the safety of adding the TLPLDC vaccine to SoC CPI.   
• To determine tumor response with the addition of the vaccine per the 
Response Evaluation Criteria in Solid Tumors (RECIST) v1.1 criteria15, 
18 and RECIST criteria specific for cancer immunotherapy trials 
(iRECIST)26. 
3.2 
Secondary Objectives 
• To compare combination therapy with currently known rates of AEs 
and ORRs of CPI monotherapy. 
3.3 
Exploratory Objectives 
• To document the immunologic response to the vaccine through T-cell 
assays recognizing known melanoma-specific antigens. 
• To correlate vaccine immune response to clinical outcome.  
 
4.0 STUDY DESIGN 
 
4.1 
Description of Study 
This will be a prospective, open label, multi-center phase I/IIa trial utilizing the 


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TLPLDC vaccine added to SoC CPI for treatment of metastatic melanoma. The 
vaccine to be used in this study remains an investigational drug under the IND 
16101. The Sponsor of this IND is Elios Therapeutics, LLC. 
The target study population includes metastatic melanoma patients eligible for (or 
currently on) CPI therapy per their provider’s choice and with measurable disease.  
Up to 45 patients will be enrolled over approximately one year at 4-8 sites.  These 
patients must be able to tolerate CPI treatment if already started.  
Each patient must have biopsy proven evidence of metastatic disease and 
measurable on imaging studies. 
Prior to participation in the trial, eligible patients will be counseled and consented 
on the process of tissue procurement. These patients will have tumor acquired for 
vaccine production via core needle biopsy or excisional biopsy (need not occur at 
the study site), and a portion (approx. 1 cm3 preferred but 1 mg minimum) of their 
melanoma sterilely frozen in provided freezing vials and storage tubes. This tissue 
will then be shipped in liquid nitrogen shippers through FedEx to our central facility 
in Greenville, SC and stored frozen until vaccine preparation.     
Upon verification of adequate amount of tumor procured, patients will then be 
counseled and consented for full participation in the trial.  Each patient will receive 
a single injection of Neupogen (G-CSF) 300 µg subcutaneously 24-48 hrs prior to 
having 70 mL of blood collected and sent to our central facility for DC isolation and 
preparation.  Patients, who cannot tolerate Neupogen or refuse it, will have 120 mL 
of blood drawn and sent to our central facility for DC isolation and preparation. 
Additional blood may be drawn if additional vaccine doses need to be made or 
remade for any reason. Excess tumor, serum and blood will be placed into a tissue 
repository and stored under the patient’s unique study number for future use in re-
creating the vaccine and performing immunologic assays.  Additionally, any stored 
tumor, serum or blood may also be utilized to assess new generations of vaccines.      
During the time between enrollment and the first vaccine inoculation 
(approximately 3-7 weeks after enrollment), each patient should undergo imaging 
to determine baseline metastatic disease and baseline labs, including lactate 
dehydrogenase.  Each patient must obtain a cross sectional chest, abdomen and 
pelvis imaging with contrast, MRI Brain/CT Head with intravenous contrast, and/or 
total body PET per institutional preference per standard of care.  Baseline imaging 
studies must be completed within 4 weeks of first vaccine dose.  At this point, a 
maximum of 5 tumor foci (maximum of 2 foci per organ) will be identified by the 
site primary investigator that are easily measurable and designated as the target 
lesions. These tumors must be at least 10mm in size per RECIST 1.1 criteria 
(Appendix B). Baseline non-target lesions will also be documented.  Additionally, 
iRECIST criteria will be applied (Appendix B)      
Vaccines will be prepared by producing tumor lysate (TL) through freeze/thaw 


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cycling of the autologous tumor and then loaded into pre-prepared yeast cell wall 
particles (YCWP).  The TL-loaded YCWP will be introduced to isolated DC for 
phagocytosis; thus creating the TLPLDC vaccine which will be frozen in single dose 
vials.   Each vial will contain 1 x 106 TLPLDC and will be labeled with the patient’s 
unique study number.  Vaccine production and QA testing for vaccine release and 
shipping will take approximately three weeks.  Excess tumor will be maintained for 
each patient in a tissue repository.   
This tissue may be used in later research to assess new generations of vaccines or to 
re-create vaccine for the patient if necessary. 
The frozen autologous TLPLDC vaccine will be sent back to the site with a total of 6 
single dose vials for intradermal injections.  The vaccination series must be initiated 
within 4 weeks of receipt of the vaccination series at the site. The primary 
vaccination series will include 4 monthly inoculations at 0, 1, 2, and 3 months 
followed by boosters at 6 and 9 months in the same lymph node draining area 
(preferably the anterior thigh).   
Safety data will be collected on local and systemic toxicities, graded and reported 
per the NCI Common Terminology Criteria for Adverse Events (CTCAE) v4.03 
(Appendix C). 
Patients will follow-up at their respective sites for evaluation of metastatic disease 
per NCCN guidelines2. They will undergo imaging, with the same modality used for 
baseline measurements, to meet Response Evaluation Criteria in Solid Tumors 
(RECIST) criteria15 to monitor disease approximately every 3 months for 1 year. 
Time to the best overall response will be from the date of first inoculation until the 
first day that the tumor meets RECIST criteria for a particular tumor response 
(Appendix B).  Additionally, iRECIST criteria will be applied (Appendix B). 
In addition to the initial blood collection (70-120 mL) for vaccine preparation, 50 
mL of blood will be collected from all patients prior to each of the six inoculations 
and at 12 months from enrollment for a total of seven time points or a total of 420 - 
470 mL of blood over one year.  The collected blood will be sent to our central 
facility for immunologic testing of the T-cell response.  The immunologic responses 
will be correlated with the clinical outcomes. 
4.2 
Rationale for Study Design 
Individually, CPI have been approved for use in metastatic melanoma and the 
TLPLDC vaccine appears to provide benefit to these patients as well in small studies.  
By stimulating the immune system to develop tumor-reactive T cells while 
simultaneously preventing down-regulation of these T cells in the tumor 
microenvironment could result in a highly effective multimodality immunotherapy 
that could significantly impact clinical outcomes of patients with metastatic 
melanoma.  While CPI have been proven to be effective in metastatic melanoma 
patients in terms of tumor response as well as survival, the majority of metastatic 


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melanoma patients still succumb to their disease.  In response to CPI treatment, 
metastatic melanoma lesions may show no response (de novo PD), an initial 
response followed by progressive disease (delayed PD), or may stabilize but persist 
(SD).  In all of these situations, the CPI monotherapy is not sufficient alone.  
 One theory is that these patients lack adequate numbers of tumor-reactive T cells 
on which the CPI can work.  The TLPLDC vaccine generates tumor-reactive T cells as 
its primary mechanism of action.   
 
In order to assess both the safety as well as the efficacy of adding the TLPLDC 
vaccine to SoC CPI therapy in metastatic melanoma patients, up to 45 patients will 
be enrolled over approximately one year at 4-8 sites into this study.  This number 
will allow an overall assessment of the safety and potential efficacy of this novel 
combination treatment regimen compared to the currently known and accepted 
rates of response to CPI monotherapy in these patients.   
 
4.3 
Outcome Measures 
4.3.1 Primary outcome measures 
Standard local and systemic toxicities will be collected and graded per the NCI 
CTCAE v4.03 graded toxicity scale (Appendix C).  For both the primary vaccine 
series and the booster inoculations, patients will be monitored closely for 30 
minutes after each inoculation with questioning, serial exams and vital signs as 
needed to observe for a hypersensitivity reaction.  Local or systemic toxicities will 
be collected and graded by the research staff at the patient’s next visit. Serious AEs 
will be reported as described in Section 6.0. 
 
Evidence of tumor response to the proposed treatment regimen will be determined 
by the primary investigator at the individual study sites during their routine follow-
up screening and assessed by the Guidelines for the Evaluation of Immune Therapy 
Activity in Solid tumors criteria (iRECIST) in addition to the Response Evaluation 
Criteria in Solid Tumors (RECIST) criteria (Appendix B).  This will occur for all 
enrolled patients, approximately every three months for 1 year. Follow-up will 
include history, full dermatologic clinical exam, laboratory and radiographic 
surveillance per NCCN guidelines.  Surveillance imaging should be conducted with 
the same modality as used for baseline imaging.  If patients develop contra-
indications to certain modalities during the trial, their cases must be discussed with 
a radiologist to determine the best alternative imaging study to used, otherwise they 
must be deemed ‘not evaluable’ from that time period.   If records are not available, 
patients, or their referring physicians, will be contacted to discern their disease 
status.   
 
The primary outcome for this trial includes safety of the TLPLDC vaccine used in 
conjunction with CPI in addition to overall tumor response to this treatment plan.  
While the safety and tumor response in individual patients will be assessed 
continuously, the assessment of the primary endpoints will be determined and 
analyzed 12 months after the last patient is enrolled into this trial.  


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An interim analysis will be performed 12 months after the initiation of this trial for 
both safety and tumor response trends.  No action regarding stopping the trial will 
be taken based on this analysis unless there is a safety concern.   It is anticipated 
that all patients will have been enrolled with approximately 6 months of median 
follow-up at this interim analysis.  
 
4.3.2 Secondary outcome measures 
 
The secondary outcome measures for this trial will compare treatment to the 
currently known rates of AEs and ORR of CPI monotherapy. These assessments 
would be completed at both the interim and final analyses.  
 
