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untitled h2

Abbreviated Title: EPOCH-R + vaccine for MCL
CC Protocol #: 00-C-0133 N
NCI CTEP Protocol #: 1033 (NOTE: Protocol was completed with CTEP on 05/04/2006)
Version Date: 06/19/2019
NCT Number: NCT00005780
pilot study of idiotype vaccine
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NCI Principal Investigator: Christopher Melani, M.D.
Lymphoid Malignancies Branch (LYMB)
Center for Cancer Research (CCR)
National Cancer Institute (NCI)
National Institutes of Health (NIH)
Building 10, Room 4N115
10 Center Drive
Bethesda, MD 20892
Phone: 240-760-6057
Email: christopher.melani@nih.gov
pilot study of idiotype vaccine
investigational agents

|               |                                        |
|:--------------|:---------------------------------------|
| Drug Name:    | Id-KLH Vaccine / GM-CSF (Sargramostim) |
| IND Numbers:  | IND#: 5427 / BB IND#: 2632             |
| Sponsor:      | CTEP                                   |
| Manufacturer: | TSI Washington / Immunex               |
precis
background

Mantle cell lymphoma presents a particular clinical challenge because it is aggressive and
incurable with chemotherapy. Thus, novel treatment approaches are needed.
In follicular center cell lymphomas, another incurable disease, recent evidence suggests
that molecular complete remissions may be achieved following idiotype vaccination in
patients who have achieved minimal residual disease with combination chemotherapy.
These results suggest that idiotype vaccines may be able to induce a clinically significant
immune response against lymphoma.  
Mantle cell lymphoma presents a particular clinical challenge because it is aggressive and
incurable with chemotherapy. Thus, novel treatment approaches are needed.  
In follicular center cell lymphomas, another incurable disease, recent evidence suggests
that molecular complete remissions may be achieved following idiotype vaccination in
patients who have achieved minimal residual disease with combination chemotherapy.  
These results suggest that idiotype vaccines may be able to induce a clinically significant
immune response against lymphoma.
precis
objectives

To assess if EPOCH-R/idiotype vaccination is associated with a median progression-free
survival consistent with 36 months;
To assess if rituximab affects generation of T-cell immunity against the idiotype.
To compare T-cell immunity using two different methods of isolating the idiotype
protein.  
To assess if EPOCH-R/idiotype vaccination is associated with a median progression-free
survival consistent with 36 months;  
To assess if rituximab affects generation of T-cell immunity against the idiotype.  
To compare T-cell immunity using two different methods of isolating the idiotype
protein.
precis
eligibility

Tissue diagnosis of mantle cell lymphoma
Age 18 years.
Previously untreated with cytotoxic chemotherapy. All stages of disease.
Lymph node of 2 cm accessible for biopsy/harvest or > 1000/ul of circulating tumor
cells in the blood.
ECOG performance status <3  
Tissue diagnosis of mantle cell lymphoma  
Age 18 years.  
Previously untreated with cytotoxic chemotherapy. All stages of disease.  
Lymph node of 2 cm accessible for biopsy/harvest or > 1000/ul of circulating tumor
cells in the blood.  
ECOG performance status <3
precis
design

In the present study, we propose to investigate the efficacy of idiotype vaccine treatment
in previously untreated patients with mantle cell lymphomas. In order to achieve
minimal residual disease, patients will receive 6 cycles EPOCH chemotherapy and
rituximab (EPOCH-R) followed by 5 idiotype vaccine injections.  
This study has completed accrual of 26 patients and is only open for follow-up.  
2
table of contents
design

PRÉCIS  
2  
TABLE OF CONTENTS  
3  
1.
INTRODUCTION  
1.1
Study Objectives  
1.2
Background and Rationale  
2.  
5  
5  
5  
ELIGIBILITY ASSESSMENT AND ENROLLMENT ELIGIBILITY CRITERIA  
9  
2.1
Eligibility Criteria  
9  
2.2
Screening Evaluation  
9  
2.3
Registration Procedures  
10  
3.
STUDY IMPLEMENTATION  
10  
3.1
Study Design  
10  
3.2
Vaccine Administration  
12  
3.3
Treatment Modifications  
12  
3.4
On Study Evaluations  
13  
3.5
Criteria for Removal from Protocol Therapy and Off-Study Criteria  
15  
15  
4.
SUPPORTIVE CARE  
4.1
Pneumocystis Jiroveci  
15  
4.2
Tumor Lysis Syndrome (Cycle 1 only)  
16  
5.
BIOSPECIMEN COLLECTION  
16  
5.1
Correlative Studies  
16  
5.2
Sample Storage, Tracking and Disposition  
18  
5.3
Genetic/Genomic Analysis  
18
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6. data collection and evaluation

19  
6.1
Data Collection  
19  
6.2
Data Sharing Plan  
20  
6.3
Response criteria  
20  
6.4
Toxicity Criteria  
21
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7. nih reporting requirements/data and

21  
21  
7.1
Definitions  
7.2
OHSRP Office of Compliance and Training / IRB Reporting  
21  
21  
7.3
NCI Clinical Director Reporting  
3  
7.4  
IND Sponsor Reporting Criteria  
21  
7.5  
Data and Safety Monitoring Plan  
21  
8.  
STATISTICAL CONSIDERATIONS  
22  
9.  
COLLABORATIVE AGREEMENTS  
23  
9.1  
Materials Transfer Agreement: Biovest International  
23  
9.2  
Material Transfer Agreement: Adaptive Biotech  
24  
10.
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human subjects protections

10.1  
24  
24  
Rationale for Subject Selection  
10.2
Participation of Subjects Unable to Give Consent  
24  
10.3
Evaluation of Benefits and Risks/Discomforts  
25  
10.4
Risk/Benefit Analysis  
25  
10.5
Consent Process and Documentation  
26  
PHARMACEUTICAL INFORMATION  
26  
11.  
11.1
EPOCH-Rituximab  
26  
12.  
30  
REFERENCES  
32  
13.  
APPENDICES  
32  
13.1
APPENDIX 1: PROCEDURES FOR STORED SPECIMENS  
4
table of contents
1.1 study objectives

1.1.1 Primary
To assess if EPOCH-R followed by idiotype vaccination is associated with a median
progression-free survival (PFS) consistent with 36 months
To assess if idiotype vaccine will generate a tumor specific T cell response
1.1.2 Secondary
To assess the response rate and toxicity of EPOCH-R in previously untreated mantle cell
lymphoma
To assess the use of molecular markers of mantle cell lymphoma, including PCR-based
methodologies for detection of bcl-1 and IgH rearrangements
To obtain cDNA microarray profiling of untreated mantle cell lymphomas
To determine overall and progression-free survival
1.1.3 Exploratory
To explore molecular and genomic studies that may predict response and outcomes  
1.1.1 Primary  
To assess if EPOCH-R followed by idiotype vaccination is associated with a median
progression-free survival (PFS) consistent with 36 months  
To assess if idiotype vaccine will generate a tumor specific T cell response  
1.1.2 Secondary  
To assess the response rate and toxicity of EPOCH-R in previously untreated mantle cell
lymphoma  
To assess the use of molecular markers of mantle cell lymphoma, including PCR-based
methodologies for detection of bcl-1 and IgH rearrangements  
To obtain cDNA microarray profiling of untreated mantle cell lymphomas  
To determine overall and progression-free survival  
1.1.3 Exploratory  
To explore molecular and genomic studies that may predict response and outcomes
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1.2 background and rationale

1.2.1
Mantle cell lymphoma  
In the 1980's, Weisenburger and Palutke described atypical small lymphoid cells in the mantle
surrounding the benign germinal center that they named mantle zone lymphoma (MCL)(1). The
cytology of MCL consists of monotonous population of atypical small to medium-size lymphoid
cells with indented nuclei, and scant cytoplasm. Histologically, the cells may range from those
with predominantly round nuclei or slight nuclear irregularity to those with markedly angulated
and cleaved nuclei. In 20 % of cases, MCL can present as "anaplastic centrocyte" or blastic
variant (2). The MCL phenotype corresponds to that of a monoclonal B cell, CD19, CD20,
CD22, CD 24, IgM, IgD positive, with co-expression of IgG in 20% and monoclonal lambda
light chain in 60% of cases. Classically, the cells are CD5 positive and CD10 negative. The
blastic variant is less likely to express CD5, IgD and CD43 and may express CD10. (1-2). MCL
has a characteristic cytogenetic abnormality t(11;14)(q13; q32). The molecular counterpart
involves a translocation of the oncogene bcl-1 breakpoint into the proximity of the enhancer
region of the heavy chain gene. The putative gene has been named CCND1 and encodes for
cyclin D1 that is overexpressed in most of cases of MCL (3). The t(11; 14) can be used to
evaluate minimal residual disease by either PCR or FISH. The presence of a complex karyotype,
and hyperdyploidy has been associated with an aggressive clinical behavior.  
MCL comprises 2.5% to 4% of all NHL in USA (1-2, 4). The clinical presentation of MCL
frequently includes an elevated LDH, lymphadenopathy, B-symptoms (40%), advance stage III
or IV (90%), splenomegaly, positive BM involvement and the GI tract is involved in 20% of
cases. The clinical behavior of MCL tends to be aggressive but may vary from relatively indolent
to very aggressive. Median survival is 3 to 4 years and patients are rarely if ever cured. The  
5  
response rate varies by series, ranging from 17% to 68 % CR and 28% to 52% PR (Table
1).
Studies have shown event-free survivals ranging from 8 to 19 months, and disease free survival
ranging from 19 to 25 months, depending on the series (Table 1). Specifically, Teodorovic et al
treated 29 patients with mantle cell lymphoma using an aggressive doxorubicin-containing
regimen (5). Overall 52% achieved a complete remission and the median disease free survival
was 20 months. This was not significantly different from their PFS of 19 months.  
| Series         |   n | PR (%)   | CR (%)   | Median DFS (months)   | Median PFS (months)   |   Median Survival (months) |
|:---------------|----:|:---------|:---------|:----------------------|:----------------------|---------------------------:|
| G.A. Velders6  |  41 | ---      | 32       | 25                    | ---                   |                         24 |
| W.Hiddenmann   |  45 | 52       | 17       | ---                   | 8                     |                         28 |
| H. Somaha      | 121 | 28       | 68       | ---                   | ---                   |                         38 |
| I. Teodorovic5 |  65 | ---      | 52       | 20                    | 19                    |                         45 |
| E. Zucca9      |  26 | ---      | 50       | 19                    | ---                   |                         33 |
| J. Armitage 10 |  83 |          |          |                       |                       |                         32 |  
Khouri et al tested an aggressive regimen of hyper-CVAD and high-dose
methotrexate/cytarabine followed by stem cell transplantation in patients with relapsed or
previously untreated mantle cell lymphoma (11). Among the 25 previously untreated patients,
the overall survival (OS) and event-free survival (EFS) at 3 years were 92% and 72%
respectively. In contrast, the EFS at 3 years was 17% in the previously treated patients.
Although the results are impressive in the untreated group, the results from the previously treated
group suggest that this combination approach can salvage few if any patients and is therefore
unlikely to be curative in the untreated group. Furthermore, other studies have shown little
evidence that high-dose treatment with transplant is potentially curative. Freedman et al treated
28 MCL patients with high-dose chemo-radiotherapy and anti-B-cell monoclonal antibody
purged autologous bone marrow transplantation (12). Twenty patients had received prior
regimens before transplant, and 8 were in first CR/PR following CHOP. Nineteen (68%)
patients relapsed at a median of 21 months, and of 8 patients in first CR/PR, 5 had relapsed.
With a median follow-up of 24 months, DFS and os were estimated to be 31% and 62%,
respectively, at 4 years, indicating that transplant cures few if any patients.  
Preliminary results with rituximab and CHOP chemotherapy suggest that, although rituximab
may increase the response rate, there is yet no evidence for prolonged response. Howard et al
reported their results of CHOP and rituximab in 40 newly diagnosed patients with mantle cell
lymphoma (13). Overall, 95% of patients responded, with 19 (48%) CR/CRu, but the median
progression-free survival was 16.2 (1.7-26.8+) months). There results show that many of the
responding patients have continued to relapse.  
Taken together, these results suggest that no approach, including aggressive chemotherapy,
monoclonal antibody/toxin and transplant, has produced a significant incidence of long-term PFS
in mantle cell lymphoma, and indicate that patients are rarely if ever cured. Thus, novel
therapeutic approaches are needed  
6
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1.2.2 epoch-r treatment