4.3.3 Exploratory outcome measures 
Immune responses will be primarily documented using CTL assays on stored blood 
and assessment of stored serum pre- and post-vaccination.  Detailed descriptions of 
these assays/tests are described in Sections 5.3.5 and 5.3.6.    
 
Phenotypic assays (dimer/tetramer) for clonal CTL expansion against common 
melanoma-associated antigens such as gp-100 and MART-1 as well as functional 
assays like ELISPOT against the same antigens will be performed on banked/stored 
blood.  Antibody and cytokine responses may be assessed on the stored serum.   
 
Blood/serum will be collected prior to each inoculation and at study completion at 
12 months from enrollment.  Comparisons will be made between the immunologic 
responses within and between each treatment group.   
 
In a series of exploratory analyses, the results of these immunologic measures will 
be correlated with clinical outcome within and between each treatment group. 
 
4.4   
Safety Considerations 
In our previous trials, the safety of the autologous tumor/DC vaccines has been 
excellent. According to the preclinical trial, mice behavior was observed for 
evidence of possible toxicities.  No abnormalities were appreciated within the 
vaccination group, nor were there differences between the vaccinated or controls23.   
In the completed melanoma phase I/IIa in stage IV melanoma patients, where the 
autologous tumor/DC dendritoma vaccine was given with IL-2, the most common 
adverse events experienced by patients included fever (60%), chills (32%), nausea 
(28%), arthralgias/myalgias (28%), erythema (20%), headache (16%), anemia 
(16%), hypotension (16%), weight gain (12%), stomatitis (12%), edema (12%), 
rash (12%), pain (12%), and fatigue (12%).  There were a total of four severe 
adverse reactions, which occurred in this trial, although they were deemed 


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unrelated to the dendritoma vaccine. Many of these toxicities were attributable to 
IL-2, which will not be used in the current study24.  In the phase I/IIa trial of the 
TLPLDC vaccine, there were only mild toxicities (grade <2) in 20% of the patients.   
Previous trials evaluating the toxicity associated with CPI have resulted in various 
immune related adverse events. The most common toxicities included fatigue, rash, 
diarrhea, and pruritus11.  Additional toxicities have been associated with specific 
CPIs at varying rates17. Ipilimumab is characterized by an overall 72.3% occurrence 
of immune-related AE. Grade 3 or 4 irAEs were observed in 25.2% of patients, 
affecting the GI tract (12%), liver (7%), skin (3%), and endocrine system (3%).  
These AE are noted to occur at predictable times based on duration of treatment – 
skin related events within the first 3 weeks, GI/hepatic AE after 6-7 weeks of 
treatment, and endocrinopathies after 9 weeks of treatment.  AE also varies based 
on dosing, with approximately 7% of Grade 3 and 4 toxicities occurring at the FDA 
approved 3mg/kg dose17.  Similarly, pembrolizumab had an overall AE rate between 
72.9 – 79% based on dosing; 10mg/kg every 2 or 3 weeks.  This CPI is noted to a 
have a lower AE profile compared to ipilimumab, 13.3% versus 19.9% respectively.  
Grade 3 and 4 toxicities included colitis and hepatitis within 1- 2.5% of treated 
patients11.  
In this trial, all patients will continue their treatment with CPI of choice by the 
primary investigator/study site. There are inherently known toxicities associated 
with each CPI, and thus baseline toxicities associated with these medications will be 
assessed prior to the initiation of the vaccines.  We anticipate similar local responses 
as seen in our prior phase I/IIa trials utilizing the TLPLDC vaccines. We anticipate a 
similar favorable safety profile for the vaccine in this trial; however, meticulous 
documentation will be performed on the impact of the vaccine on baseline toxicities 
associated with the CPI.  
Patients will be monitored after each inoculation, and local and systemic toxicities 
will be documented, graded by the NCI CTCAE v4.03 and reported as indicated 
below in Section 6.0. 
Additionally, there is a small risk associated with the protocol-dictated single dose 
of Neupogen prior to the initial blood draw for DC isolation.  Neupogen is a FDA-
approved drug for increasing the white blood count, is commonly used in oncology 
patients, and has a well-tolerated toxicity profile. 
4.5   
Compliance with Laws and Regulations 
This study will be conducted in accordance with current FDA Good Clinical Practices 
(GCPs), and local ethical and legal requirements. 
5.0   MATERIALS AND METHODS 
5.1 
Subjects 
Up to 45 patients over the age of 18 years with a diagnosis metastatic melanoma, 


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with evidence of measurable disease, and eligible for (or being treated with) CPI 
therapy may be included.  Patients should have completed biochemotherapy or 
targeted therapy per standard of care as indicated. Each patient must be currently 
eligible for (or being treated with) a FDA-approved CPI. Patients will be recruited 
from medical and surgical oncology and/or hematology/oncology clinics at the 
individual study sites.   All patients will be properly counseled and consented. 
5.1.1 Subject selection 
Potentially eligible patients will be identified by staff in the medical and surgical 
and/or the hematology/oncology clinics at the individual study sites.   
A research nurse and/or study coordinator will approach these patients about being 
in the trial and will introduce the trial to the prospective volunteer.  If the volunteer 
is interested and appears eligible, the nurse will arrange to counsel the patient.  The 
nurse will thoroughly screen the patient for inclusion and exclusion eligibility 
criteria.  If the patient remains interested and eligible, the research nurse 
coordinator and/or study coordinator, or Principal Investigator (PI), will explain the 
study and review the consent form with the patient.  Prospective participants will be 
provided a copy of the consent form to read and given ample time to ask and have 
all questions answered prior to signing the consent form.   After all questions have 
been answered, and the patient wishes to participate in the trial, they will sign the 
consent form to undergo tissue procurement (consent#1).   
Tumor procurement may be completed using core needle biopsy or excisional 
biopsy, depending on the location of the tumor.  
After tissue procurement (which need not occur at the study site), if sufficient tumor 
is available for vaccine production (1 cm3 preferred, 1mg minimum) (minimum 3 
passes with core needle), and the patient is able to continue treatment with a CPI, 
they will then be consented for participation in the clinical trial (consent#2).  Blood 
will be obtained from the patient per below.   
The patient will receive a single injection of Neupogen (G-CSF) 300 µg 
subcutaneously 24-48 hours prior to having 70 mL of blood collected and sent to 
our central facility for DC isolation and preparation.  Patients who cannot tolerate 
Neupogen or refuse it, will have 120 mL of blood drawn and sent. Additional blood 
may be drawn if additional vaccine doses need to be made or remade for any reason.  
The full course (six doses) of the TLPLDC vaccine will be produced at one time after 
tumor and blood is received at the central laboratory facility.  The production and 
QA testing for vaccine release will take approximately three weeks at which point 
the entire vaccine series and boosters will be shipped back to the site for storage 
until use.  Frozen tumor, serum and blood will be maintained on all patients under 
their unique study number for re-creation of the vaccine as needed.  Vaccinations 
must begin within 4 weeks after vaccine is received at the site. 


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5.1.2 Inclusion criteria 
Patients will be included in the study based on the following criteria: 
• 18 years or older 
• Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1 
(Appendix A) 
• Metastatic melanoma eligible for (or on) standard of care CPI (treating 
physician’s choice) with measurable disease.   
• Approximately 1  cm3 preferred but 1 mg minimum of accessible and 
dispensable tumor (minimum of 3 passes with a core needle)  
• Able to continue their CPI treatment regimen (if already started) 
• Adequate organ function as determined by the following laboratory 
values: 
• ANC ≥ 1,000/μL 
• Platelets ≥ 75,000/μL 
• Hgb ≥ 9 g/dL 
• Creatinine ≤ 1.5 x upper limit of normal (ULN) or Creatinine clearance 
≥ 50% of lower limit of normal (LLN) 
• Total bilirubin ≤ 1.5 ULN 
• ALT and AST ≤ 1.5 ULN 
• For women of child-bearing potential, agreement to use adequate birth 
control (abstinence, hysterectomy, bilateral oophorectomy, bilateral tubal 
ligation, oral contraception, IUD, or use of condoms or diaphragms) 
• Signed informed consent 
 
5.1.3 Exclusion criteria 
 
Patients will be excluded from the study based on the following criteria: 
• 
Inability to continue treatment with CPI (if already started) 
• 
Rapidly progressing multi-focal metastatic melanoma  
• 
Insufficient tumor available to produce vaccine 
• 
ECOG >2 performance status (Appendix A) 
• 
Immune deficiency disease or known history of HIV, active HBV, or 
active HCV 


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• 
Receiving immunosuppressive therapy including chronic steroids 
(except physiologic maintenance doses), methotrexate, or other known 
immunosuppressive agents 
• 
Pregnancy (assessed by urine HCG) 
• 
Breast feeding 
• 
Active pulmonary disease requiring medication to include multiple 
inhalers (>2 inhalers and one containing steroids) 
• 
Involved in other experimental protocols (except with permission of the 
other study PI) 
5.2 
Study Treatment 
5.2.1 Vaccine production  
Vaccines will be produced by Orbis Health Solutions (Greenville, SC).  Tumor lysate 
from the patient’s tumor is loaded into YCWP which are phagocytized by the 
patient’s dendritic cells in vitro to generate TLPLDC.   
The final vaccine contains 1x106 TLPLDC per dose and will be provided in frozen 
single dose vials in 250 µl of freezing media.  The final vaccine is prepared for 
injection by thawing the single dose vial and diluting the TLPLDC by adding 500 µl 
of sterile saline for injection. 
5.2.1.1 Preparation of dendritic cells 
Dendritic cells will be generated from the patient's peripheral blood monocytes 
(PBMC) obtained from the post-Neupogen 70 mL blood draw or from 120 mL of 
blood drawn if Neupogen not used.  The PBMCs are initially diluted and placed in a 
plastic culture flask for 2 hours.  Non-adherent cells are washed away and collected.  
These cells are rich in lymphocytes and will be frozen for future assays.   
The adherent cells will be incubated at 37°C in 5% CO2 for two days in serum-free 
cell culture medium with the appropriate cytokines added to generate immature 
monocyte-derived dendritic cells. 
5.2.1.2 Tumor tissue preparation 
A minimum of 1 mg sample of viable tumor tissue is required to be collected and 
verified prior to consent#2 for study participation.  The specimens will be collected 
and placed in sterile freezing vials that will be provided and then shipped in 
specialized FedEx shippers designed to keep the specimens frozen (also provided).  
The cells of the tumor tissue will be lysed by multiple freeze/thaw cycles in lysis 
buffer to produce tumor lysate. 
5.2.1.3 YCWP preparation 


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YCWP are prepared by NaOH digestion of all non-cell wall material from 
Fleishman’s Bakers’ yeast, Saccharomyces cerevisiae, followed by thorough 
aqueous, ethanol, and acetone washings. 
5.2.1.4 Loading of YCWP with tumor lysate 
TLPLDC are generated by incubating tumor lysate loaded YCWP in the presence of 
dendritic 
cells 
at 
a 
specific 
time 
during 
day 
2 
of 
the 
DC 
isolation/incubation/maturation process.  The timing is essential in that the 
immature DC are given the YCWP at their most phagocytic phase.   
5.2.2 Storage 
Six doses of 1 x 106 autologous TLPLDC will be cryopreserved in patient-specific 
labeled single dose vials and maintained at the central production facility at -80◦C 
until shipped.  Once approved for release, the entire vaccine series (all six doses) 
will be shipped to the site frozen in specialized LN shippers.  The patient-specific 
dose series will be stored at the site at least -70°C in the research pharmacy until 
serially thawed for use.   
5.2.3 Inoculation series – administration 
Patients will receive six intradermal inoculations on the anterior or medial side of 
the same thigh or arm. The general area of inoculation will be at a location midway 
between the inguinal ligament and the knee. 
Before injection, this cellular vaccine will either be thawed slowly in a 370 C water 
bath or the vaccine vial can be held in a gloved hand until thawed if water bath is not 
available. The vial should not be left lying out to thaw at ambient temperature. The 
250 µl of thawed TLPLDC will be diluted with 500 µl of sterile saline for injection.  
The final 750 µl volume will be drawn up into a 1 mL syringe and should be injected 
within 4 hours.   
The entire contents of the syringe will be injected intradermally in two 
approximately equal inoculums at two different sites 5 cm from each other on the 
anterior or medial thigh or arm. Inoculations will be administered in the same 
lymph node draining area (same arm or leg)(see also Appendix D).   
The research nurse coordinator will administer the inoculations sterilely in the 
clinic facility located at each study site. For female patients with childbearing 
potential, a urine pregnancy test will be performed before each inoculation. If this 
test is positive at any time, the patient will be discontinued from the study. 
Initial inoculations will be performed at 0, 1, 2 and 3 months + 1 week followed by 
booster inoculations at 6 and 9 months + 2 weeks from initial inoculation for a total 
of six doses.  


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5.3 
Study Assessments 
Signed, IRB-approved informed consents must be obtained from patients prior to 
any pretreatment assessments.   
5.3.1 Pretreatment assessments 
This trial requires two consents; the first for tumor tissue procurement, and a second 
for blood draw and treatment.  The consents will be signed once the patient has been 
adequately and appropriately counseled and all eligibility criteria are met.  The 
second consent will be signed once adequate tissue is received for vaccine production. 
 
All patients must have a CBC, CMP, and LDH within 4 weeks of trial initiation and, for 
female patients, a urine pregnancy test (upon consent to study), for screening and 
immediately prior to any vaccine inoculations.  If the pregnancy test is positive the 
patient will be excluded from the study.  Women who have had a hysterectomy, 
bilateral oophorectomy, tubal ligation, documented absence of menses for two years, 
or FSH hormonal laboratory results that verify menopause, will not be required to 
have pregnancy testing.   
All patients must have a complete metastatic evaluation within 4 weeks of vaccine 
initiation as a baseline evaluation.  Overall health screen will be assessed utilizing the 
ECOG performance status grading system (Appendix A). 
All patients will be assessed for baseline and post-vaccination immunologic 
responses.  Blood samples will be obtained prior to each inoculation (0, 1, 2, 3, 6, 
and 9 months) and at study completion at 12 months from enrollment. The protocol 
schedule of events is listed in Appendix E.   Specimen handling, processing, and 
assays are described in Sections 5.3.4, 5.3.5, and 5.3.6. 
5.3.2 Assessments during treatment 
Any laboratory evaluations or imaging studies ordered by the treating oncologist as 
part of standard practice will be reviewed by the research nurses or study 
coordinators and any abnormal results will be reviewed by the study investigators. 
For both the primary inoculations and booster series, the patients will be monitored 
closely for 30 minutes after inoculation with questioning, serial exams, and vital 
signs as needed to observe for a hypersensitivity reaction.   Local or systemic 
toxicities will be collected and graded by the research staff at the patient’s next visit. 
The NCI CTCAE v4.03 graded toxicity scale (Appendix C) will be utilized to assess 
local and systemic toxicity.   
Blood samples will be obtained from all patients to determine induction of 
anticancer immune responses as described in Sections 5.3.4, 5.3.5, and 5.3.6. 


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5.3.3 Follow-up assessments 
The clinical endpoint of objective tumor response as defined as progressive disease 
(PD), stable disease (SD), partial response (PR), and complete response (CR) will be 
determined by the primary investigator at the individual study sites during routine 
follow-up.  This will include history and physical examination every 3 months for all 
patients for 1 year.   
Additional laboratory and radiographic surveillance will be performed as indicated 
and directed by the patients treating physicians and per standard of care.  The 
determination of CR, PR, SD, or PD will be assessed per RECIST criteria and iRECIST 
(Appendix B).  These results will be communicated by the primary study 
investigators on a routine basis.   
For the purposes of this trial, the timing associated with tumor response will be 
calculated from the date of initial inoculation to the first date that the tumor meets 
RECIST criteria and iRECIST criteria.   If records are not available, patients, or their 
referring physicians, will be contacted to discern their disease status and every 
effort will be made to obtain documentation.   
All enrolled patients will be followed for 1 year after enrollment. 
5.3.4  Blood collection and processing 
Multiple blood draws will be required for this trial. All blood tubes will be labeled 
only with the patients’ unique study number.  Approximately 50 mL will be collected 
for immunologic assessments prior to each inoculation (0, 1, 2, 3, 6, and 9 months) 
and at the final study visit.     
Thus, including the initial blood draw for vaccine production (70-120 mL), a total of 
approximately 420-470 mL of blood will be drawn over the one-year course of the 
study.  De-identified patient blood samples showing only the unique study ID 
number will be sent from study sites via overnight delivery to our central lab facility 
in Greenville, SC where they will be stored until used for immunologic assays 
(Section 5.4.6).  At no point will laboratory personnel have access to patient 
identifiers.  Blood will be frozen and stored under unique study numbers for up to 
five years for additional immunologic studies related to this protocol or for 
additional studies for melanoma treatment (for example, to repeat assays or 
perform new immunologic assays that do not exist at present but may become 
available) as needed and then destroyed.  No genetic testing will be performed on 
this material.  Study participants will not be contacted in the future for additional 
use of these stored blood specimens.  If study participants want their blood 
specimens removed from storage and destroyed, they may do so by contacting the 
PI or research nurse at any time.  Additionally, any stored blood may also be utilized 
to assess new generations of vaccines.      
The 50 mL of blood will be collected as follows: 10 mL into a BD Vacutainer Rapid 
Serum tube (BD, Franklin Lakes, NJ) which contain a clot activator and silicone 


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coated interior. After receipt and centrifugation, serum will be collected, aliquoted 
in vials and frozen. The remaining 40 mL will be collected into four BD Vacutainer 
Heparin tubes (green tops) which contain an anticoagulant (sodium heparin).  Once 
received, the heparinized blood will be pooled, diluted, and added to FICOLL 
HYPAQUE density gradient fluid containing tubes to allow for the separation of 
PBMC from the red blood cells by a single step centrifugation process.   
The PBMC fraction will be collected, aliquotted, and frozen for future use in 
immunologic assays. 
5.3.5  Phenotypic assay (for example, dextramer assay) for melanoma-specific 
antigens 
 