EPOCH-Rituximab (EPOCH-R) is a novel combination of chemotherapy and the CD-20
monoclonal antibody, rituximab. In a phase II trial of EPOCH alone in relapsed and refractory
non-Hodgkin's lymphomas, EPOCH produced a 74% response rate, and a 57% response rate in
patients with refractory disease (Gutierrez et al, submitted) (14). Additionally, dose-adjusted
EPOCH has produced a 73% progression-free survival at 38 months in patients with previously
untreated aggressive B-cell lymphomas (unpublished data), and a 92% complete remission rate
(15).
Recent evidence suggests that rituximab may increase the efficacy of chemotherapy. Czuczman
et al treated 40 patients with rituximab and CHOP and obtained an overall response rate of 95%
of which 55% were complete (16). Of 8 patients in this trial who achieved CR and had
pretreatment evidence of a BCL-2 translocation by PCR, 7 had no evidence post-treatment of the
BCL-2 clone by PCR, a result that is rarely achieved with CHOP alone. Furthermore, in 30
patients with aggressive B-cell lymphomas treated with rituximab and CHOP, 93% responded
and 63% were complete. Recently, we have treated 6 patients with relapsed and refractory NHL
with EPOCH-R and have observed a high rate of response (data too early). There is also
preclinical evidence that rituximab and chemotherapy are synergistic. Based on these findings,
we project that EPOCH-R can achieve at least 80% CR/CRu in previously untreated patients
with mantle cell lymphomas.  
EPOCH-Rituximab (EPOCH-R) is a novel combination of chemotherapy and the CD-20
monoclonal antibody, rituximab. In a phase II trial of EPOCH alone in relapsed and refractory
non-Hodgkin's lymphomas, EPOCH produced a 74% response rate, and a 57% response rate in
patients with refractory disease (Gutierrez et al, submitted) (14). Additionally, dose-adjusted
EPOCH has produced a 73% progression-free survival at 38 months in patients with previously
untreated aggressive B-cell lymphomas (unpublished data), and a 92% complete remission rate
(15).  
Recent evidence suggests that rituximab may increase the efficacy of chemotherapy. Czuczman
et al treated 40 patients with rituximab and CHOP and obtained an overall response rate of 95%
of which 55% were complete (16). Of 8 patients in this trial who achieved CR and had
pretreatment evidence of a BCL-2 translocation by PCR, 7 had no evidence post-treatment of the
BCL-2 clone by PCR, a result that is rarely achieved with CHOP alone. Furthermore, in 30
patients with aggressive B-cell lymphomas treated with rituximab and CHOP, 93% responded
and 63% were complete. Recently, we have treated 6 patients with relapsed and refractory NHL
with EPOCH-R and have observed a high rate of response (data too early). There is also
preclinical evidence that rituximab and chemotherapy are synergistic. Based on these findings,
we project that EPOCH-R can achieve at least 80% CR/CRu in previously untreated patients
with mantle cell lymphomas.
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1.2.3 idiotype vaccine

Studies in experimental animals and patients have demonstrated the utility of the Ig idiotype as a
tumor-specific antigen for the treatment of B-cell lymphoma (17) Eisen and co-workers first
demonstrated that active immunization against idiotypic determinants on malignant B cells
produced resistance to tumor growth in syngeneic mice (18). Since that time, the phenomenon of
idiotype-specific tumor resistance, as well as specific anti-tumor therapy against established
tumors, has been reproduced in a number of animal models (19-25). These results, taken
together, provided the rationale for testing autologous tumor-derived idiotypic surface Ig (Id) as
a
therapeutic "vaccine" against human B-cell lymphoma  
In a series of laboratory and clinical studies, Kwak at et. have shown the feasibility of an
idiotype vaccine strategy (26-29). Clinical experience by the Kwak laboratory revealed the
induction of particularly potent anti-idiotypic immunity by the addition of free GM-CSF to the
Id-KLH formulation as an adjuvant. Furthermore, this effect was dependent on the selective
activation of the T-cell arm of the immune response. Results in a subsequent, larger clinical trial
of Id vaccination in-patients with follicular lymphoma receiving standard dose chemotherapy
(96-C-0133) have confirmed the potency of this cytokine adjuvant in humans. Specifically, 42
previously untreated patients with follicular lymphoma have first been treated with modified
ProMACE chemotherapy to induce a minimal residual disease state (complete or partial
remission). Twenty patients have subsequently received a series of five monthly subcutaneous
vaccinations with autologous Ig-KLH, together with locally administered free GM-CSF (patients
are randomized to receive either 500 or 100 mcg/m2)(30). In contrast to the previous study, local
reactions characterize by erythema and induration (at least 8 cm) have been consistently
observed at the vaccination sites of all patients, starting with the second vaccination sites of all
patients, starting with the second vaccination in the series. These local reactions were
subsequently reproduced at distant sites by a challenge with unconjugated autologous Ig alone
(without KLH), but not with GM-CSF alone, suggesting that a significant component of this  
7  
response is directed against the autologous Ig. In five of six patients formally tested, this
response was specific for the individual idiotype, as demonstrated by lack of a reaction to a
control, isotype-matched, Ig. These early results provide convincing in vivo evidence that it is
possible to induce a specific immune response against a self-tumor antigen and that GM-CSF is a
potent immune stimulant in human patients. Moreover, CD8+ T cell responses to autologous
tumor were demonstrated in 95% (19/20) of patients (31).  
An important and unanswered question is the impact of rituximab on the generation of a T-cell
response to the idiotype vaccine. This is of practical clinical importance because of the
increasing use of rituximab with chemotherapy by treating physicians, as well as of scientific
importance. For vaccines which primarily produce an antibody response, there is a concern that
rituximab may abrogate the immunological response. However, for vaccines which generate a
T-cell response, such as the idiotype vaccine in the present study, recent evidence suggests that
rituximab could increase the T-cell response to the vaccine. Elegant experimental evidence in
mice has shown that depleting the host of B cells may actually INCREASE anti-tumor immunity
elicited by vaccines (32). Specifically, in a murine tumor model, immunization with irradiated
tumor cells produced only a humoral response which was non-protective. However, this same
vaccination strategy in B-cell deficient mice (genetically engineered knock-out mice) produced
potent T-cell mediated protective anti-tumor immunity. The conclusion from these experiments
was that the presence of B cells in the priming phase results in disabled CD4+ T-cell help for
CD8+, CTL-mediated tumor immunity.
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1.2.4 summary

In light of these observations, the current protocol will evaluate the effect of anti-idiotypic
vaccination on the generation of a T cell-based vaccine response after treatment with EPOCH-R
chemotherapy using two different methods of idiotype isolation and scale-up. The clinical
endpoint of the trial will be to determine if patients on this trial have at least a median PFS of 36
months. Clinically, we consider achieving a PFS of 36 months to represent a significant
improvement over standard treatment which has been reported to produce a median PFS of 18
months at the longest.  
8
2. eligibility assessment and enrollment
2.1 eligibility criteria

2.1.1 Inclusion  
2.1.1.1
Tissue diagnosis of mantle cell lymphoma (confirmed in Laboratory of Pathology).
Blastic cell variant will be eligible.
2.1.1.2
Age > 18 years.
2.1.1.3 Previously untreated with cytotoxic chemotherapy. Patients may have received
local radiation or a short course of steroids for control of symptoms.
2.1.1.4
All stages of disease.
2.1.1.5 Lymph node of 2 cm accessible for biopsy/harvest or > 1000/ul of circulating
tumor cells in the blood.
2.1.1.6
ECOG performance status 3.
2.1.1.7 Adequate major organ function (serum creatinine 1.5 mg/dl or creatinine clearance
> 60 ml/min; bilirubin < 2 mg/dl (total) except < 5 mg/dl in patients with Gilbert's
syndrome as defined by > 80% unconjugated; ANC > 1000 and platelets > 100,000)
unless impairment due to organ involvement by lymphoma.
2.1.1.8
No active symptomatic ischemic heart disease, myocardial infarction or congestive
heart failure within the past year. If MUGA is obtained, the LVEF should exceed
40%.
2.1.1.9 Ability to give informed consent.
2.1.2 Exclusion
2.1.2.1
Antibodies to HIV or presence of hepatitis B surface antigen.
2.1.2.2
Pregnant or lactating.
2.1.2.3
Prior malignancy in past 5 years except squamous or basal cell carcinoma or
curatively treated in situ of the cervix.
2.1.2.4 Involvement of central nervous system by lymphoma.
2.2
SCREENING EVALUATION
2.2.1
Complete History and Physical examination.
2.2.2 CBC, differential, PT, PTT, SGOT, SGPT, LDH, alkaline phosphatase, bilirubin,
albumin, calcium, Phosphate, uric acid, creatinine (24 hour creatinine clearance if serum
creatinine > 1.5 mg/dl), electrolytes, urinalysis.
2.2.3 HIV antibody and hepatitis B surface antigen.
2.2.4 HCG (urine) in women of childbearing potential.
2.2.5 Electrocardiogram.
2.2.6 Staging: Chest x-ray, CT scan of chest, abdomen and pelvis; colonoscopy if not
performed in previous 2 months; SPECT gallium as indicated.  
2.1.1.1
Tissue diagnosis of mantle cell lymphoma (confirmed in Laboratory of Pathology).
Blastic cell variant will be eligible.  
2.1.1.2
Age > 18 years.  
2.1.1.3 Previously untreated with cytotoxic chemotherapy. Patients may have received
local radiation or a short course of steroids for control of symptoms.  
2.1.1.4
All stages of disease.  
2.1.1.5 Lymph node of 2 cm accessible for biopsy/harvest or > 1000/ul of circulating
tumor cells in the blood.  
2.1.1.6
ECOG performance status 3.  
2.1.1.7 Adequate major organ function (serum creatinine 1.5 mg/dl or creatinine clearance
> 60 ml/min; bilirubin < 2 mg/dl (total) except < 5 mg/dl in patients with Gilbert's
syndrome as defined by > 80% unconjugated; ANC > 1000 and platelets > 100,000)
unless impairment due to organ involvement by lymphoma.  
2.1.1.8
No active symptomatic ischemic heart disease, myocardial infarction or congestive
heart failure within the past year. If MUGA is obtained, the LVEF should exceed
40%.  
2.1.1.9 Ability to give informed consent.  
2.1.2 Exclusion  
2.1.2.1
Antibodies to HIV or presence of hepatitis B surface antigen.  
2.1.2.2
Pregnant or lactating.  
2.1.2.3
Prior malignancy in past 5 years except squamous or basal cell carcinoma or
curatively treated in situ of the cervix.  
2.1.2.4 Involvement of central nervous system by lymphoma.  
2.2
SCREENING EVALUATION  
2.2.1
Complete History and Physical examination.  
2.2.2 CBC, differential, PT, PTT, SGOT, SGPT, LDH, alkaline phosphatase, bilirubin,
albumin, calcium, Phosphate, uric acid, creatinine (24 hour creatinine clearance if serum
creatinine > 1.5 mg/dl), electrolytes, urinalysis.  
2.2.3 HIV antibody and hepatitis B surface antigen.  
2.2.4 HCG (urine) in women of childbearing potential.  
2.2.5 Electrocardiogram.  
2.2.6 Staging: Chest x-ray, CT scan of chest, abdomen and pelvis; colonoscopy if not
performed in previous 2 months; SPECT gallium as indicated.  
9  
2.2.7 Head CT and lumbar puncture with cytology as clinically indicated.
2. eligibility assessment and enrollment
2.3 registration procedures

Authorized staff must register an eligible candidate with NCI Central Registration Office (CRO)
within 24 hours of signing consent. A registration Eligibility Checklist from the web site
(http://home.ccr.cancer.gov/intra/eligibility/welcome.htm). must be completed and sent via
encrypted email to: NCI Central Registration Office incicentralregistration-1@mail.nih.gov.
After confirmation of eligibility at Central Registration Office, CRO staff will call pharmacy to
advise them of the acceptance of the patient on the protocol prior to the release of any
investigational agents. Verification of Registration will be forwarded electronically via e-mail to
the research team. A recorder is available during non-working hours.
2. eligibility assessment and enrollment
3.1 study design

3.1.1 Summary
Patients will receive 6 cycles of EPOCH-R. All patients will receive idiotype vaccine regardless
of their response to EPOCH-R unless they require non-protocol chemotherapy or radiation
between completion of EPOCH-R and beginning of vaccination. If patients require
chemotherapy during vaccination, vaccination will be stopped. The decision to begin non-
protocol chemotherapy or radiation will be made by the PI based on good medical practice;
generally, major organ system compromise or the presence of systemic symptoms are reasons to
begin treatment. Vaccination will begin when the vaccine is available following a minimum of
12 weeks after completion of EPOCH-R.
2. eligibility assessment and enrollment
3.1.2 epoch-r administration

Infusional agents are administered via central venous access, and cycles are repeated every 21
days. Dose adjustment: To provide optimal dose intensity, doses will be adjusted based on the
level of hematopoietic toxicity as follows:  
a. Neutrophil  
Nadir ANC on previous cycle
Dose Level
>500/mm3
Escalate one level  
10  
<500/mm3 < 2 measurements¹
No change
<500/mm3 3 measurements
Reduce one level
2. eligibility assessment and enrollment
note 'measurements based on twice