Thawed and cultured PBMC will be stained with aqua live/dead stain (Invitrogen) 
and the following antibodies:  CD8 APC-H7 (BD Biosciences), CD3 PE Cy7 (BD 
Biosciences), gp100-APC-conjugated dextramer (Immudex), and the following 
pacific blue conjugated lineage antibodies:  CD14 (BD Biosciences), CD16 (BD 
Biosciences), and CD19 (Biolegend).  Cells will be analyzed on a Canto flow 
cytometer (BD Biosciences).   
The frequency of gp100-specific CD8+ T-cells will be determined as the percentage 
of cells that are alive, lineage-, CD3+ CD8+ and gp100-dextramer+.  This assay may 
be performed for other known CD8+ epitopes from known melanoma-specific 
antigens.  
5.3.6  Functional assay (for example, ELISPOT assay) for melanoma-specific antigens 
Thawed and isolated PBMC are cultured/stimulated overnight in complete medium 
(RPMI + 5 %FCS + PSG) supplemented with IL-7 (20 ng/mL) with the individual 
peptides at 25 μg/mL (gp100, MART-1, etc) or PMA + Ionomycin in flat-bottom anti-
human IFN-γ ELISPOT plates (BD PharMingen) at 5 x 105 cells/well/200 μL in 
duplicate wells.  The plate is incubated at 37ºC overnight after which the wells will 
be washed and incubated with the biotinylated-anti-IFN-γ mAb for two hours.  The 
wells will be washed again and incubated with streptavidin-conjugated HRP for one 
hour.  After a final wash the AEC-substrate solution will be added to the wells and 
allowed to develop for approximately 5-10 minutes at which time the wells will be 
washed with deionized water to stop the reaction.  The number of spots present in 
each well will be enumerated using the CTL ELISPOT analyzer (CTL Analyzers LLC, 
Cleveland, OH). 
5.4 
Discontinuation of Protocol-Specific Therapy 
Protocol-specific therapy may be discontinued for any of the following reasons:    
• Progressive disease 
• Unacceptable toxicity as described in the protocol:  


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o Please refer to Section 4.4 (Safety Considerations).  Adverse events 
that do not respond to clinical management of the reaction will result 
in discontinuation from the study. 
o Please refer to Section 5.5 (Subject Discontinuation) for a list of severe 
adverse reactions warranting discontinuation from the study.  
• Patient election to discontinue therapy (for any reason) 
• Physician’s judgment 
5.5 
Subject Discontinuation 
Those patients who display significant reactions (i.e. anaphylactic reaction 
immediately after vaccine administration) or serious toxicities will be discontinued 
from the study as discussed below and as determined by the PI and/or Sponsor.  
They will be followed by the study investigator until resolution of the adverse event. 
Inoculations will be immediately halted if any serious adverse reactions occur to 
include: death, life-threatening adverse drug experience (i.e., severe anaphylactic 
reaction immediately after vaccine administration), inpatient hospitalization or 
prolongation 
of 
existing 
hospitalization, 
a 
persistent 
or 
significant 
disability/incapacity, a congenital anomaly/birth defect, or other important medical 
events that may not result in death, be life-threatening, or require hospitalization 
but which, when based upon appropriate judgment of the PI, be determined to 
jeopardize the patient or require medical or surgical intervention to prevent an 
outcome listed above.   
Any death or grade 4 adverse drug experience found to be directly related to the 
experimental vaccine will result in suspension of patient enrollment to the study. 
In the event a patient develops a severe adverse reaction to the CPI that is unable to 
be managed with immunosuppressive medications may also be discontinued from 
the study. 
Patients may withdraw from the study at any time and for any reason.  A patient 
may be asked to withdraw from the study by the PI if they are not compliant with 
the timing of the inoculation series, observation period, or return visits to monitor 
for study-associated toxicities.   
Additionally, if the PI determines that it is no longer safe for a patient to continue in 
the trial for any reason, they may be withdrawn.   
Because it is not known whether these inoculations might harm an unborn child, 
patients who are pregnant, plan on becoming pregnant, or who are breast-feeding 
will not be enrolled into the study.  Women of childbearing potential will take a 
urine pregnancy test before starting this study and prior to each inoculation; a 
positive test result will terminate the patient’s participation in the study.  Patients 


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will be counseled to avoid becoming pregnant while participating in this study, and 
that in order to prevent pregnancy they should either have no sexual relations or 
use a reliable type of birth control. They will be counseled that with the exception of 
hysterectomy, bilateral oophorectomy, or tubal ligation, birth control methods are 
not totally effective in preventing pregnancy, and that the only ways to completely 
avoid the risk of the vaccine or immunoadjuvant alone to an unborn baby are (1) 
avoid becoming pregnant, or (2) do not receive these inoculations. Patients will be 
counseled to avoid becoming pregnant for at least six months after receiving the 
inoculations, as pregnancy within this time after inoculation administration may be 
a risk to an unborn baby.   
If a patient is discontinued from the study for an adverse event or pregnancy, they 
will continue to be followed for resolution of adverse event and clinical recurrences 
unless the patient withdraws consent for further study evaluation.  
The reason for any premature discontinuation of a patient from the study will be 
recorded on the appropriate Case Report Form.  
5.6 
Study Discontinuation 
The IND sponsor, the Data Safety Monitoring Board, and the overall study Principal 
Investigator have the right to suspend or terminate this study entirely or at a 
specific site at any time.  Reasons for suspending or terminating the study may 
include the following: 
• The incidence or severity of AEs in this or other studies indicates a potential 
health hazard to subjects 
• Subject enrollment is unsatisfactory 
• Data recording are inaccurate or incomplete 
• Study protocol not followed 
5.7 
Data Collection 
Basic demographic, pathologic, and relevant clinical information will be gathered on 
each patient and entered into an Electronic Data Capture (EDC) database.  The URL 
for the EDC system is https://cancerinsight.eclinicalhosting.com/OpenClinica.  The 
EDC system can be accessed from any major web browser. User name and password 
will be generated by the Data Manager of Cancer Insight, LLC and sent via email to 
appropriate site personnel prior to enrolling their first patient. Clinical nurses at the 
site will be provided with Source Document Flow Sheets to capture data at 
enrollment and for each study visit.  Although some data fields on the Flow Sheets 
will not be entered into EDC, they must be captured on the Flow Sheets for 
monitoring purposes.  
All data must be submitted within 72 hours of the data collection visit.  Data entry 
will begin when the patient signs the second informed consent, with enrollment 
date to be date of signed informed consent.  


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Edit checks will fire in real time as data is being entered in the EDC system to ensure 
quality data is provided.  In addition to edit checks, queries will be generated as 
Discrepancy Notes from the Data Manager and Monitors.  Sites will have ten 
business days to update a query.  It is the responsibility of the coordinator at each 
site to ensure that data has been submitted.  Cancer Insight QA personnel or the 
Sponsor’s representative will perform an audit of the site-specific Flow Sheets and 
will match them against source documents to ensure the quality of data coming to 
the Data Manager in the EDC per the internal monitoring plan. 
The database, hosted by OpenClinica, resides in a SAS 70 Type II data center and 
meets ISO 17799 standards for information security. The EDC system is HIPAA and 
21 CFR Part 11 compliant with robust audit logs, controlled user access, and 
electronic signature/password management.   
In addition to the site user, the Data Manager, the Monitors, the study PI and 
Sponsor/Sponsor representative have access to the database.  Each user is assigned 
a role, which grants limited access and functionalities dependent upon that specific 
role.  
5.8 
Statistical Methods 
5.8.1  Rationale for study design 
Individually, CPI therapies have been approved for use in metastatic melanoma and 
the TLPLDC vaccine appears to provide benefit to these patients as well in small 
studies.   
 
By stimulating the patients’ immune system to produce tumor-reactive T-cells 
against their personal cancer, while simultaneously preventing down-regulation of 
these newly induced/amplified T cells in the tumor microenvironment could result 
in a highly effective multimodality immunotherapy that could significantly impact 
clinical outcomes of patients with metastatic melanoma.  While CPI have been 
proven to be effective in metastatic melanoma patients in terms of tumor response 
as well as survival, the majority of metastatic melanoma patients still succumb to 
their disease.  Thus, the CPI monotherapy is not sufficient alone.  One theory is that 
these patients lack adequate numbers of tumor-reactive T cells on which the CPI can 
work.  The TLPLDC vaccine generates tumor-reactive T cells as its primary 
mechanism of action.  Therefore, intuitively there is rationale for combining the two 
forms of immunotherapy.  
 
 5.8.2  Sample size determination 
In order to assess both the safety as well as the efficacy of adding the TLPLDC 
vaccine to SoC CPI in metastatic melanoma patients, a total of up to 45 patients will 
be enrolled into this study.  The primary endpoint of efficacy is defined as the 
objective tumor response rate (ORR) (CR + PR) per RECIST criteria and iRECIST.  
With 45 patients, the study will have an 80% power to detect an absolute 25% 


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improvement in ORR compared to SoC CPI monotherapy in these patients with an 
alpha = 0.05 (one-tailed).  Furthermore, this number of patients will allow for a 
similar level of detection of safety/toxicity parameters.   
 
5.8.3  Data analysis 
Tumor response to the CPI+TLPLDC vaccine will be evaluated by the site primary 
investigators for each patient at multiple time points (approximately every 3 
months for a year).   
 
The time to best tumor response for each patient will be determined from the date 
of first inoculation until they meet a specified tumor response based on the RECIST 
criteria and iRECIST (Appendix B).  ORR (CR + PR) as well as the clinical beneficial 
response rate (CBR) (CR + PR + SD) will be calculated and represented in waterfall 
plots and line graphs.  The progression free survival and overall survival will be 
determined using the Kaplan-Meyer method.  
 
5.8.3.1  Study patient characteristics 
Demographic characteristics of all patients will be summarized including age, race, 
disease histology, tumor location, tumor depth, ulceration, number of mitoses, nodal 
status (number and micro- vs macro-metastasis), AJCC clinical stage, location and 
number of distant metastases (if present), and other disease-directed therapies to 
include chemotherapy, radiation therapy, and biologic therapy including the 
checkpoint inhibitor used.  Continuous variables will be summarized using the 
number of patients, mean, standard deviation, median, minimum, and maximum; 
and categorical variables will be summarized using the frequency count and the 
percentage of patients in each category.   
5.8.3.2  Primary efficacy analysis 
The primary endpoint for efficacy is the overall study-wide objective tumor 
response rate in response to the TLPLDC vaccine being added to SoC CPI therapy. 
The primary investigators at each site will determine each patient’s tumor response 
to the TLPLDC vaccine + CPI and classify the patient as a CR, PR, SD, or PD per 
RECIST criteria and iRECIST criteria as delineated in Appendix B.  Each patient will 
be assessed approximately every 3 months for a year.  Durability of response will 
also be reported. 
The primary efficacy analysis will be an accumulation of the individual patients’ 
responses.  The overall study ORR (CR + PR) will be calculated and reported as well 
as the median durability of response.  Additionally, the CBR (CR + PR + SD) will also 
be reported with median durability of response. 
5.8.3.3  Secondary efficacy analysis 


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The ORR and rate/type of AEs will be compared to currently available CPI 
monotherapy ORR and rate/type of AEs  using proportional statistical analysis.   
5.8.3.4 Safety analysis 
The incidence of treatment-emergent AEs, SAEs, severe AEs, AEs related to study 
drug (defined as not, unlikely, possibly, probably, or definitely related to study drug) 
will be summarized.  
Time to AE onset will be estimated using the Kaplan-Meier method. In addition, 
duration of any AE with >10% incidence, total number of AEs, SAEs, and related AEs 
will be summarized..  
5.8.3.5 Immunologic analysis 
Immunologic responses will be determined using phenotypic and functional assays 
(ex vivo).  
Expression percentages will be compared using a chi-square test while continuous 
outcomes will be compared using a paired t-test.   
For the ex vivo response evaluated by the phenotypic and functional assays, the 
number of peptide-specific CTL will be determined at multiple time points (see 
Sections 5.3.4, 5.3.5, and 5.3.6) during the trial.  
Changes from pre-vaccination levels to each time point will be compared, and 
differences will be evaluated using a paired t-test. 
In a series of exploratory analyses, the different immunologic response indicators 
(in vivo and ex vivo) at different time points will be correlated with clinical outcome 
in order to assess for any predictors of outcome.  
5.8.3.6 Planned analyses 
1) Safety will be monitored continuously. 
2) Objective tumor response rates will be assessed in real time. 
3) The interim analysis response rates and comparisons will be completed 
12 months after initiation of this trial to assess the vaccine safety profile and 
tumor response trends.  No action regarding stopping the trial will be taken 
based on this analysis unless there is a safety concern.    
 4) The final analysis will be completed after 12 months follow-up from the 
last enrolled patient. 
5.8.4 Withdrawal 
Subjects may withdraw or be discontinued from the study as discussed in Section 
5.6.  Subjects who do withdraw or are discontinued will be included in the efficacy 


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analyses unless a subject withdraws consent to participate.  In the instance of a 
subject withdrawing consent, any data collected will be excluded from analysis. 
5.8.5 Missing data 
Every reasonable attempt will be made to recover any missing data.  If any data 
remains missing that data point will be excluded from analysis for that patient.   
6.0 ADVERSE EVENTS 
 
Reporting of adverse events will be performed in accordance with the Data Safety 
Monitoring Plan (DSMB) (Appendix F) and Sections 6.2 and 6.3. 
6.1 
Adverse Event and Reporting Definitions 
With the occurrence of an AE, the first concern will be for the safety of the subject. 
Investigators are required to report to the IRB, medical monitor, clinical research 
organization (CRO) QA Officer, or designee and CRO Regulatory Affairs Officer any 
serious adverse event, whether expected or unexpected, and which is assessed by 
the investigator to be possibly or probably related to or caused by the vaccine 
components.  All events meeting the outlined criteria will be reported for the time 
period beginning with any amount of exposure to vaccine components through the 
protocol-defined follow-up period. The Regulatory Affairs Officer will then report 
the event to the Sponsor. The IND Sponsor or Sponsor’s representative will report 
these to the FDA per the requirements of 21 CFR Section 312.32.  Serious criteria, 
definitions, and guidance for reporting follow. 
An adverse event (AE) is any untoward medical occurrence in a subject 
participating in an investigational study or protocol regardless of causality 
assessment.  
An adverse event can be an unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, syndrome or disease associated with or 
occurring during the use of an investigational product whether or not considered 
related to the investigational product. 
Serious adverse events (SAE) are AEs occurring at any dose which meet one or more 
of the following serious criteria: 
• Results in death (i.e., the AE caused or led to death) 
• Is life-threatening (i.e. the AE placed the subject at immediate risk of death; it 
does not apply to an AE which hypothetically might have caused the death if 
it were more severe) 
• Requires or prolongs inpatient hospitalization (i.e., the AE required at least a 
24-hour 
hospitalization. 
(Inpatient 
hospitalization 
or 
prolonged 
a 
hospitalization beyond the expected length of stay; hospitalizations for 


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elective medical/surgical procedures, scheduled treatments, or routine 
check-ups are not SAEs by this criterion.) 
• Is disabling (i.e., the AE resulted in a substantial disruption of the subject’s 
ability to carry out normal life functions) 
• Is a congenital anomaly/birth defect (i.e., an adverse outcome in a child or 
fetus of a subject exposed to the study drug prior to conception or during 
pregnancy) 
• Does not meet any of the above serious criteria but may jeopardize the 
subject and may require medical or surgical intervention to prevent one of 
the outcomes listed above 
Expected AEs are those AEs that are listed or characterized in the current 
Investigator Brochure. 
Unexpected AEs are those not listed in the current Investigator Brochure (IB).  
This includes AEs for which the specificity or severity is not consistent with the 
description in the IB. For example, under this definition, hepatic necrosis would be 
unexpected if the Investigator Brochure only referred to elevated hepatic enzymes 
or hepatitis. 
6.2  
Reporting of Serious Adverse Events Associated with This Study 
Each site PI will within 24 hours of notification of the event report all related or 
unrelated serious AEs occurring in subjects enrolled at their respective study site to 
the Internal Review Board (IRB) of their site (see AE Reporting Algorithm, Appendix 
G). This will be accomplished by submitting an AE report memorandum to the IRB 
per the IRB’s site-specific standard operating procedures.  
The site PI will also, within 24 hours of notification of the event, forward a copy of 
the serious adverse event report (CRF Form 3.1) to the CRO QA Officer or designee, 
and to the CRO Regulatory Affairs Officer.  
The QA Officer or designee will then forward the report to the Sponsor. The Sponsor 
or Sponsor’s representative will review the serious AE to determine the need for 
expedited reporting to the FDA. If expedited reporting is required, the site nurse 
coordinator will be notified by the QA Officer or designee to complete a MedWatch 
FDA Form 3500 (Appendix H).  
The Regulatory Affairs Officer will then submit the final report to the Sponsor or 
Sponsor’s representative who will then report to the FDA. 


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6.2.1  MedWatch 3500A reporting guidelines 
In addition to completing appropriate patient demographic and suspect medication 
information, the report should include the following information within the Event 
Description of the MedWatch 3500A form: 
o Protocol description (and number, if assigned) 
o Description of event, severity, treatment, and outcome if known 
o Supportive laboratory results and diagnostics 
o Investigator’s assessment of the relationship of the AE to each 
investigational product and suspect medication 
Follow-up information: 
Additional information may be added to a previously submitted report by any of the 
following methods: 
o Adding to the original MedWatch 3500A report and submitting as follow-up 
o Adding supplemental summary information and submitting it as follow-up with 
the original MedWatch 3500A form 
o Summarizing new information and faxing it with a cover letter including 
subject identifiers (i.e. D.O.B. initial, subject number), protocol description and 
number, if assigned, brief adverse event description, and notation that additional 
or follow-up information is being submitted. (The patient identifiers are 
important so that the new information is added to the correct initial report.) 
The CRO or Sponsor may contact the reporter for additional information, 
clarification, or current status of the subject for whom an AE was reported. For 
questions regarding SAE reporting, you may contact the CRO QA Officer or designee. 
Study Drug Relationship: 
The PI will determine which events are associated with the use of study drug. For 
reporting purposes, an AE should be regarded as possibly related to the use of 
vaccine components if the PI believes: 
o There is a clinically plausible time sequence between onset of the AE and 
administration of vaccine components; and/or 
o There is a biologically plausible mechanism for vaccine components to cause or 
contribute to the AE; and 
o The AE cannot be attributed solely to concurrent/underlying illness, other drugs, 
or procedures. 