If both unacceptable neutropenia and thrombocytopenia occur, use the lower of the two dose
level reduction options. If the patient has extensive bone marrow involvement at the start of
therapy, the responsible physician has the option not to attenuate drug doses for unacceptable
durations of neutropenia.  
Dose Level 1:  
Doxorubicin: 10 mg/m2/day CIV days 1-4 (96 hours).
Etoposide: 50 mg/m2/day CIV days 1-4 (96 hours).
Vincristine 0.4 mg/m2/day CIV days 1-4 (96 hours).
Cyclophosphamide: 750 mg/m² IV day 5 after infusions.
Prednisone 60 mg/m2 P.O. bid days 1-5.
Rituximab 375 mg/m2 IV day 1 immediately before infusions.
Filgrastim 300 ug/day SC day 6 to post-nadir AGC >5, 000/mm³.
2. eligibility assessment and enrollment
table of doses per level

| Drugs                        | -2   | -1   | 1   | 2   | 3    | 4    | 5     | 6     |
|:-----------------------------|:-----|:-----|:----|:----|:-----|:-----|:------|:------|
|                              |      |      |     |     |      |      |       |       |
| Doxorubicin (mg/m2/day)      | 10   | 10   | 10  | 12  | 14.4 | 17.3 | 20.7  | 24.8  |
| Etoposide (mg/m2/day)        | 50   | 50   | 50  | 60  | 72   | 86.4 | 103.7 | 124.4 |
| Cyclophosphamide (mg/m2/day) | 480  | 600  | 750 | 900 | 1080 | 1296 | 1555  | 1866  |  
Escalation on subsequent dose levels: Doses of doxorubicin, etoposide, and
cyclophosphamide increased by 20% over the immediate preceding level.
Dose Level (-1)(mg/m2/day): 20% reduction of cyclophosphamide alone from level I
(cyclophosphamide 600 mg/m2); other drug doses unchanged.
Reduction on subsequent dose levels: Dose of cyclophosphamide reduced by 20%
over the immediate preceding level.
Duration of therapy: Patients will receive 6 cycles.  
Escalation on subsequent dose levels: Doses of doxorubicin, etoposide, and
cyclophosphamide increased by 20% over the immediate preceding level.  
Dose Level (-1)(mg/m2/day): 20% reduction of cyclophosphamide alone from level I
(cyclophosphamide 600 mg/m2); other drug doses unchanged.  
Reduction on subsequent dose levels: Dose of cyclophosphamide reduced by 20%
over the immediate preceding level.  
Duration of therapy: Patients will receive 6 cycles.  
11
2. eligibility assessment and enrollment
3.2.1 vaccine preparation

Two different methods of idiotype isolation and scale-up will be employed in the vaccine
manufacture process. The first 13 patients will receive vaccine produced by the somatic
hybridization technique (accrual completed) and the second 13 patients will receive vaccine
produced by the recombinant method.
2. eligibility assessment and enrollment
3.2.2 vaccine administration

Patients will receive a series of 5 Id/KLH vaccinations [0.5 mg tumor-derived Ig conjugated to
KLH] beginning 12 weeks (or at such later time, up to 12 months, that the Id vaccine becomes
available) after completion (i.e. designated as day 21 of last cycle) of EPOCH-R on the schedule
outlined in this section. If patients have progressive disease that requires chemotherapy
treatment before or while receiving vaccination, vaccination will either not begin or will be
stopped.
2. eligibility assessment and enrollment
3.2.3 schedule

Id/KLH vaccine and GM-CSF will be administered subcutaneously on the following schedule:  
Day 0:
Id-KLH 0.5 mg S.C.
Days 0, 1, 2, 3
GM-CSF 100 ug/m2/d S.C.  
Day 0:
Id-KLH 0.5 mg S.C.  
Days 0, 1, 2, 3
GM-CSF 100 ug/m2/d S.C.  
Injection sites are rotated between upper and lower extremities. Each dose of vaccine or GM-
CSF is split equally between the two upper or lower extremities. GM-CSF injection is to be
given in close proximity (<5 cm) to the Id/KLH injection site. However, if local reactions to
GM-CSF are severe, GM-CSF injections may be given elsewhere. Patients will be observed in
the clinic for two hours following Id-KLH and/or GM-CSF administration with vital signs taken
before injection and every 30 minutes. Non-steroidal anti-inflammatory drugs and/or steroids
should be avoided. Use lymphoma vaccine vital sign sheet. Any local skin reactions will be
carefully noted and scored for erythema, induration, pain and disruption of the barrier surface.
We will only follow reactions X 4 days while patients are at NIH. If any patient has a reaction
suggestive of sensitization, the vaccine may be split into its component parts; specifically, the
patient will be tested with Id-KLH alone and then GM-CSF alone. Toxicities will be graded
according to the NCI CTC version 2.0 at http://ctep.info.nih.gov.
2. eligibility assessment and enrollment
3.3.1 epoch-r

EPOCH dose reductions: Adjustments based on nadir as outlined in Section 3.1.2.
Adjustment based on day 1 counts: If the ANC < 1000/mm³ or platelets < 75K on day
one of the next cycle, treatment should be delayed by up to 1 week until recovery
above these levels with treatment at the last administered dose level. If treatment is
deferred due to low ANC, filgrastim 300ug/day may be administered; note that
filgrastim should be stopped at least 24 hours before restarting EPOCH. If the counts
do not recover by 1 week, reduce EPOCH by one dose level when counts recover.
However, if the delayed recovery is felt to be secondary to bone marrow disease, the
patient may be treated with reduced counts at the discretion of the principal
investigator.  
12  
Rituximab: Side effects of rituximab may be infusion rate related and may be reduced
by slower administration or premedication. Thus, dose reductions of rituximab will
not be made. Rituximab will be discontinued for the duration of the cycle in patients
with grade 4 allergic reactions. At the discretion of the PI, rituximab may be
administered on the following cycles using slower infusion rates and pretreatment
with benadryl and prednisone using standard medical practice.
Ileus: All patients should receive stool softeners as indicated to prevent constipation
during EPOCH-R. Occasionally, symptomatic ileus may occur and this should be
treated with a vincristine dose reduction. Because the degree of ileus may vary and be
affected by comorbid events, dose reductions will be based on good medical practice.
Generally, a dose reduction of 25% will result in abrogation of the ileus. The
vincristine dose may be increased back to full dose if symptoms of ileus do not occur
following a dose reduction, based on good medical practice.
Neurological toxicity:  
Rituximab: Side effects of rituximab may be infusion rate related and may be reduced
by slower administration or premedication. Thus, dose reductions of rituximab will
not be made. Rituximab will be discontinued for the duration of the cycle in patients
with grade 4 allergic reactions. At the discretion of the PI, rituximab may be
administered on the following cycles using slower infusion rates and pretreatment
with benadryl and prednisone using standard medical practice.  
Ileus: All patients should receive stool softeners as indicated to prevent constipation
during EPOCH-R. Occasionally, symptomatic ileus may occur and this should be
treated with a vincristine dose reduction. Because the degree of ileus may vary and be
affected by comorbid events, dose reductions will be based on good medical practice.
Generally, a dose reduction of 25% will result in abrogation of the ileus. The
vincristine dose may be increased back to full dose if symptoms of ileus do not occur
following a dose reduction, based on good medical practice.  
Neurological toxicity:  
| Toxicity   |   Grade | Vincristine Dose   |
|:-----------|--------:|:-------------------|
| Sensory    |       3 | 75%                |
|            |       4 | 50%                |
| Motor      |       2 | 75%                |
|            |       3 | 0%                 |
2. eligibility assessment and enrollment
3.3.2 gm-csf

Fever: Grade 1-3 fever/chills associated with vaccine and/or GM-CSF administration is
treated with acetaminophen and/or meperidine. For grade 4 fever unresponsive to
Acetaminophen, hold GM-CSF until < grade 2, and restart at 50% of original dose for
remainder of injections.
Neurologic toxicity: For grade 2-3, hold treatment until symptoms resolved, and then
restart at 50% of original dose for remainder of injections. If toxicity recurs or persists,
or grade 4 toxicity occurs, GM-CSF will be discontinued.
Cardiac toxicity: For grade 3 likely associated with GM-CSF, discontinue GM-CSF.
Gastrointestinal: For ALT/AST > 10 X normal, hold GM-CSF until < 5 X normal, and
then restart at 50% of original dose for remainder of doses. For grade 3 vomiting
(unresponsive to therapy), hold GM-CSF until < grade 2 and then restart at 50% of
original dose for remainder of doses.  
Fever: Grade 1-3 fever/chills associated with vaccine and/or GM-CSF administration is
treated with acetaminophen and/or meperidine. For grade 4 fever unresponsive to
Acetaminophen, hold GM-CSF until < grade 2, and restart at 50% of original dose for
remainder of injections.  
Neurologic toxicity: For grade 2-3, hold treatment until symptoms resolved, and then
restart at 50% of original dose for remainder of injections. If toxicity recurs or persists,
or grade 4 toxicity occurs, GM-CSF will be discontinued.  
Cardiac toxicity: For grade 3 likely associated with GM-CSF, discontinue GM-CSF.  
Gastrointestinal: For ALT/AST > 10 X normal, hold GM-CSF until < 5 X normal, and
then restart at 50% of original dose for remainder of doses. For grade 3 vomiting
(unresponsive to therapy), hold GM-CSF until < grade 2 and then restart at 50% of
original dose for remainder of doses.
2. eligibility assessment and enrollment
3.4.1 pre-treatment