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6.3 
Reporting Requirements for IND Sponsor 
For sponsored IND Studies, there are additional reporting requirements for the FDA 
in accordance with the guidance set forth in 21 CFR § 600.80. Events meeting the 
following criteria need to be submitted to the FDA as expedited IND Safety Reports 
according to the following guidance and timelines: 
7 Calendar-Day Telephone or Fax Report: The Sponsor is required to notify the FDA 
of any fatal or life-threatening AE that is unexpected and assessed by the 
investigator to be possibly related to the use of the investigational product. An 
unexpected AE is one that is not already described in the IB for the vaccine. Such 
events are to be reported by the sponsor to the FDA and within seven calendar days 
of first learning of the event. 
15 Calendar-Day Written Report: The Sponsor is also required to notify the FDA and 
all participating investigators, in a written IND Safety Report, of any serious, 
unexpected AE that is considered reasonably or possibly related to the use of the 
study agents. An unexpected AE is one that is not already described in the 
Investigator Brochure for vaccine. 
 
o Written IND Safety Reports should include an Analysis of Similar Events in 
accordance with regulation 21 CFR § 312.32. All safety reports previously filed 
with the IND concerning similar events should be analyzed and the significance 
of the new report in light of the previous, similar reports commented on. 
o Written IND safety reports with Analysis of Similar Events are to be submitted 
to the FDA and all participating investigators within 15 calendar days of first 
learning of the event. The FDA prefers these reports on a MedWatch 3500A 
Form but alternative formats are acceptable (e.g. summary letter). 
7.0 INVESTIGATOR REQUIREMENTS 
7.1  
Study Initiation 
Before the start of this study, the following documents must be on file with the 
Sponsor or Sponsor’s representative: 
o Original U.S. FDA Form 1572 for each site (for all studies conducted under 
U.S. Investigational New Drug [IND] regulations), signed by the Principal 
Investigator. The names of any sub-investigators must appear on this form. 
Investigators must also complete all regulatory documentation as required by 
local and national regulations. 
o Current curriculum vitae of the Principal Investigator 
o Written documentation of IRB approval of protocol and informed consent 
document 


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o A copy of the IRB-approved informed consent document 
o A signed Clinical Research Agreement 
o A signed investigator’s agreement (Appendix I) 
7.2  
Study Completion 
The following materials are requested by the Sponsor when the study is considered 
complete or terminated: 
o A summary, prepared by the Principal Investigator, of the study, and/or a study 
manuscript, and/or a study abstract submitted to scientific conferences. 
7.3  
Informed Consent 
Informed consent form templates will be provided, and the final IRB-approved 
document must be provided to the Sponsor or Sponsor’s representative for 
regulatory purposes.  
The informed consent document must be signed by the subject before his or her 
participation in the study. The case history for each subject shall document that 
informed consent was obtained prior to participation in the study.  
Copies of the informed consent form documents must be provided to the subject. If 
applicable, it will be provided in a certified translation of the local language. 
Signed consent forms must remain in each subject’s study file and must be available 
for verification by study monitors at any time. 
7.4 
Institutional Review Board or Ethics Committee Approval 
This protocol, the informed consent document, and relevant supporting information 
must be submitted to the IRB for review and must be approved before the study is 
initiated. The study will be conducted in accordance with U.S. FDA, applicable 
national and local health authorities, and IRB requirements. 
The Principal Investigator is responsible for keeping the IRB apprised of the 
progress of the study and of any changes made to the protocol as deemed 
appropriate, but in any case the IRB must be updated at least once a year. The 
Principal Investigator must also keep the IRB informed of any significant adverse 
events. Investigators are required to promptly notify their respective IRB of all 
adverse drug reactions that are both serious and unexpected. This generally refers 
to serious adverse events that are not already identified in the IB and that are 
considered possibly or probably related to the molecule or study drug by the 
investigator.  
Some IRBs may have other specific adverse event requirements to which 
investigators are expected to adhere. Investigators must immediately forward to 
their IRB any written safety report or update provided by the Sponsor (e.g., IND 


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safety report, IB, safety amendments and updates, etc.). 
Ethics and Regulatory Considerations 
The protocol will be reviewed and approved by the IRB or Independent Ethics 
Committee (IEC) of each participating center prior to study initiation. A list of 
IRB/IEC members should be obtained by the investigator and provided to the 
sponsor and sponsor representative. Any documents that the IRB/IEC may need to 
fulfill its responsibilities, such as protocol amendments and/or information from the 
sponsor will be submitted to the IRB/IEC. The IRB/IEC’s written unconditional 
approval of the study protocol and the informed consent form will be in the 
possession of the PI and the Sponsor before the study is initiated.  
 
 
The IRB/IEC’s unconditional approval statement will be transmitted by the 
investigator or designee to the sponsor/sponsor representative prior to shipment of 
study drug supplies to the site. This approval document must refer to the study by 
exact protocol title and protocol version number/date and must identify the 
documents reviewed and the date of review. 
 
Protocol modifications or changes may not be initiated without prior written 
IRB/IEC approval except when necessary to eliminate immediate hazard to the 
patients. Such modifications will be submitted to the IRB/IEC and written 
verification 
that 
the 
modification 
was 
submitted 
and 
IRB/IEC 
acknowledgement/approval 
should 
be 
obtained 
and 
transmitted 
to 
the 
Sponsor/Investigator or Sponsor/Investigator’s representative.  
The IRB/IEC must be informed by the principal investigator of any changes or 
revisions of informed consent forms or other documents originally submitted for 
review; serious and/or unexpected adverse experiences occurring during the study; 
any new information that may affect adversely the safety of the patients or the 
conduct of the study; annual updates and/or request for re-approval; and when the 
study has been completed. 
 
 7.5 
Study Monitoring Requirements 
Site visits may be conducted by authorized Sponsor representative or CRO 
representatives to inspect study data, subjects’ medical records, and CRFs in 
accordance with current U.S. GCPs and the respective local and national government 
regulations and guidelines (if applicable). 
The Principal Investigator will permit authorized representatives of Sponsor, CRO, 
the FDA, and the respective national or local health authorities to inspect facilities 
and records relevant to this study. 


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7.6 
Data Safety Monitoring Plan 
A DSMP (Appendix F) describing the CRO internal monitoring plan includes data 
safety and integrity and site initiation/QA monitoring, as well as external 
monitoring plan, the Data Safety Monitoring Board (DSMB) charter and 
responsibilities. 
7.7  
Study Medication Accountability 
The study drug will be provided by the Sponsor.  The recipient will acknowledge 
receipt of the drug by returning the INDRR-1 form indicating shipment content and 
condition. Damaged supplies will be replaced. Accurate records of all study drug 
dispensed from and returned to the study site should be recorded by using the 
institution’s drug inventory log or the NCI drug accountability log.   
All partially used or empty containers should be disposed of at the study site 
according to institutional standard operating procedure. Return unopened, expired, 
or unused study drug with the Inventory of Returned Clinical Material form as 
directed by the Sponsor. 
7.8  
Disclosure of Data  
Subject medical information obtained by this study is confidential, and disclosure to 
third parties other than those noted above is prohibited. Upon the subject’s 
permission, medical information may be given to his or her personal physician or 
other appropriate medical personnel responsible for his or her welfare. Data 
generated by this study must be available for inspection upon request by 
representatives of the FDA, national and local health authorities, the Sponsor, and 
the IRB for each study site, if appropriate. 
7.9  
Retention of Records  
U.S. FDA regulations (21 CFR §312.62[c]) require that records and documents 
pertaining to the conduct of this study and the distribution of investigational drug, 
including CRFs, consent forms, laboratory test results, and medication inventory 
records, must be retained by the Principal Investigator for two years after 
marketing application approval.  
If no application is filed, these records must be kept two years after the investigation 
is discontinued and the FDA and the applicable national and local health authorities 
are notified. The Sponsor will notify the Principal Investigator of these events.  
For studies conducted outside the United States under a U.S. IND, the Principal 
Investigator must comply with U.S. FDA IND regulations and with the record 
retention policies of the relevant national and local health authorities. 


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7.10  Publications  
The investigator must agree to send to the Sponsor or Sponsor’s representative, for 
review all manuscripts, abstracts and presentations using data from this study prior 
to their submission. The Sponsor or Sponsor’s representative reserves the right to 
delete from such materials any part or parts deemed to be confidential or 
proprietary. 
7.11  Changes to Protocol  
The protocol may not be modified without written approval of the Sponsor or 
Sponsor’s representative, or the Study Director. All changes to the protocol must be 
submitted to the FDA, the overseeing IRB, and local IRB/IEC. Additionally, changes 
must be approved by overseeing IRB prior to their implementation. Documentation 
of IRB/IEC approval must be sent to the Sponsor or Sponsor’s representative, and 
the Study Director immediately upon receipt.   
Any changes and modifications to the informed consent language must be reviewed 
and approved by the Sponsor or Sponsor’s representative, and the Study Director 
prior to submission to the local IRB. 