3.4.1.1
Twenty milliliters of serum for storage.  
3.4.1.2
Quantitative immunoglobulin, serum protein electrophoresis.
3.4.1.3
Lymphopheresis: 1 X 10 10 lymphocytes. Send to Dr. Kopp, Clinical Immunology
Services, NCI-FCRDC, Frederick, MD. These samples will be used for baseline
studies of T-cell response to Id.  
3.4.1.2
Quantitative immunoglobulin, serum protein electrophoresis.  
3.4.1.3
Lymphopheresis: 1 X 10 10 lymphocytes. Send to Dr. Kopp, Clinical Immunology
Services, NCI-FCRDC, Frederick, MD. These samples will be used for baseline
studies of T-cell response to Id.  
13  
3.4.1.4 Tumor biopsy- Prior to treatment, all patients must undergo a biopsy of a clinically
involved lymph node to provide material for idiotype vaccine unless tumor cells
available by apheresis. The biopsy should be at least 2 cm square in size. Bone
marrow biopsy. Five cc of marrow will be aspirated into 0.5 ml of PFH for PCR
analysis. When possible, FACS will be done on the marrow.
3.4.1.5
FACS of peripheral blood for disease detection- send 20 cc in green tops.
3.4.1.6 Lymphocyte subset analysis: Pre-treatment obtain 6 cc green top tube for FACS to
Bill Kopp
3.4.2 During EPOCH-R Cycles
3.4.2.1 Each cycle (day 1): Physical exam, CBC/differential, electrolytes, liver function,
LDH.
3.4.2.2
All treatment weeks: CBC/differential twice weekly.
3.4.2.3
End of cycle 4 and 6: Whole body CT scans. SPECT gallium, colonoscopy_and
bone marrow biopsy if positive on last exam. For cases in which the investigators
strongly suspect residual disease (e.g. abdominal masses is gallium avid), imaging-
guided needle biopsy may be performed.
3.4.2.4 Pharmacokinetics of etoposide, doxorubicin and vincristine will be drawn on all
cycles in which sampling can be obtained. Draw 5 cc green top tube at the
following times on each cycle: Time 0 (baseline); Time 22 hours (draw 2 tubes);
Time 94 hours (draw 2 tubes). Send tubes to Dr Frank Balis's laboratory in
13C118.
3.4.2.5
Lymphocyte subset analysis: Cycle 6 D21 obtain 6 cc green top tube for FACS to
Bill Kopp
3.4.2.6 FACS of peripheral blood for disease detection after cycle 4 and after cycle 6 if
positive on cycle 4- send 20 cc in green tops.
3.4.3 During Vaccine Treatment
3.4.3.1 Obtain immediately pre- (within 4 weeks of starting vaccinations) and 4 weeks
post-vaccine (after 5 vaccine treatments) tumor measurements and staging disease
sites (CT) and gallium/PET if positive on last exam. For cases in which the
investigators strongly suspect residual disease (e.g. abdominal masses is gallium
avid), image-guided needle biopsy may be performed.
3.4.3.2
Lymphocyte subset analysis: Pre and post-vaccine treatment obtain 6 cc green top
tube for FACS to Bill Kopp.
3.4.3.3
PT,PTT, UA and B2-microglobulin on day 0 of each immunization:
3.4.3.4
Five tiger top tubes of peripheral blood (60-120cc in PFH) for serum and
lymphocyte preparation, respectively, for the Clinical Immunology Service on day
0 of each the first immunization, and 2 tiger top tubes on day 0 of subsequent
immunizations.
3.4.3.5 Skin Biopsy at the discretion of the Principal Investigator. Obtain near planned
immunization site on day 0 of first immunization (baseline sample) and again on  
3.4.1.4 Tumor biopsy- Prior to treatment, all patients must undergo a biopsy of a clinically
involved lymph node to provide material for idiotype vaccine unless tumor cells
available by apheresis. The biopsy should be at least 2 cm square in size. Bone
marrow biopsy. Five cc of marrow will be aspirated into 0.5 ml of PFH for PCR
analysis. When possible, FACS will be done on the marrow.  
3.4.1.5
FACS of peripheral blood for disease detection- send 20 cc in green tops.  
3.4.1.6 Lymphocyte subset analysis: Pre-treatment obtain 6 cc green top tube for FACS to
Bill Kopp  
3.4.2 During EPOCH-R Cycles  
3.4.2.1 Each cycle (day 1): Physical exam, CBC/differential, electrolytes, liver function,
LDH.  
3.4.2.2
All treatment weeks: CBC/differential twice weekly.  
3.4.2.3
End of cycle 4 and 6: Whole body CT scans. SPECT gallium, colonoscopy_and
bone marrow biopsy if positive on last exam. For cases in which the investigators
strongly suspect residual disease (e.g. abdominal masses is gallium avid), imaging-
guided needle biopsy may be performed.  
3.4.2.4 Pharmacokinetics of etoposide, doxorubicin and vincristine will be drawn on all
cycles in which sampling can be obtained. Draw 5 cc green top tube at the
following times on each cycle: Time 0 (baseline); Time 22 hours (draw 2 tubes);
Time 94 hours (draw 2 tubes). Send tubes to Dr Frank Balis's laboratory in
13C118.  
3.4.2.5
Lymphocyte subset analysis: Cycle 6 D21 obtain 6 cc green top tube for FACS to
Bill Kopp  
3.4.2.6 FACS of peripheral blood for disease detection after cycle 4 and after cycle 6 if
positive on cycle 4- send 20 cc in green tops.  
3.4.3 During Vaccine Treatment  
3.4.3.1 Obtain immediately pre- (within 4 weeks of starting vaccinations) and 4 weeks
post-vaccine (after 5 vaccine treatments) tumor measurements and staging disease
sites (CT) and gallium/PET if positive on last exam. For cases in which the
investigators strongly suspect residual disease (e.g. abdominal masses is gallium
avid), image-guided needle biopsy may be performed.  
3.4.3.2
Lymphocyte subset analysis: Pre and post-vaccine treatment obtain 6 cc green top
tube for FACS to Bill Kopp.  
3.4.3.3
PT,PTT, UA and B2-microglobulin on day 0 of each immunization:  
3.4.3.4
Five tiger top tubes of peripheral blood (60-120cc in PFH) for serum and
lymphocyte preparation, respectively, for the Clinical Immunology Service on day
0 of each the first immunization, and 2 tiger top tubes on day 0 of subsequent
immunizations.  
3.4.3.5 Skin Biopsy at the discretion of the Principal Investigator. Obtain near planned
immunization site on day 0 of first immunization (baseline sample) and again on  
14  
days 1, 2, or 3 of immunization 3 at site of erythema and/or induration. Skin biopsy
not required for eligibility.
3.4.3.6
Fine needle aspiration or core biopsy of an enlarged lymph node draining the
vaccination sites may be performed to obtain lymphocytes for in vitro assays. FNA
or core biopsy of lymph node not required for eligibility.
3.4.3.7 FACS of peripheral blood for disease detection pre and post vaccine- send 20 cc in
green tops.
3.4.3.8 CBC with differential and Chem 20 on Day 0, 1, 2, 3 of each immunization.
3.4.3.9
Immune studies on peripheral blood at each post-vaccine follow-up- send 60 cc in
PFH and SST tubes.
3.4.4 Post-Therapy Evaluations
3.4.4.1 Following the last immunization, restage all sites of disease by CT scans q 3 months
X 4, q 6 months X 4 and yearly thereafter.
3.4.4.2
Studies at each follow-up visit: Hgb, HCT, WBC, and differential, SGOT, alkaline
phosphatase, LDH.
NOTE: These may be done less frequently at the discretion of the investigator.  
days 1, 2, or 3 of immunization 3 at site of erythema and/or induration. Skin biopsy
not required for eligibility.  
3.4.3.6
Fine needle aspiration or core biopsy of an enlarged lymph node draining the
vaccination sites may be performed to obtain lymphocytes for in vitro assays. FNA
or core biopsy of lymph node not required for eligibility.  
3.4.3.7 FACS of peripheral blood for disease detection pre and post vaccine- send 20 cc in
green tops.  
3.4.3.8 CBC with differential and Chem 20 on Day 0, 1, 2, 3 of each immunization.  
3.4.3.9
Immune studies on peripheral blood at each post-vaccine follow-up- send 60 cc in
PFH and SST tubes.  
3.4.4 Post-Therapy Evaluations  
3.4.4.1 Following the last immunization, restage all sites of disease by CT scans q 3 months
X 4, q 6 months X 4 and yearly thereafter.  
3.4.4.2
Studies at each follow-up visit: Hgb, HCT, WBC, and differential, SGOT, alkaline
phosphatase, LDH.  
NOTE: These may be done less frequently at the discretion of the investigator.
2. eligibility assessment and enrollment
3.5 criteria for removal from

3.5.1 Criteria for Removal from Protocol Therapy
Completion of protocol treatment
Inability to tolerate therapy or felt to be detrimental to the patient's health.
Patient voluntary withdrawal
Institution of or requirement for non-protocol chemotherapy
3.5.2 Off Study Criteria
Patient does not follow the instructions given by the study team
Patient voluntary withdrawal
Death
3.5.3 Off Protocol Therapy and Off-Study Procedure
Authorized staff must notify Central Registration Office (CRO) when a subject is taken off
protocol therapy and when a subject is taken off-study. A Participant Status Updates Form from
the website (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm)1 main page must be
completed and sent via encrypted email to: NCI Central Registration Office
incicentralregistration-1@mail.nih.gov.  
3.5.1 Criteria for Removal from Protocol Therapy  
Completion of protocol treatment  
Inability to tolerate therapy or felt to be detrimental to the patient's health.  
Patient voluntary withdrawal  
Institution of or requirement for non-protocol chemotherapy  
3.5.2 Off Study Criteria  
Patient does not follow the instructions given by the study team  
Patient voluntary withdrawal  
Death  
3.5.3 Off Protocol Therapy and Off-Study Procedure
Authorized staff must notify Central Registration Office (CRO) when a subject is taken off
protocol therapy and when a subject is taken off-study. A Participant Status Updates Form from
the website (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm)1 main page must be
completed and sent via encrypted email to: NCI Central Registration Office
incicentralregistration-1@mail.nih.gov.
2. eligibility assessment and enrollment
4. supportive care

4.1
PNEUMOCYSTIS JIROVECI
All patients will receive prophylaxis during EPOCH-R. Trimethoprim/sulfamethoxazole I DS  
15  
P.O bid for three consecutive days each week is preferred. Allergic patients may receive inhaled
pentamidine 300 mg once a month.
2. eligibility assessment and enrollment
4.2 tumor lysis syndrome (cycle

Patients with high tumor burden may be treated with allopurinol 600mg prior to cycle 1 EPOCH-
R followed by 300 mg daily for up to 7 days. Hospitalization with aggressive IV hydration and
urinary alkalization may be used.
2. eligibility assessment and enrollment
5. biospecimen collection

NOTE: As of Amendment L, no samples are being prospectively collected for this protocol;
however, analyses of previously collected samples are ongoing. Sections 5.1.1-5.1.7 below
represent the original collection information and analyses on the samples and are retained here
for historical purposes; Section 5.1.8 represents new analyses. In addition, subjects may be
reconsented, if required, to allow the ongoing use of their samples for future research analyses,
including genetic testing.
2. eligibility assessment and enrollment
5.1 correlative studies

5.1.1 Lymph Node Harvest/Biopsy
Lymph node biopsies will be divided approximately as follows: (a) One-quarter of the specimen
will be sent in saline or media to Dr. Elaine Jaffe, Hematopathology Section, Laboratory of
Pathology, to be processed for routine histology and for immunophenotypic characterization (i.e.
monotypic heavy and light chain expression); (b) One-quarter of the specimen will be sent in
cold saline or media to Dr. Staudt for analysis of cDNA microarray and; (c) One-half of the
specimen will be sent in sterile RPMI medium to Dr. Kwak's laboratory, NCI-FCRDC, where it
will be assigned a unique accession number. Processing into a single-cell suspension and
cryopreservation will be performed by Dr. Kwak's laboratory.
5.1.2 Peripheral Blood Harvesting
In patients with adequate circulating tumor cells (> 500 cells/ul) may have tumor cells harvested
by apheresis to obtain 500 X 106 tumor cells for production of vaccine. A small aliquot (< 10 X
106 cells) will be analyzed by FACS and cytology to confirm presence of tumor cells.
Collection of lymphocytes (> 2 X 106/kg) by apheresis will also be performed prior to beginning
EPOCH-R and prior to beginning vaccine for immunological assays. If an apheresis is done pre-
EPOCH-R for collection of tumor cells, this will also suffice for collection of lymphocytes for
immunological assays. All cells will be sent to Dr. Kwak's laboratory, NCI-FCRDC, where they
will be assigned a unique accession number. Processing and cryopreservation will be performed
by Dr. Kwak's laboratory.
5.1.3 Blood and Bone Marrow Samples
Obtain pre- and post-vaccine (within 4 weeks) unilateral bone marrow biopsy and aspirate for
assessment of minimal residual disease by pcr. Five cc of marrow will be aspirated into 0.5 ml of
PFH for PCR analysis. All peripheral blood and bone marrow aspirate samples will be sent in an
expedited manner to Clinical Immunology Services, NCI-FCRDC. Tiger top tubes will be spun
down and serum divided into 1 ml aliquots for frozen storage. Peripheral blood mononuclear
cells (PBMC) will be isolated prior to freezing by Ficoll-hypaque centrifugation using standard
protocols.  
5.1.1 Lymph Node Harvest/Biopsy  
Lymph node biopsies will be divided approximately as follows: (a) One-quarter of the specimen
will be sent in saline or media to Dr. Elaine Jaffe, Hematopathology Section, Laboratory of
Pathology, to be processed for routine histology and for immunophenotypic characterization (i.e.
monotypic heavy and light chain expression); (b) One-quarter of the specimen will be sent in
cold saline or media to Dr. Staudt for analysis of cDNA microarray and; (c) One-half of the
specimen will be sent in sterile RPMI medium to Dr. Kwak's laboratory, NCI-FCRDC, where it
will be assigned a unique accession number. Processing into a single-cell suspension and
cryopreservation will be performed by Dr. Kwak's laboratory.  
5.1.2 Peripheral Blood Harvesting  
In patients with adequate circulating tumor cells (> 500 cells/ul) may have tumor cells harvested
by apheresis to obtain 500 X 106 tumor cells for production of vaccine. A small aliquot (< 10 X
106 cells) will be analyzed by FACS and cytology to confirm presence of tumor cells.
Collection of lymphocytes (> 2 X 106/kg) by apheresis will also be performed prior to beginning
EPOCH-R and prior to beginning vaccine for immunological assays. If an apheresis is done pre-
EPOCH-R for collection of tumor cells, this will also suffice for collection of lymphocytes for
immunological assays. All cells will be sent to Dr. Kwak's laboratory, NCI-FCRDC, where they
will be assigned a unique accession number. Processing and cryopreservation will be performed
by Dr. Kwak's laboratory.  
5.1.3 Blood and Bone Marrow Samples  
Obtain pre- and post-vaccine (within 4 weeks) unilateral bone marrow biopsy and aspirate for
assessment of minimal residual disease by pcr. Five cc of marrow will be aspirated into 0.5 ml of
PFH for PCR analysis. All peripheral blood and bone marrow aspirate samples will be sent in an
expedited manner to Clinical Immunology Services, NCI-FCRDC. Tiger top tubes will be spun
down and serum divided into 1 ml aliquots for frozen storage. Peripheral blood mononuclear
cells (PBMC) will be isolated prior to freezing by Ficoll-hypaque centrifugation using standard
protocols.  
16  
5.1.4 Assessment of Immune Function
Lymphocyte subset analysis (B- and T-cells) will be assessed by FACS at the following time
points: 1. Pre-EPOCH-R; 2. Post-EPOCH-R (Cycle 6 D21); 3. Pre-Vaccine; 4. Post-vaccine.
Send 6 cc in Green Top (Sodium Heparin) to Bill Kopp (301-846-1491) as outlined above.
5.1.5 Assay for Serum Anti-Idiotypic Antibody
In a direct enzyme-linked immunoabsorbent assay (ELISA), pre-immune and hyper-immune
serum samples from each patient will be diluted over wells of a microtiter plate that are coated
with either autologous immunoglobulin idiotype or a panel of isotype-matched human tumor
immunoglobulins of unrelated idiotype. 27 Bound antibody is detected with horseradish
peroxidase-goat antihuman light-chain antibodies directed against the light chain not present in
the immunoglobulin idiotype (Caltag laboratories, South San Francisco).
5.1.6 Assay for Idiotype-Specific Proliferative Response
When feasible, fresh PBMC will be used on the same day they are obtained for analysis. 27
Stored frozen PBMC will be available as a back-up. PBMC will be washed and plated at a
concentration of 4 X 105 cells per well in Iscove's modified Dulbecco's medium (IMDM) with 1
percent human AB serum (IMDM-1 percent AB). KLH, autologous Immunoglobulin idiotype, or
a panel of isotype-matched immunoglobulins of irrelevant idiotypes at concentrations of 0 to 100
ug per milliliter in IMDM-1 percent AB preparation will be added in triplicate. After the cells
are incubated for three days at 37°C in an atmosphere containing 5 percent carbon dioxide, they
will be transferred to a preparation of IMDM and 5 percent fetal-calf serum containing
recombinant interleukin-2 (30 U per milliliter). The plates will then be incubated for two days
and pulsed for 16 to 20 hours with 3-H-labeled thymidine (1 uCi per well). Data are expressed as
mean (+SEM) counts per minute of HHthymidine incorporation. Initial five-day cultures of
PBMCs established as described above will be expanded in IMDM-5 percent fetal-calf serum
containing interleukin-2 (30 U/ml). Harvested cells will be replaced in IMDM-1 percent AB
containing autologous immunoglobulin idiotype and fresh irradiated (5000 R) autologous
PBMCs (4 X 105 cells per well) as antigen-presenting cells for five days, before pulsing with
[3H]thymidine.
5.1.7 Definition of a Positive Idiotype T-Cell Response
Procedures and definitions as outlined by Bendandi et al (30).
5.1.8 Detecting Minimal Residual Disease (MRD)
5.1.8.1 Rationale for MRD assessment
Detecting Minimal Residual Disease (MRD) can be a powerful tool to monitor patients'
response to treatment and early detection of relapse.
It is of research interest to determine if circulating tumor DNA before, during or after therapy
is predictive of long-term disease-free survival. Adaptive Biotechnologies Corp will assess
whether immune repertoire data (e.g., B-cell immunoglobulin receptor sequences) from the
Human Material can be used as biomarkers that correlate with disease-free survival.
Adaptive Biotechnologies Corp will use a proprietary method, Immune Cell Receptor
Sequencing (ICRS) platform, for amplifying and analyzing immune cell receptor sequences,
allowing unprecedented sensitivity and specificity. Data from experiments conducted by
Adaptive Biotechnologies, Corp. using the human material will be provided to NCI and such  
5.1.4 Assessment of Immune Function
Lymphocyte subset analysis (B- and T-cells) will be assessed by FACS at the following time
points: 1. Pre-EPOCH-R; 2. Post-EPOCH-R (Cycle 6 D21); 3. Pre-Vaccine; 4. Post-vaccine.
Send 6 cc in Green Top (Sodium Heparin) to Bill Kopp (301-846-1491) as outlined above.  
5.1.5 Assay for Serum Anti-Idiotypic Antibody
In a direct enzyme-linked immunoabsorbent assay (ELISA), pre-immune and hyper-immune
serum samples from each patient will be diluted over wells of a microtiter plate that are coated
with either autologous immunoglobulin idiotype or a panel of isotype-matched human tumor
immunoglobulins of unrelated idiotype. 27 Bound antibody is detected with horseradish
peroxidase-goat antihuman light-chain antibodies directed against the light chain not present in
the immunoglobulin idiotype (Caltag laboratories, South San Francisco).  
5.1.6 Assay for Idiotype-Specific Proliferative Response  
When feasible, fresh PBMC will be used on the same day they are obtained for analysis. 27
Stored frozen PBMC will be available as a back-up. PBMC will be washed and plated at a
concentration of 4 X 105 cells per well in Iscove's modified Dulbecco's medium (IMDM) with 1
percent human AB serum (IMDM-1 percent AB). KLH, autologous Immunoglobulin idiotype, or
a panel of isotype-matched immunoglobulins of irrelevant idiotypes at concentrations of 0 to 100
ug per milliliter in IMDM-1 percent AB preparation will be added in triplicate. After the cells
are incubated for three days at 37°C in an atmosphere containing 5 percent carbon dioxide, they
will be transferred to a preparation of IMDM and 5 percent fetal-calf serum containing
recombinant interleukin-2 (30 U per milliliter). The plates will then be incubated for two days
and pulsed for 16 to 20 hours with 3-H-labeled thymidine (1 uCi per well). Data are expressed as
mean (+SEM) counts per minute of HHthymidine incorporation. Initial five-day cultures of
PBMCs established as described above will be expanded in IMDM-5 percent fetal-calf serum
containing interleukin-2 (30 U/ml). Harvested cells will be replaced in IMDM-1 percent AB
containing autologous immunoglobulin idiotype and fresh irradiated (5000 R) autologous
PBMCs (4 X 105 cells per well) as antigen-presenting cells for five days, before pulsing with
[3H]thymidine.  
5.1.7 Definition of a Positive Idiotype T-Cell Response
Procedures and definitions as outlined by Bendandi et al (30).  
5.1.8 Detecting Minimal Residual Disease (MRD)  
5.1.8.1 Rationale for MRD assessment  
Detecting Minimal Residual Disease (MRD) can be a powerful tool to monitor patients'
response to treatment and early detection of relapse.  
It is of research interest to determine if circulating tumor DNA before, during or after therapy
is predictive of long-term disease-free survival. Adaptive Biotechnologies Corp will assess
whether immune repertoire data (e.g., B-cell immunoglobulin receptor sequences) from the
Human Material can be used as biomarkers that correlate with disease-free survival.
Adaptive Biotechnologies Corp will use a proprietary method, Immune Cell Receptor
Sequencing (ICRS) platform, for amplifying and analyzing immune cell receptor sequences,
allowing unprecedented sensitivity and specificity. Data from experiments conducted by
Adaptive Biotechnologies, Corp. using the human material will be provided to NCI and such  
17  
data provided by Adaptive Biotechnologies Corp to NCI may be used by NCI for any
purpose.
2. eligibility assessment and enrollment
5.1.8.2 samples to be sent

Coded, (linked) frozen or formalin fixed and paraffin embedded (FFPE) human tissue and
serum and/or plasma samples and data from select patients will be sent, if available.
2. eligibility assessment and enrollment
5.1.8.3 shipping information

Only coded (linked) samples will be shared as described below; see Section 13.1.1 for
process of sample coding, and sample request instructions. The samples and data will be
stored in the Clinical Support Laboratory, Leidos Biomedical Research, Inc. and sent in
batches to Adaptive Biotechnologies Corp at the address listed below:  
Adaptive Biotechnologies Corp.
1551 Eastlake Ave E
Suite 200
Seattle WA 98102
2. eligibility assessment and enrollment
5.2 sample storage tracking and

All specimens obtained in the protocol are used as defined in the protocol. Samples will be
ordered in CRIS and tracked through a Clinical Trial Data Management system. Should a CRIS
screen not be available, the CRIS downtime procedures will be followed. Samples will not be
sent outside NIH without IRB notification and an executed MTA.
2. eligibility assessment and enrollment
5.2.2 study completion future use

The study will remain open SO long as sample or data analysis continues. Following completion
of the planned analyses, samples will remain in storage as detailed above.  
Tissue specimens and derived tissue lysates, RNA and DNA collected in the course of this
research project may be banked and used in the future to investigate new scientific questions
related to this study that are not expressly stated in the present protocol. However, this research
may only be done if the risks of the new questions and the proposed research have undergone
prospective IRB review and approval. If new risks are associated with the research the Principal
Investigator must amend the protocol and obtain informed consent from all research subjects.  
If, at any time, a patient withdraws from the study and does not wish for their existing samples to
be utilized, the individual must provide a written request. Following receipt of this request, data
will be excluded from future distributions, but data that have already been distributed for
approved research use will not be able to be retrieved; additionally, the samples will be
destroyed.  
The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will
be per the requirements of section 7.2.
2. eligibility assessment and enrollment
5.3 genetic/genomic analysis

5.3.1
Description of the scope of genetic/genomic analysis  
18  
At any point in the analyses, normal genome could be analyzed for comparison with other testing
(e.g., cancer genome).  
5.3.2 Description of how privacy and confidentiality of medical information/biological
specimens will be maximized  
Confidentiality for genetic samples will be maintained as described (Section 5.1.8.3 and 13.1.1).
In addition, a Certificate of Confidentiality has been obtained for this study.
2. eligibility assessment and enrollment
5.3.3 management of results

Subjects will be contacted if a clinically actionable gene variant is discovered. Clinically
actionable findings for this study are defined as disorders appearing in the American College of
Medical Genetics and Genomics recommendations for the return of incidental findings that is
current at the time of primary analysis. (A list of current guidelines is maintained on the CCR
intranet: https://ccrod.cancer.gov/confluence/display/CCRCRO/Incidental+Findings+Lists).
2. eligibility assessment and enrollment
5.3.4 genetic counseling

Subjects will be contacted with a request to provide a blood sample to be sent to a CLIA
certified laboratory. If the research findings are verified in the CLIA certified lab, the subject
will be offered the opportunity to come to NIH to have genetic education and counseling to
explain this result; at the time of any such event(s), these activities will be funded by the
NCI/CCR in consideration of the specific circumstances. If the subject does not want to come
to NIH, a referral to a local genetic healthcare provider will be provided (at their expense).  
This is the only time during the course of the study that incidental findings will be returned. No
interrogations regarding clinically actionable findings will be made after the primary analysis.
2. eligibility assessment and enrollment
6.1 data collection

The PI will be responsible for overseeing entry of data into an in-house password protected
electronic system DCS clinical trials database and ensuring data accuracy, consistency and
timeliness. The principal investigator, associate investigators/research nurses and/or a contracted
data manager will assist with the data management efforts. All data obtained during the conduct
of the protocol will be kept in secure network drives or in approved alternative sites that comply
with NIH security standards. Primary and final analyzed data will have identifiers SO that
research data can be attributed to an individual human subject participant.  
All AEs, including clinically significant abnormal findings on laboratory evaluations, regardless
of severity, will be followed until return to baseline or stabilization of event. Serious adverse
events that occur more than 30 days after the last administration of investigational
agent/intervention and have an attribution of at least possibly related to the agent/intervention
should be recorded and reported.  
An abnormal laboratory value will only be considered an AE if the laboratory abnormality is
characterized by any of the following:  
Results in discontinuation from the study  
19  
Is associated with clinical signs or symptoms
Requires treatment or any other therapeutic intervention
Is associated with death or another serious adverse event, including hospitalization.
Is judged by the Investigator to be of significant clinical impact
If any abnormal laboratory result is considered clinically significant, the investigator will
provide details about the action taken with respect to the test drug and about the patient's
outcome.  
Is associated with clinical signs or symptoms  
Requires treatment or any other therapeutic intervention  
Is associated with death or another serious adverse event, including hospitalization.  
Is judged by the Investigator to be of significant clinical impact  
If any abnormal laboratory result is considered clinically significant, the investigator will
provide details about the action taken with respect to the test drug and about the patient's
outcome.  
End of study procedures: Data will be stored according to HHS, FDA regulations and NIH
Intramural Records Retention Schedule as applicable.  
Loss or destruction of data: Should we become aware that a major breach in our plan to protect
subject confidentiality and trial data has occurred, this will be reported expeditiously per
requirements in section 7.2.1.
2. eligibility assessment and enrollment
6.2 data sharing plan

6.2.1
Genomic Data Sharing Plan
Unlinked genomic data will be deposited in public genomic databases such as dbGaP in
compliance with the NIH Genomic Data Sharing Policy.
2. eligibility assessment and enrollment
6.3 response criteria

From the International Workshop to Standardize Response Criteria for non-Hodgkin's
Lymphomas. Responses must last for at least 4 weeks off respective treatment (i.e. post-EPOCH-
R and post-Id immunization).  
Complete response (CR): Complete disappearance of all detectable clinical and
radiographic evidence of disease and disappearance of all disease-related symptoms if
present before therapy, and normalization of those biochemical abnormalities (e.g. LDH)
definitely assignable to the lymphoma. All lymph nodes must have regressed to normal
size (< 1.5 cm in greatest diameter if > 1.5 cm before therapy). Previously involved
nodes that were 1.1 to 1.5 cm in greatest diameter must have decreased to < 1 cm or by
more than 75% in the sum of the products of the greatest diameters (SPD). Spleen, if
considered to be enlarge before therapy, must have regressed in size and not be palpable
on physical examination. The bone marrow must show no evidence of disease by
histology. Flow cytometric, molecular or cytogenetic studies will not be used to
determine response.
Complete response unconfirmed (CRu): As per CR criteria except that if a residual node
is > 1.5 cm, it must have regressed by > 75% in SPD. Lymphocyte aggregates within the
bone marrow must be negative for B-cell markers (e.g. L26).
Partial response: 50% decreased in SPD of 6 largest dominant nodes or nodal masses.
No increase in size of nodes, liver or spleen and no new sites of disease. Splenic and
hepatic nodules must regress by 50% in the SPD. Bone marrow is irrelevant for
determination of a PR.
Progressive disease: > 50% increase from nadir in the SPD of any previously involved
node or the appearance of any new lesion.  
Complete response (CR): Complete disappearance of all detectable clinical and
radiographic evidence of disease and disappearance of all disease-related symptoms if
present before therapy, and normalization of those biochemical abnormalities (e.g. LDH)
definitely assignable to the lymphoma. All lymph nodes must have regressed to normal
size (< 1.5 cm in greatest diameter if > 1.5 cm before therapy). Previously involved
nodes that were 1.1 to 1.5 cm in greatest diameter must have decreased to < 1 cm or by
more than 75% in the sum of the products of the greatest diameters (SPD). Spleen, if
considered to be enlarge before therapy, must have regressed in size and not be palpable
on physical examination. The bone marrow must show no evidence of disease by
histology. Flow cytometric, molecular or cytogenetic studies will not be used to
determine response.  
Complete response unconfirmed (CRu): As per CR criteria except that if a residual node
is > 1.5 cm, it must have regressed by > 75% in SPD. Lymphocyte aggregates within the
bone marrow must be negative for B-cell markers (e.g. L26).  
Partial response: 50% decreased in SPD of 6 largest dominant nodes or nodal masses.
No increase in size of nodes, liver or spleen and no new sites of disease. Splenic and
hepatic nodules must regress by 50% in the SPD. Bone marrow is irrelevant for
determination of a PR.  
Progressive disease: > 50% increase from nadir in the SPD of any previously involved
node or the appearance of any new lesion.  
20  
Stable disease: Defined as less than a PR but not progressive disease.
6.4 TOXICITY CRITERIA
The NCI Common Toxicity Criteria version 2.0 will be used for toxicity and adverse event
reporting. A copy of the CTC version 2.0 can be downloaded from http://ctep:info.nih.gov.  
Stable disease: Defined as less than a PR but not progressive disease.  
6.4 TOXICITY CRITERIA
The NCI Common Toxicity Criteria version 2.0 will be used for toxicity and adverse event
reporting. A copy of the CTC version 2.0 can be downloaded from http://ctep:info.nih.gov.
7. nih reporting requirements/data and
7.1 definitions

Please refer to definitions provided in Policy 801: Reporting Research Events found here.
7. nih reporting requirements/data and
7.2 ohsrp office of compliance

7.2.1 Expedited Reporting  
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy
802 Non-Compliance Human Subjects Research found here.
7.2.2 IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found here.  
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy
802 Non-Compliance Human Subjects Research found here.  
7.2.2 IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found here.
7. nih reporting requirements/data and
7.3 nci clinical director reporting

Problems expeditiously reported to the OHSRP/IRB in iRIS will also be reported to the NCI
Clinical Director. A separate submission is not necessary as reports in iRIS will be available to
the Clinical Director.  
In addition to those reports, all deaths that occur within 30 days after receiving a research
intervention should be reported via email to the Clinical Director unless they are due to
progressive disease.  
To report these deaths, please send an email describing the circumstances of the death to Dr.
Dahut at NCICCRQA@mail.nih.gov within one business day of learning of the death.
7. nih reporting requirements/data and
7.4 ind sponsor reporting criteria

Reporting of Adverse Events to CTEP has not been required since 05/04/2006, as the protocol
was completed with CTEP on that date.
7. nih reporting requirements/data and
7.5 data and safety monitoring

7.5.1 Principal Investigator/Research Team
All data will be collected in a timely manner and reviewed by the principal investigator or a lead
associate investigator. Events meeting requirements for expedited reporting as described in
section 7.2.1will be submitted within the appropriate timelines.
7.5.2 Sponsor
This study was monitored by the Clinical Data Update System (CDUS) version 1.1 until  
7.5.1 Principal Investigator/Research Team
All data will be collected in a timely manner and reviewed by the principal investigator or a lead
associate investigator. Events meeting requirements for expedited reporting as described in
section 7.2.1will be submitted within the appropriate timelines.  
7.5.2 Sponsor
This study was monitored by the Clinical Data Update System (CDUS) version 1.1 until  
21
7. nih reporting requirements/data and
8. statistical considerations

This is a study intended to provide a small test of a therapeutic strategy in a disease with
recognized poor outcomes. The primary objectives of this study are to form an estimate of the
progression-free survival (PFS) in patients treated with EPOCH-R and (idiotype vaccine)
beginning from the start of chemotherapy.  
This study will require a maximum of 26 patients to address the principal objectives posed by the
protocol. Estimates of median PFS range from 8 to 19 months for combination chemotherapy,
and is 16.2 months for rituximab and CHOP chemotherapy. We are aiming to demonstrate,
within a small single arm study, whether the combination of EPOCH-R and idiotype vaccine
may demonstrate a potentially superior outcome to other therapeutic approaches with a target
median PFS of 36 months.  
Because a formal two-stage design will not be practical with 36 months as the time at which the
main endpoint is evaluated, this study will use a single stage phase II design in order to estimate
the number of patients to enter into the evaluation of PFS as follows. It will be desirable if 50%
of patients are able to have a PFS equal to or greater than 36 months (p1=.50). By contrast, if
only 25% achieve 36 month PFS (p0=0.25), then this is no better than the best that would have
been expected from a cohort treated on other trials, which have a median PFS of up to
approximately 18 months (expected PFS would be 25% at 36 months if median were 18 months,
assuming an exponential survival distribution). With alpha=0.10 and beta=0.10, 26 patients will
be entered. If 10+/26 have 36 month PFS, this will be desirable in order to show consistency
with a median of 36 months PFS (33). Confidence intervals about the 36-month PFS point will
also be constructed. A 95% one-sided confidence bound beneath 10/26 extends downward to
23%; thus, if 10/26 patients are observed to have 36 month PFS, then there is a 95% chance that
the true proportion with 36 month PFS exceeds 23%.  
In order to provide a stopping rule based on PFS, in the absence of a formal two-stage design, the
following will be used: After the study has been open and has accrued patients for 36 months,
the Kaplan-Meier curve for PFS will be constructed, and the 18 month PFS estimate will be
calculated, along with its standard deviation. If the 18 month estimate minus one standard
deviation includes 50% PFS, then accrual will stop, because this will indicate consistency with
the potentially expected median PFS of 50% at 18 months.  
It is hypothesized that a factor which may greatly influence the duration of PFS will be
production of an immune response. The immune response will be defined as previously
published ²7. A prior study of idiotype vaccine showed a 95% frequency of immune response in
patients with follicular lymphoma treated with ProMACE chemotherapy27. However, the impact
of EPOCH chemotherapy, mantle cell histology and/or rituximab on the frequency of a positive
immune response is currently unknown. In order to allow the trial to end accrual of patients prior
to the planned accrual in the event that the immune response rate is lower than expected, we plan
to use an early stopping rule for immune responses. If the observed immune response rate is
much less than 70% at an early point, we plan to re-evaluate the trial design. For this purpose,
we will employ a simple one-stage stopping rule as follows. Approximately 15 patients will be
enrolled in order to expect to have 10 who would be treated with EPOCH-R and receive the full
vaccine. If 4+/10 exhibit an immune response, then accrual will proceed until there are 26  
22  
patients in order to see the magnitude of PFS as described; otherwise, with 0 to 3 immune
responses in 10 patients who have completed all vaccinations, there is only a 1% probability of
observing such a rare outcome if the true response proportion were 70%. If this were to happen,
accrual would be suspended until an evaluation of the immunological and clinical endpoints is
undertaken. Only if there was demonstrated merit in continuing the trial, such as favorable
clinical results or information suggesting that the chosen immune response assays do not reflect
efficacy, would accrual be reopened. This evaluation would be done in consultation with the
IND holder. 5.4.6 It is anticipated that 2 years of accrual will be required in order to enter up
to 26 patients onto this trial.  
Based on the above estimates and assumptions, up to 25% of entered patients may not have
received all of their vaccine treatments due to disease progression. A subset analysis evaluating
PFS among patients who received all vaccine treatments will be performed to arrive at an
estimate of potential benefit of vaccine in this subset.
7. nih reporting requirements/data and
9. collaborative agreements

9.1 MATERIALS TRANSFER AGREEMENT: BIOVEST INTERNATIONAL
There is a Materials Transfer Agreement (MTA) with Biovest International, Inc. As of
Amendment N, this MTA is no longer valid.  
9.1.1 According to the terms of the MTA:  
As of Amendment N, this section is no longer relevant. It is being kept for historical
purposes. Biovest is no longer involved in the study; therefore the collaborators
listed below do not have access to any data or samples. Biovest will have access to the
MCL vaccine clinical data and results and raw data in NIH's possession and control as
needed to support the registration of the Agent (Id-KLH Vaccine) by the FDA in this
disease. Furthermore, Biovest will be provided safety data generated from the use of the
Agent (Id-KLH Vaccine) that is in the possession and control of NIH as needed to
support the FDA registration. Collaborator's access to and use of said data is limited to
use for regulatory filings only.
Clinical Data and results under NCI Protocol # 00C0133 may be used by Biovest in
obtaining FDA approval for the commercial marketing of Agent (Id-KLH Vaccine)
products.
Biovest access to and review of Identifiable Private Information (IPI) shall be only for
onsite quality auditing. Biovest will receive IPI only for purposes of satisfying FDA or
other health authorities' reporting requirements, and for internal research purposes
directly related to obtaining regulatory approval of Agent (Id-KLH Vaccine). Biovest
is
prohibited from access, review, receipt, or use of such information for other purposes.
If the Data being provided is coded, the Provider (NCI) will not release, and the Biovest
will not request, the key to the code. Biovest will not contact or make any effort to
identify individuals who are or may be the sources of Data without specific written
approval from Provider.  
As of Amendment N, this section is no longer relevant. It is being kept for historical
purposes. Biovest is no longer involved in the study; therefore the collaborators
listed below do not have access to any data or samples. Biovest will have access to the
MCL vaccine clinical data and results and raw data in NIH's possession and control as
needed to support the registration of the Agent (Id-KLH Vaccine) by the FDA in this
disease. Furthermore, Biovest will be provided safety data generated from the use of the
Agent (Id-KLH Vaccine) that is in the possession and control of NIH as needed to
support the FDA registration. Collaborator's access to and use of said data is limited to
use for regulatory filings only.  
Clinical Data and results under NCI Protocol # 00C0133 may be used by Biovest in
obtaining FDA approval for the commercial marketing of Agent (Id-KLH Vaccine)
products.  
Biovest access to and review of Identifiable Private Information (IPI) shall be only for
onsite quality auditing. Biovest will receive IPI only for purposes of satisfying FDA or
other health authorities' reporting requirements, and for internal research purposes
directly related to obtaining regulatory approval of Agent (Id-KLH Vaccine). Biovest
is
prohibited from access, review, receipt, or use of such information for other purposes.  
If the Data being provided is coded, the Provider (NCI) will not release, and the Biovest
will not request, the key to the code. Biovest will not contact or make any effort to
identify individuals who are or may be the sources of Data without specific written
approval from Provider.  
23  
9.1.2
Contact Information for Responsible Parties at Biovest International, Inc. As of
Amendment N, these collaborators are no longer involved in the study. This
information is being kept for historical purposes.  
Carlos F. Santos, Ph.D.
Sr. VP Product Development and Regulatory Affairs
Biovest International, Inc.
324 South Hyde Park Ave
Suite 350
Tampa, FL 33606
www.accentia.net  
David Moser
Director of Legal Affairs
324 S. Hyde Park Ave.
Suite 350
Tampa FL 33606
Email: Dmoser@accentia.net
7. nih reporting requirements/data and
9.2 material transfer agreement adaptive

The MTA with Adaptive Biotechnologies Corp has been fully executed to allow the samples
described in Section 5.1.8 to be shipped to Adaptive Biotechnologies, Corp.
7. nih reporting requirements/data and
10.1 rationale for subject selection

Non-Hodgkin's lymphomas affect all races and genders. However, males are more likely than
females to be affected and this will be reflected in the gender distribution of our cases. We have
selected mantle cell lymphomas for inclusion in this trial because they are considered to be
incurable with chemotherapy. Thus, they would potentially benefit from the use of a novel
chemotherapy regimen like EPOCH-R. Additionally, the testing of a novel vaccination approach
to potentially stimulate an immune reaction against the lymphoma could result in an improved
clinical outcome. Patients under the age of 18 are excluded because mantle cell lymphoma is
rare in young patients, and the inclusion of an occasional younger patient will not provide
generalizable information that would justify their inclusion on this phase I study. Additionally,
patients with HIV infection will be excluded due to the severe immunosuppression of this
therapy, and pregnant or nursing mothers are excluded because of the potential teratogenic
effects of therapy.
7. nih reporting requirements/data and
10.2 participation of subjects unable

Adults unable to give consent were excluded from enrolling in the protocol. However, re-
consent may be necessary and there is a possibility, though unlikely, that subjects could become
decisionally impaired. For this reason and because there is a prospect of direct benefit from
research participation (Section 10.4), all subjects will be offered the opportunity to fill in their
wishes for research and care, and assign a substitute decision maker on the "NIH Advance
Directive for Health Care and Medical Research Participation" form SO that another person can
make decisions about their medical care in the event that they become incapacitated or  
24  
cognitively impaired during the course of the study. Note: The PI or AI will contact the NIH
Ability to Consent Assessment Team (ACAT) for evaluation as needed for the following: an
independent assessment of whether an individual has the capacity to provide consent; assistance
in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the
capacity to appoint a surrogate. For those subjects that become incapacitated and do not have
pre-determined substitute decision maker, the procedures described in  
NIH HRPP SOP 14E for appointing a surrogate decision maker for adult subjects who are (a)
decisionally impaired, and (b) who do not have a legal guardian or durable power of attorney,
will be followed.
7. nih reporting requirements/data and
10.3 evaluation of benefits and