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REFERENCES 
1. Gogas H, Polyzos A, Kirkwood J. Immunotherapy for advanced melanoma: 
Fulfilling the promise. Cancer Treat Rev. 2013;39(8):879-885.  
2. NCCN Practical Guidelines in Oncology: Melanoma. National Comprehensive 
Cancer Network 2015; Version 3.2015. 
3. Sabistons – Melanoma 
4. Bhatia S, Tykodi SS, Thompson J a. Treatment of metastatic melanoma: an 
overview. Oncology (Williston Park). 2009;23(6):488-496. 
5. Atkins MB, Lotze MT, Dutcher JP, Fisher RI, Weiss G, Margolin K, Abrams J, 
Sznol M, Parkinson D, Hawkins M, Paradise C, Kunkel L RS. High dose 
recombinant IL-2 therapy for patients with metastatic melanoma: analysis of 
270 pts between 1985 and 1993. Jco. 1999;17(7):2105. 
6. Eggermont AMM, Suciu S, Santinami M, et al. Adjuvant therapy with 
pegylated interferon alfa-2b versus observation alone in resected stage III 
melanoma: final results of EORTC 18991, a randomised phase III trial. Lancet. 
2008;372(9633):117-126.  
7. McArthur G a., Chapman PB, Robert C, et al. Safety and efficacy of 
vemurafenib in BRAFV600E and BRAFV600K mutation-positive melanoma 
(BRIM-3): Extended follow-up of a phase 3, randomised, open-label study. 
Lancet Oncol. 2014;15(3):323-332.  
8. Small EJ, Schellhammer PF, Higano CS, et al. Placebo-controlled phase III trial 
of immunologic therapy with Sipuleucel-T (APC8015) in patients with 
metastatic, asymptomatic hormone refractory prostate cancer. J Clin Oncol. 
2006;24(19):3089-3094.  
9. Robert C, Long G V., Brady B, et al. Nivolumab in Previously Untreated 
Melanoma without BRAF Mutation. N Engl J Med. 2015;372(4):320-330. 
10. Robert C, Schachter J, Long G V, et al. Pembrolizumab versus Ipilimumab in 
Advanced Melanoma for the KEYNOTE-006 investigators*. 2015:2521-2532.  
11. Kumar SS, McNeil CM. Pembrolizumab for the treatment of melanoma. Expert 
Rev Clin Pharmacol. 2015;8(5):1-12.  
12. Postow MA, Chesney, J, Pavlick AC, et al. Nivolumab and Ipilimumab versus 
Ipilimumab in Untreated Melanoma. N Engl J Med. 2015;372:2006-2017. 
13. Arigan, David. Dendritic Cells tumor fusion vaccines for Renal cell carcinoma. 
Clinical Cancer Research. 2004;10:6347. 
14. Jackson DO, Greene JM, Hale DF, et al. Preclinical testing of a novel 
personalized cancer vaccine for all solid tumors and all patients. SITC 
abstract 2015. 
15. Eisenhauer E a., Therasse P, Bogaerts J, et al. New response evaluation 
criteria in solid tumours: Revised RECIST guideline (version 1.1). Eur J 
Cancer. 2009;45(2):228-247.  
16. Greene JM, Schneble E, Hale DF, et al. A Phase I/IIa Clinical Trial in Stage IV 
Melanoma of an Autologous Tumor-Dendritic Cell Fusion (Dendritoma) 
Vaccine with Low Dose Interleukin-2. JCO In review 
17. Weber JS, Kähler KC, Hauschild A. Management of immune-related adverse 
events and kinetics of response with ipilimumab. J Clin Oncol. 
2012;30(21):2691-2697.  


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18. Wolchok JD, Hoos A, O’Day SJ, et al. Guidelines for the Evaluation of Immune 
Therapy Activity in Solid Tumors: Immune Related Response Criteria. Clincal 
Cancer Research. 2009; 15:7412. 
19. Eggermont AMM, Suciu S, Testori A, et al. Long-term results of the 
randomized phase III trial EORTC 18991 of adjuvant therapy with pegylated 
interferon alfa-2b versus observation in resected stage III melanoma. J Clin 
Oncol. 2012;30(31):3810-3818. 
20. Harris A, Sc M, Johnson DW, et al. New England Journal. Science. 2010:609-
619.  
21. Hodi FS, O’Day SJ, McDermott DF, et al. Improved survival with Ipilimumab in 
patients with metastatic melanoma. NEJM 2010;363(8): 712-723 
22. Kyi C, Postow M a. Checkpoint blocking antibodies in cancer immunotherapy. 
FEBS Lett. 2014;588(2):368-376. 
23. Wei YC, Sticca RP, Li J, et al. Combined treatment of dendritoma vaccine and 
low-dose interleukin-2 in stage IV renal cell carcinoma patients induced 
clinical response: A pilot study. Oncol Rep. 2007;18(3):665-671. 
24. Wolchok JD, Kluger H, Callahan MK, et al. Nivolumab plus ipilimumab in 
advanced melanoma. N Engl J Med. 2013;369(2):122-133.  
25. Wolchok JD, Weber JS, Hamid O, et al. Ipilimumab efficacy and safety in 
patients with advanced melanoma: a retrospective analysis of HLA subtype 
from four trials. Cancer Immun  a J Acad Cancer Immunol. 
2010;10(September):9. 
26. Seymour L, Bogaerts J, Perrone A, et al. iRECIST: guidelines for response 
criteria for use in trials testing immunotherapeutics. The Lancet Oncology. 
2017;18(3):e143-52. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix A 
 
ECOG Performance Status Criteria 
 
Score 
Description 
0 
Fully active, able to carry on all pre-disease performance 
without restriction 
1 
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 
2 
Ambulatory and capable of all self-care but unable to carry 
out any work activities.  Up and about more than 50% of 
waking hours. 
3 
Capable of only limited self-care, confined to bed or chair 
more than 50% of waking hours 
4 
Completely disabled.  Cannot carry on any self-care.  Totally 
confined to bed or chair. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix B 
 
1. Quick Reference for the Response Evaluation Criteria in Solid Tumors 
(RECIST Criteria) 
 
 
A. Indications for use of RECIST Criteria 
- 
The RECIST criteria is useful in all trials where objective response is 
the primary study endpoint, as well as in trials where assessment of 
stable disease, tumor progression or time to progression analyses are 
undertaken, since all of these outcome measures are based on an 
assessment of anatomical tumor burden and its change on the study. 
 
B. Identification of Lesions 
I. 
Measurable disease 
- 
All patients must have measurable disease to be enrolled into this trial. 
- 
All baseline imaging for determining these target lesions must be 
completed no more than 4 weeks prior to beginning treatment 
- 
Measurable disease includes: 
§ Tumors that can be accurately measured along the 
longest diameter  
§ Tumors must be >10mm by CT (CT must use 5mm cuts 
or smaller) 
§ If tumor lesions are measured on clinical exam, the lesion 
should be superficial, >10mm in diameter when 
measured by a caliber 
§ Tumors must be >20mm by chest xray.  
 
II. 
Lymph nodes must be measured along its shortest axis  
§ Nodes must be >15mm by CT scan (CT must use 5mm 
cuts or smaller) 
 
III. 
Target lesions 
- 
Target lesions must be determined by each primary investigator 
- 
Baseline imaging must be completed no more than 4 weeks before 
initiation of trial 
- 
All target lesions must be measurable tumors that are easily monitored 
with reproducible repeated measurements. 
§ Maximum of 5 target lesions 
§ Maximum of 2 lesions per organ   
§ A sum of all the diameters for each target lesion is 


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recorded and monitored throughout the study forming a 
baseline sum of diameters. 
- 
All other lesions will be deemed non-target lesions.  They may be 
followed throughout the trial, but will not be incorporated into the 
baseline sum of diameters.  These non-target tumors must be 
recorded separately. 
IV. 
Imaging Modalities 
- 
All lesions must be measureable.  It is preferred to monitor each lesion 
with an imaging study if able.   
§ CT scans must be completed as IV contrast and a 5mm 
cuts. 
§ MRI may also be used. 
§ FDG-PET useful in monitoring lesions.  It should be 
combined with a CT scan for complete evaluation of 
tumors. 
C. Evaluation of Tumor Response  
- 
Tumor response of target lesions include: 
§ Complete response (CR): Disappearance of all target 
lesions.  Any pathologic lymph nodes must be <10mm 
(target or non-target nodes).  
§ Partial Response (PR): At least a 30% decrease in the 
sum of diameters for target lesions in comparison to 
baseline sum of diameters. 
§ Progressive Disease (PD): At least a 20% increase in the 
sum of diameters for target lesions.  In addition to this 
increase, the sum of diameters must increase by at least 
5mm.  The development of new lesions is also evidence 
of PD. 
§ Stable Disease (SD): Tumors neither fit criteria for PR or 
PD. 
- 
Tumor response of non-target lesions include: 
§ CR - Disappearance of all target lesions.  Any pathologic 
lymph nodes must be <10mm (target or non-target 
nodes). 
§ Non-CR/Non-PD - Persistence of one or more non-target 
lesions and maintenance of tumor marker level above the 
normal limits. 
§ PD – Unequivocal progression of existing non-target 
tumors, or the appearance of new lesions.  
- 
The primary investigator at each site will verify the presence of 
changes in target/non-target lesions.   
- 
Target lesions which shrink, and are deemed too small to measure 
should be given a default measurement of 5mm.   
- 
If target lesions have completely disappeared is should be measured 
as 0mm.   
- 
Lymph nodes may regress to <10mm but because they are still 


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measurable, the sum of diameters may never equal 0mm in the setting 
of CR when they are included as target lesions. 
- 
Please see table below regarding the Best overall response 
 
 
Target lesions 
Non-Target lesions 
New Lesions 
Overall response 
CR 
CR 
No 
CR 
CR 
Incomplete 
response/SD 
No 
PR 
PR 
Non-PD 
No 
PR 
SD 
Non-PD 
No 
SD 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
 
 
* Please refer to the complete New response evaluation criteria in solid tumours: 
Revised RECIST guidelines – version 1.1 for further details15.  
 
2. Quick Reference for iRECIST Criteria 
 
A. 
Indications: 
- The guidelines continue to recommend use of RECIST 1.1 to define 
whether tumor lesions are measurable or non-measurable and the 
principles used to determine objective tumor response are largely 
unchanged from RECIST 1.1. The concept change for iRECIST is the 
resetting the bar if RECIST 1.1 progression is followed at the next 
assessment by tumor shrinkage. 
-iRECIST defines unconfirmed progress (iUPD) on the basis of RECIST 
1.1 principles; however, iUPD requires confirmation, which is done on the 
basis of observing either a further increase in size (or in the number of 
new lesions) in the lesion category in which progression was first identified 
in (ie, target or non-target disease), or progression (defined by RECIST 
1.1) in lesion categories that had not previously met RECIST 1.1 
progression criteria. However, if progression is not confirmed, but instead 
tumor shrinkage occurs (compared with baseline), which meets the criteria 
of iCR, iPR, or iSD, then the bar is reset so that iUPD needs to occur 
again (compared with nadir values) and then be confirmed (by further 
growth) at the next assessment for iCPD to be assigned. If no change in 
tumor size or extent from iUPD occurs, then the time point response would 
again be iUPD. This approach allows atypical responses, such as delayed 
responses that occur after pseudoprogression, to be identified, further 


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understood, and better characterized. 
-However, many aspects of new lesion assessment are unique to 
iRECIST. If a new lesion is identified (thus meeting the criteria for iUPD) 
and the patient is clinically stable, treatment should be continued. New 
lesions should be assessed and categorized as measurable or non-
measurable using RECIST 1.1 principles.  
-The algorithm for patients with no previous iUPD is identical to RECIST 
1.1. For patients with iUPD at the last timepoint response, the next 
timepoint response is dependent on the status of all lesions, including 
target, non-target, new lesion target, and new lesion non-target; on 
whether any increase in size has occurred (either a further increase in size 
or a sufficient increase to assign a new iUPD if the criteria were not 
previously met); or the appearance of additional new lesions. 
 