Patients may obtain direct benefit from treatment with EPOCH-R, a regimen which includes
non-experimental cytotoxic agents and rituximab. The risks and benefits of EPOCH-R are
comparable to standard treatment approaches. Patients may also potentially benefit from the
idiotype vaccine. It is possible but unknown if one technique for idiotype isolation and scale-up
is superior to the other one. Risks of idiotype vaccine I previous trials have been due to
administrations of GM-CSF with occasional fever, chills and body aches. Although it is possible
to have a life-threatening allergic reaction, this has not been observed in previous trials. If this
approach is effective, patients may be directly benefited.  
The potential risks of genetic testing are as outlined in the informed consent document
(included/revised with Amendment L). This study has a Certificate of Confidentiality, which
helps to protect patient's research information. The researchers involved in this study cannot be
forced to disclose the identity or any information collected in this study in any legal proceedings
at the federal, state, or local level, regardless of whether they are criminal, administrative, or
legislative proceedings. However, the patient or the researcher may choose to voluntarily
disclose the protected information under certain circumstances. Furthermore, federal agencies
may review patient's records under limited circumstances, such as a DHHS request for
information for an audit or program evaluation or an FDA request under the Food, Drug and
Cosmetics Act. The Certificate of Confidentiality will not protect against the required reporting
by hospital staff of information on suspected child abuse, reportable communicable diseases,
and/or possible threat of harm to self or others. The procedures involved in this protocol, with
their attendant risks and discomforts and potential benefits will be carefully explained to the
patient.
7. nih reporting requirements/data and
10.4 risk/benefit analysis

Patients often benefit from administration of CHOP and are likely to derive benefit from
EPOCH-R, which contains the same agents. Patients may also benefit from the addition of the
idiotype vaccine. A clinical trial of idiotype vaccine in follicular center cell lymphomas suggests
that it may stimulate immune-mediated clearly of minimal residual disease as assessed by PCR
for the 14-18 translocation. If the idiotype vaccine is able to stimulate immune-mediated tumor
clearance, this will be a major and important step in more effectively treating lymphomas. Thus,
the knowledge that will be gained from this trial is potentially important and may be of direct
benefit to patients.  
Given the prospect of direct benefit, this same risks/benefits analysis applies also to adults who
may become unable to consent during participation.  
25
7. nih reporting requirements/data and
10.5 consent process and documentation

Informed consent will be obtained in all patients on this trial. There will be no minors enrolled <
18 years old SO that assent is unnecessary. The informed consent contains all elements required
for consent. In addition, the Principal Investigator or his designee will provide oral consent and
will be available to answer all patient questions.
7. nih reporting requirements/data and
10.5.1 telephone re-consent

The informed consent document will be sent to the subject. An explanation of the study will be
provided over the telephone after the subject has had the opportunity to read the consent form.
The subject will sign and date the informed consent.  
The original informed consent document will be sent back to the consenting investigator who
will sign and date the consent form with the date the consent was obtained via telephone.  
A fully executed copy will be returned via mail for the subject's records.  
The informed consent process will be documented in the medical record.
11. pharmaceutical information
11.1 epoch-rituximab

11.1.1 Cyclophophamide  
Commercial pharmacy supply will be used. Available in white crystalline formulation for
intravenous injection, in vials containing 100 mg, 200 mg, 500 mg, 1 gm, and 2 gm. All
preparations are stable at room temperature (not to exceed 30'C). Reconstitute with appropriate
amounts of sterile water to produce a final concentration of 20 mg/ml. Discard solution after 24
hours at room temperature. Stable up to 6 days if refrigerated (2- 8'C). Administer IV in 100
0.9% NaCl over 15 min. Toxicities: myelosuppression, nausea and vomiting, hemorrhagic
cystitis, alopecia. Cystitis can be largely prevented by maintaining a good state of hydration and
good urine flow during and after drug administration using the following Hydration Guidelines:
All patients should received normal saline at the following volumes (based on cyclophosphamide
dose levels) and rates with half given before and half given after the cyclophosphamide injection.  
Levels 1-2: 1 liter NS @ 300-500 cc/hr
Levels 3-5: 2 liter NS @ 300-500 cc/hr
Levels 6: 2.5 liter NS @ 300-500 cc/hr  
Levels 1-2: 1 liter NS @ 300-500 cc/hr  
Levels 3-5: 2 liter NS @ 300-500 cc/hr  
Levels 6: 2.5 liter NS @ 300-500 cc/hr  
11.1.2 Doxorubicin  
Commercial pharmacy supply will be used. Available in 10, 20, 50, and 150 mg vials with 50
mg, 100 mg, and 250 mg of lactose, respectively; the three dosage strengths are reconstituted
with 2 ml, 4 ml, 10 ml. and 30 ml of normal saline or sterile water for injection, respectively,
giving a final drug concentration of 5 mg/ml. Reconstituted solution is stable for 24 hours at
room temperature and for 48 hours under refrigeration and should be protected from sunlight.
Toxicities: Myelosuppression, stomatitis, alopecia, nausea and vomiting, and acute and chronic
cardiac toxicity, manifested as arrhythmias or a congestive cardiomyopathy, the latter
uncommon at total cumulative doses less than 500 mg/m². The drug causes local necrosis if
infiltrated into subcutaneous tissue.  
26  
11.1.3 Vincristne
Commercial pharmacy supply will be used. Available in I mg, 2 mg, and 5 mg vial sizes. Each
ml contains I mg of vincristine, 100 mg mannitol, 1.3 mg methylparaben, and 0.2 mg
propylparaben. Drug should be stored at 2-8°C and should be protected from light. Toxicities:
peripheral neuropathy, autonomic neuropathy, alopecia. Local necrosis if injected
subcutaneously.
11. pharmaceutical information
11.1.4 etoposide

Commercial pharmacy supply will be used. Available as a concentrate for parenteral use in 100
mg vials; each ml contains 20 mg etoposide, 2 mg citric acid, 30 mg benzyl alcohol, 80 mg
polysorbate 80, 650 mg of polyethylene glycol 300, and 30.5% alcohol. Drug should be diluted
before administration in D5W or normal saline. Toxicities: myelosuppression, nausea, vomiting,
anaphylactic reactions, alopecia, and hypotension if infusion is too rapid.  
ADMINISTRATION OF VINCRISTNE/DOXORUBICIN/ETOPOSIDE Stability
studies conducted by the Pharmaceutical Development Service, Pharmacy Department,
NIH Clinical Center, have demonstrated that admixtures of vincristine, doxorubicin, and
etoposide in 0.9% Sodium Chloride Injection, USP at concentrations, respectively, of 1,
25 and 125 mcg/mL- 1.4, 35 and 175 mcg/mL; 2, 50 and 250 mcg/mL; and 2.8, 70 and
350 mcg/mL are stable for at least 36 hours at room temperature when protected from
light. Also admixtures containing vincristine, doxorubicin and etoposide concentrations
of 1.6, 40 and 200 mcg/mL are stable for at least 30 hours at 32 degrees C. In this study,
THE DAILY DOSE (i.e. 24 hour supply) of vincristine, doxorubicin and etoposide will
be admixed together in 500 mL of 0.9% Sodium Chloride. Injection and delivered with a
suitable infusion pump through a central venous access device. The bag will be
exchanged daily for each of the four days to complete the 96 hour infusion.
Cyclophosphamide will be diluted in 100 mL of D5W or NS and infusion over 15
minutes. Patients will be instructed to drink an adequate amount of fluids and empty their
bladders frequently during cyclophosphamide administration.
11. pharmaceutical information
11.1.5 prednisone

Commercial pharmacy supply will be used. Available in a large number of oral dosage strengths
including pills and liquid formulations. Tablets should be stored in well-closed containers at
temperatures between 15-30°C. Toxicities: proximal muscle weakness, glucose intolerance,
thinning of skin, redistribution of body fat, Cushingoid facies, immunosuppression, and
propensity to gastrointestinal ulceration.  
11.1.6 Rituximab
Commercial pharmacy supply will be used. Rituximab is provided 10 ml (100 mg) and 50 ml
(500 mg) pharmaceutical grade glass vials at a concentration of 10 mg of protein per ml. Storage:
Rituximab for clinical use should be stored in a secure refrigerator at 2 to 8 °C. Reconstitution
and Dilution: The antibody should be diluted into a final volume of 0.9% sodium chloride or 5%
dextrose in water for final concentration of 1-4 mg/ml. Caution should be taken during the
preparation of the drug, as shaking can cause aggregation and precipitation of the antibody.
Rituximab solutions for infusion are stable at 2-8 degrees C (36-46 degrees F) for 24 hours and
at room temperature for an additional 12 hours. Administration: Rituximab will be administered
as an intravenous infusion at 375 mg/m² on day 1 of each cycle of EPOCH immediately prior to  
27  
the start of the infusions of chemotherapy. Rituximab infusions will be administered to patients
in an outpatient clinic setting. Oral pre-medication (2 tablets of acetaminophen and 50-100 mg
diphenhydramine hydrochloride) will be administered 30 to 60 minutes prior to starting each
infusion of rituximab. A peripheral or central intravenous line will be established. During the
rituximab infusion, the patient's vital signs (blood pressure, pulse, respiration, temperature)
should be monitored every 15 minutes times 4 or until stable and then hourly until the infusion is
discontinued. Available at the bedside prior to rituximab administration will be epinephrine for
subcutaneous injection, diphenhydramine hydrochloride for intravenous injection, and
resuscitation equipment for the emergency management of anaphylactoid reactions. The initial
dose rate at the time of the first rituximab infusion should be 50mg/hr for the first hour. If no
toxicity is seen, the dose rate may be escalated gradually (50 mg/hr increments at 30 minute
intervals) to a maximum of 400 mg/hr. If the first dose of rituximab is well tolerated, the starting
flow-rate for the administration of subsequent doses will be 100 mg/hr then increased gradually
(100 mg/hr increments at 30 minute intervals) not to exceed 400 mg/hr. CAUTION: DO NOT
ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS. Toxicities: Common toxicities
include fever, chills, nausea, asthenia, headache, angioedema, pruritus and rash. Leukopenia
occurs in approximately 10% but grade 3 or 4 neutropenia is uncommon. Hypotension occurred
in 10% of patients during rituximab infusion, and serious bronchospasm and urticaria associated
with rituximab infusion each occurred in fewer than 10% of patients. Less common toxicities
include abdominal pain, vomiting, thrombocytopenia, anemia, myalgia, arthralgia, dizziness, and
rhinitis.
11. pharmaceutical information
11.1.7 filgrastim (neupogenr)

Commercial pharmacy supply will be used. It is provided in two vial sizes of 300 and 450
ug/mL. It should be stored at 2-8'C (do not freeze) and is stable for at least I year at this
temperature. Toxicities: Rare anaphylactic reactions with the first dose; bone pain at sites of
active marrow with continued administration. Local reactions at injection sites. Constitutional
symptoms, increased alkaline phosphatase, LDH, uric acid; worsening of pre-existing
inflammatory conditions.
11. pharmaceutical information
11.1.8 id-klh vaccine

Idiotype protein from the individual B cell lymphomas will be obtained using two different
methods. The first 13 patients (accrual completed) will receive vaccine manufactured with
idiotype isolated using a somatic hybridoma technique. The second 13 patients will receive
vaccine manufactured with idiotype manufactured with idiotype isolated by recombinant
techniques. Idiotype isolated by either technique will be covalently coupled to keyhole limpet
hemocyanin (KLH) using the identical techniques and contractor. All vaccines will be produced
according to Good Manufacturing Practices standards and tested for sterility, endotoxin
contamination, and general safety prior to its use in any patient. The preparation and quality
control/quality assurance testing of the Id-KLH conjugate will be performed by TSI Washington
under DCS/NCI contract. The IND for the Id-KLH vaccine will be held by the Drug Regulatory
Affairs Section, CTEP. How Supplied: Formulated product for subcutaneous administration
contains 0.5 mg if Id and KLH each per ml of normal saline. Id-KLH will be supplied as a 1 ml
vial.  
Storage - Prior to administration, Id-KLH will be stored at -20°C.  
28  
Administration - One of the following investigators will be available for vaccine
preparation: Drs. Kwak, Wilson or Fowler. After thawing and gentle agitation, the vial
contents should be drawn up using an 18-gauge needle on a syringe. After the entire
contents have been drawn up, a 25-gauge needle for injection may replace the 18-gauge
needle. This procedure is important to ensure that all particulates (normal components of
this vaccine) are obtained from the vial.
Toxicity - Toxicities described with Id-KLH vaccine administration include local site
reactions (erythema, induration, swelling and tenderness), fever, chills, rash, myalgias
and arthralgia. Mild elevations in creatinine phosphokinase (CPK) have been observed.  
Administration - One of the following investigators will be available for vaccine
preparation: Drs. Kwak, Wilson or Fowler. After thawing and gentle agitation, the vial
contents should be drawn up using an 18-gauge needle on a syringe. After the entire
contents have been drawn up, a 25-gauge needle for injection may replace the 18-gauge
needle. This procedure is important to ensure that all particulates (normal components of
this vaccine) are obtained from the vial.  
Toxicity - Toxicities described with Id-KLH vaccine administration include local site
reactions (erythema, induration, swelling and tenderness), fever, chills, rash, myalgias
and arthralgia. Mild elevations in creatinine phosphokinase (CPK) have been observed.  
11.1.9 GM-CSF (Sargramostim: NSC #613795; BB-IND 2632)  
Source and Pharmacology - The GM-CSF to be used in this study is glycosylated,
recombinant human GM-CSF. This GM-CSF is an altered form of the native molecule;
the position 23 arginine has been replaced with a leucine to facilitate expression of the
protein in yeast (Saccharomyces cerevisiae).
Formulation and Stability - The GM-CSF is formulated as a white lyophilized cake and is
provided in vials containing 500 ug of the GM-CSF protein as well as 10.0 mg of
sucrose, 40.0 mg of mannitol, and 1.2 mg of Tris (Trimethamine). To prepare a vial of
GM-CSF for direct subcutaneous use, aseptically inject 1.0 ml of Sterile Water for
Injection, USP, into the vial to dissolve the lyophilized cake. The diluent should be
directed against the side of the vial to avoid excess foaming. Avoid vigorous agitation of
the vial; do not shake. This yields a solution containing 500 ug/ml. The unreconstituted
material should be kept refrigerated at 2-8°C and is stable for at least eighteen months.
Once reconstituted, the solution is stable for at least 24 hours at 2-8°C or at 18-25°C.
Because the product does not contain a preservative, vials should be treated as unit-dose
containers; reconstituted solution should be held at 2-8°C and discarded after no more
than six hours. Do not freeze GM-CSF.
Supplier - Manufactured by Immunex. Will be provided by CTEP.
Route of Administration - The appropriate total dose is withdrawn into and administered
from a plastic tuberculin syringe. The GM-CSF will be injected subcutaneously as close
as possible to the Id-KLH injection site. All GM-CSF doses for each patient will be
administered by the nursing staff in the outpatient unit.
Toxicity - Toxicities described in patients receiving GM-CSF include: Fever, chills,
diaphoresis, myalgias, fatigue, malaise, headache, dizziness, dyspnea, bronchospasm,
pleural effusion, anorexia, indigestion, nausea, vomiting, diarrhea, injection site
tenderness, urticaria, rash, pruritus, hypersensitivity reaction, bone pain, thromboembolic
events, phlebitis, hypotension, peripheral edema, leukocytosis, thrombocytosis or
thrombocytopenia, hepatic enzyme abnormalities, and bilirubin elevation. The first
administration of GM-CSF has provoked a syndrome of dyspnea and hypotension within
two hours after GM-CSF injection in a single patient receiving yeast-derived GM-CSF;
this type of reaction has more frequently been observed in patients receiving GM-CSF
produced in E. coli. One report of a vascular leak-like syndrome occurring after
autologous bone marrow transplant in a patient receiving continuous IV infusion of GM-
CSF has been recorded.  
Source and Pharmacology - The GM-CSF to be used in this study is glycosylated,
recombinant human GM-CSF. This GM-CSF is an altered form of the native molecule;
the position 23 arginine has been replaced with a leucine to facilitate expression of the
protein in yeast (Saccharomyces cerevisiae).  
Formulation and Stability - The GM-CSF is formulated as a white lyophilized cake and is
provided in vials containing 500 ug of the GM-CSF protein as well as 10.0 mg of
sucrose, 40.0 mg of mannitol, and 1.2 mg of Tris (Trimethamine). To prepare a vial of
GM-CSF for direct subcutaneous use, aseptically inject 1.0 ml of Sterile Water for
Injection, USP, into the vial to dissolve the lyophilized cake. The diluent should be
directed against the side of the vial to avoid excess foaming. Avoid vigorous agitation of
the vial; do not shake. This yields a solution containing 500 ug/ml. The unreconstituted
material should be kept refrigerated at 2-8°C and is stable for at least eighteen months.
Once reconstituted, the solution is stable for at least 24 hours at 2-8°C or at 18-25°C.
Because the product does not contain a preservative, vials should be treated as unit-dose
containers; reconstituted solution should be held at 2-8°C and discarded after no more
than six hours. Do not freeze GM-CSF.  
Supplier - Manufactured by Immunex. Will be provided by CTEP.  
Route of Administration - The appropriate total dose is withdrawn into and administered
from a plastic tuberculin syringe. The GM-CSF will be injected subcutaneously as close
as possible to the Id-KLH injection site. All GM-CSF doses for each patient will be
administered by the nursing staff in the outpatient unit.  
Toxicity - Toxicities described in patients receiving GM-CSF include: Fever, chills,
diaphoresis, myalgias, fatigue, malaise, headache, dizziness, dyspnea, bronchospasm,
pleural effusion, anorexia, indigestion, nausea, vomiting, diarrhea, injection site
tenderness, urticaria, rash, pruritus, hypersensitivity reaction, bone pain, thromboembolic
events, phlebitis, hypotension, peripheral edema, leukocytosis, thrombocytosis or
thrombocytopenia, hepatic enzyme abnormalities, and bilirubin elevation. The first
administration of GM-CSF has provoked a syndrome of dyspnea and hypotension within
two hours after GM-CSF injection in a single patient receiving yeast-derived GM-CSF;
this type of reaction has more frequently been observed in patients receiving GM-CSF
produced in E. coli. One report of a vascular leak-like syndrome occurring after
autologous bone marrow transplant in a patient receiving continuous IV infusion of GM-
CSF has been recorded.  
29
11. pharmaceutical information
12. references

1. Weisenburger D D, Armitage J 0.: Mantle cell lymphoma- An entity comes of age. Blood 87:
4483-4494, 1996
2. Fisher R I: Mantle-cell lymphoma: Classification and therapeutic implications. Annals of
Oncology 7 (Suppl. 6): 535-539, 1996
3.
Armitage JO: Management of mantle cell lymphoma. Oncology 12: 49-55, 1998
4.
Pittaluga S, Bijnens I, Teodorovic I, et al: Clinical analysis of 670 cases in two trials of the
European Organization for the Research and Treatment of Cancer Lymphoma Cooperative
Group Subtype according to the Revised European-American Classification of Lymphoid
Neoplasms: A comparison with the Working Formulation. Blood 87:4358-4367, 1996.
5.
Teodorovic I, Pittaluga S, Kluin-Nelemons J, et al: Efficacy of four different regimens in 64
mantle cell lymphoma cases: Clinicopathologic comparison with 498 other non-Hodgkin's
lymphoma subtypes. J Clin Oncol 13: 2819-2826, 1995.
6.
Velders GA, Kluin-Nelemans JC, De Boer CJ, et al: Mantle cell lymphoma: A Population-
Based Clinical Study. J Clin Oncol 14: 1269-1274, 1996.
7. Hiddemann W, Unterhalt M, Herrmann R, et al: Mantle cell lymphomas have more
widespread disease and slower response to chemotherapy compared with follicle center
lymphomas: Results of a prospective comparative analysis of the German low-grade
lymphoma study group. J Clin Oncol 16: 1922-1930, 1998.
8. Samaha H, Dumontet C, Ketterer N, et al: Mantle cell lymphoma: A retrospective study of
121 cases. Leukemia 12:1281-1281, 1998.
9. Zucca E, Fontana, S, Roggero E, et al: Treatment and prognosis of centrocytic (mantle cell)
lymphoma: A retrospective analysis of 26 patients treated in one institution. Leuk
Lymphoma 13:105-110, 1994.
10.
Armitage J, et al (The non-Hodgkin's Lymphoma Classification Project): A clinical
evaluation of the International Lymphoma Study Group classification of non-Hodgkin's
lymphoma. Blood 89:3909-3918, 1997.
11. Khouri IF, Romaguera J, Kantarjian H, et al: Hyper-CVAD and high-dose
methotrexate/cytarabine followed by stem-cell transplantation: An active regimen for
aggressive mantle-cell lymphoma. J Clin Oncol 16:3803-3809, 1998.
12. Freedman AS, Neubert D, Gribben JG, et al: High-dose chemoradiotherapy and anti-B-cell
monoclonal antibody-purged autologous bone marrow transplantation in mantle-cell
lymphoma; No evidence for long-term remission. J Clin Oncol 16:3-5, 1998.
13. Howard O, Gribben J, Neuberg D, et al: Rituxan/CHOP induction therapy in newly
diagnosed patients with mantle cell lymphoma. Proc Am Soc Heme 94:absrt #2804, 1999.
14. Wilson WH, Bryant G, Bates, S, et al: EPOCH chemotherapy: Toxicity and efficacy in
relapsed and refractory non-Hodgkin's lymphoma. J Clin Oncol 11:1573, 1993
15. Wilson WH, Grossbard ML, Alvarez M, et al: Dose-escalating EPOCH chemotherapy in
previously untreated large cell lymphoma. Proc Am Soc Oncol 17:65, 1998
16. Cruczman MS, Grillo-Lopez AJ, White CA, et al: Treatment of patients with low-grade B-
cell lymphoma with the combination of chimeric anti-CD20 monoclonal antibody and CHOP
chemotherapy. J Clin Oncol 17:268,1999
17. Stevenson GT, Stevenson FK: Antibody to molecularly defined antigen confined to a tumor
cell surface. Nature 1975, 254:714-6  
1. Weisenburger D D, Armitage J 0.: Mantle cell lymphoma- An entity comes of age. Blood 87:
4483-4494, 1996  
2. Fisher R I: Mantle-cell lymphoma: Classification and therapeutic implications. Annals of
Oncology 7 (Suppl. 6): 535-539, 1996  
3.
Armitage JO: Management of mantle cell lymphoma. Oncology 12: 49-55, 1998  
4.
Pittaluga S, Bijnens I, Teodorovic I, et al: Clinical analysis of 670 cases in two trials of the
European Organization for the Research and Treatment of Cancer Lymphoma Cooperative
Group Subtype according to the Revised European-American Classification of Lymphoid
Neoplasms: A comparison with the Working Formulation. Blood 87:4358-4367, 1996.  
5.
Teodorovic I, Pittaluga S, Kluin-Nelemons J, et al: Efficacy of four different regimens in 64
mantle cell lymphoma cases: Clinicopathologic comparison with 498 other non-Hodgkin's
lymphoma subtypes. J Clin Oncol 13: 2819-2826, 1995.  
6.
Velders GA, Kluin-Nelemans JC, De Boer CJ, et al: Mantle cell lymphoma: A Population-
Based Clinical Study. J Clin Oncol 14: 1269-1274, 1996.  
7. Hiddemann W, Unterhalt M, Herrmann R, et al: Mantle cell lymphomas have more
widespread disease and slower response to chemotherapy compared with follicle center
lymphomas: Results of a prospective comparative analysis of the German low-grade
lymphoma study group. J Clin Oncol 16: 1922-1930, 1998.  
8. Samaha H, Dumontet C, Ketterer N, et al: Mantle cell lymphoma: A retrospective study of
121 cases. Leukemia 12:1281-1281, 1998.  
9. Zucca E, Fontana, S, Roggero E, et al: Treatment and prognosis of centrocytic (mantle cell)
lymphoma: A retrospective analysis of 26 patients treated in one institution. Leuk
Lymphoma 13:105-110, 1994.  
10.
Armitage J, et al (The non-Hodgkin's Lymphoma Classification Project): A clinical
evaluation of the International Lymphoma Study Group classification of non-Hodgkin's
lymphoma. Blood 89:3909-3918, 1997.  
11. Khouri IF, Romaguera J, Kantarjian H, et al: Hyper-CVAD and high-dose
methotrexate/cytarabine followed by stem-cell transplantation: An active regimen for
aggressive mantle-cell lymphoma. J Clin Oncol 16:3803-3809, 1998.  
12. Freedman AS, Neubert D, Gribben JG, et al: High-dose chemoradiotherapy and anti-B-cell
monoclonal antibody-purged autologous bone marrow transplantation in mantle-cell
lymphoma; No evidence for long-term remission. J Clin Oncol 16:3-5, 1998.  
13. Howard O, Gribben J, Neuberg D, et al: Rituxan/CHOP induction therapy in newly
diagnosed patients with mantle cell lymphoma. Proc Am Soc Heme 94:absrt #2804, 1999.  
14. Wilson WH, Bryant G, Bates, S, et al: EPOCH chemotherapy: Toxicity and efficacy in
relapsed and refractory non-Hodgkin's lymphoma. J Clin Oncol 11:1573, 