B. 
Identification of tumors, refer to RECIST 1.1 
 
C. 
Assignment of time point response using iRECIST26 
 
Time point 
response with 
no previous 
iUPD in any 
category 
Time point response with 
previous iUPD in any 
category * 
Target lesions: iCR; non-target 
lesions: iCR; new lesions: no  
iCR 
iCR 
Target lesions: iCR; non-target 
lesions: non-iCR/non-iUPD; 
new lesions: no  
iPR 
iPR 
Target lesions: iPR; non-target 
lesions: non-iCR/non-iUPD; 
new lesions: no  
iPR 
iPR 
Target lesions: iSD; non-target 
lesions: non-iCR/non-iUPD; 
new lesions: no  
iSD 
iSD 
Target lesions: iUPD with no 
change, or with a decrease 
from last timepoint; non-target 
lesions: iUPD with no change, 
or decrease from last 
timepoint; new lesions: yes  
Not Applicable 
New lesions confirm iCPD if new 
lesions were previously identified 
and they have increased in size (≥5 
mm in sum of measures for new 
lesion target or any increase for new 
lesion non-target) or number; if no 
change is seen in new lesions (size 
or number) from last timepoint, 
assignment remains iUPD  
Target lesions: iSD, iPR, iCR; 
non-target lesions: iUPD; new 
lesions: no  
iUPD 
Remains iUPD unless iCPD is 
confirmed on the basis of a further 
increase in the size of non-target 
disease (does not need to meet 
RECIST 1.1 criteria for unequivocal 
progression)  
Target lesions: iUPD; non-
target lesions: non-iCR/non-
iUPD, or iCR; new lesions: no  
iUPD 
Remains iUPD unless iCPD is 
confirmed on the basis of a further 
increase in sum of measures ≥5 mm; 


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otherwise, assignment remains iUPD  
Target lesions: iUPD; non-
target lesions: iUPD; new 
lesions: no  
 
iUPD 
Remains iUPD unless iCPD is 
confirmed based on a further 
increase in previously identified 
target lesion iUPD in sum of 
measures ≥5 mm or non-target 
lesion iUPD (previous assessment 
need not have shown unequivocal 
progression)  
Target lesions: iUPD; non-
target lesions: iUPD; new 
lesions: yes  
 
iUPD 
Remains iUPD unless iCPD is 
confirmed on the basis of a further 
increase in previously identified 
target lesion iUPD sum of measures 
≥5 mm, previously identified non-
target lesion iUPD (does not need to 
be unequivocal), or an increase in 
the size or number of new lesions 
previously identified  
Target lesions: non-iUPD or 
progression; non-target 
lesions: non-iUPD or 
progression; new lesions: yes  
iUPD 
Remains iUPD unless iCPD is 
confirmed on the basis of an 
increase in the size or number of 
new lesions previously identified  
Target lesions, non-target lesions, and new lesions defined according to RECIST 1.1 
principles; if no pseudoprogression occurs, RECIST 1.1 and iRECIST categories for 
complete response, partial response, and stable disease would be the same. *Previously 
identified in assessment immediately before this timepoint. “i” indicates immune responses 
assigned using iRECIST. iCR=complete response. iPR=partial response. iSD=stable 
disease. iUPD=unconfirmed progression. non-iCR/non-iUPD=criteria for neither CR nor PD 
have been met. iCPD=confirmed progression. RECIST=Response Evaluation Criteria in 
Solid Tumors. 
 
 
* Please refer to the complete Guidelines for iRECIST.26   
 
 
 
 
 
 
 
 
 


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Appendix C 
 
NCI Common Terminology Criteria for Adverse Events, v4.03 
 
obtained from http://ctep.cancer.gov/forms/CTCAEv4.03.pdf 
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06 14_QuickReference_8.5x11.pdf 
 


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Appendix D- Study Timeline 
 


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Appendix E - Protocol Schedule 
 
 
CLINIC VISIT 
 
PROCEDURES 
 
TOTAL 
Visit # 
Time Req     
(hr) 
 
Time Point 
 
Purpose 
 
Screeni
ng 
 
History 
Nursing 
Visit 
 
UPT 
Blood 
Draws 
Inoculation 
# of Shots 
This Visit 
Time for 
Inoc + 
Follow-Ups 
1 
2 
Pre-treatment 
 
Consent/Tissue Procurement 
Gather Baseline Data 
 
x 
x 
x 
x 
 
 
0 
N/A 
2 
2 
Baseline 
 
Consent/Randomization & Treatment 
Neupogen Injection 
Gather Current Baseline Data 
 
x 
x 
x 
x 
 
X 
(Neupogen 
injection) 
1 
N/A 
3 
1 
Baseline 
Draw Blood to Obtain Dendritic Cells 
 
 
x 
x 
 
x 
 
0 
N/A 
 
START PRE-INOCULATION BLOOD DRAWS AND ADMINISTRATION OF INOCULATIONS 
4 
1 
Starting Time 
Point 
Draw blood for Immunologic Sample R0 
Administer Inoculation #1 
 
x 
x 
x 
x 
x 
2 
 
1 hr  
5 
1 
Week 4 
+ 1 week 
Draw blood to record immunologic levels pre-
inoculation #2  
Administer Inoculation #2 
 
x 
x 
x 
x 
x 
2 
 
1 hr  
6 
1 
Week 8 
+ 1 week 
Draw blood to record immunologic levels pre-
inoculation #3 
Administer Inoculation #3 
 
x 
x 
x 
x 
x 
2 
 
1 hr  
7 
1 
Week 12 
+ 1 week 
Draw blood to record immunologic levels pre-
inoculation #4 
Administer Inoculation #4 
 
x 
x 
x 
x 
x 
2 
1 hr 
 
START PRE-BOOSTER BLOOD DRAWS AND ADMINISTRATION OF BOOSTERS 
8 
1 
Month 6 from 
Starting Time 
Point (+2 weeks) 
Draw blood to record immunologic levels pre-booster 
#1 
Administer Booster #1 
 
x 
x 
x 
x 
x 
2 
 
1 hr 
9 
1 
Month 9 
(+ 2 weeks) 
Draw blood to record immunologic levels pre-booster 
#2 
Administer Booster #2 
 
x 
x 
x 
x 
x 
2 
1 hr 
10 
1 
Month 12 
(+2 weeks) 
Draw Blood for final Immunologic Sample 
Final Study Assessment 
 
x 
x 
x 
x 
 
0 
1 hr 
Total Number of Visits:10 /Total Number of Inoculation Visits:  7 (1 Neupogen injection, 6 vaccines)/Total Number of Blood Draws: 8 (1 for dendritic cells, 6 prior to inoculation, 1 at end 
of study) 


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Appendix F 
 
Data Safety Monitoring Plan 
 
This is a free standing document 
 
 


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Appendix G 
Adverse Events Reporting Algorithm 
 
 
 
 
 


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Appendix H 
 
MedWatch FDA Form 3500 Link 
 
 
http://www.fda.gov/downloads/Safety/MedWatch/DownloadForms/ucm082728.pdf 
 
 
 
 
 
 
 


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Appendix I 
 
PROTOCOL TITLE:  
 
 
STUDY DRUG:  
Autologous tumor lysate (TL) + yeast cell wall   
particles (YCWP) + dendritic cells (DC) 
 
PRINCIPAL INVESTIGATOR:  
 
 
PROGRAM DIRECTOR:  
George E. Peoples, MD, FACS 
 
PROTOCOL VERSION/DATE:  2.0/23 June 2017 
 
INVESTIGATOR’S AGREEMENT / INVESTIGATOR’S SIGNATURE PAGE 
I have read the protocol described above. I have fully discussed the objectives of 
this trial and the content of this protocol with the Sponsor or Sponsor’s 
representative. I understand that the information in this protocol is confidential 
and should not be disclosed, other than to those directly involved in the execution 
or the ethical review of the trial, without written authorization from Cancer InCITe. 
It is, however, permissible to provide information to a patient in order to obtain 
consent.  I agree to conduct this trial according to the protocol and to comply with 
its requirements, subject to ethical and safety considerations and guidelines, and 
to conduct the trial in accordance with all applicable regulations, and guidelines 
as stated in the protocol and other information supplied to me. I understand that 
the Sponsor may decide to suspend or prematurely terminate the trial at any 
time, for whatever reason. Such a decision will be communicated to me in 
writing. Conversely, should I decide to withdraw from execution of the 
trial, I will communicate my intention immediately, in writing to the Sponsor. 
 
Signed:  
 
 
 
 
 Date:  
 
 
 
 
                       
 
Investigator’s Name and Address: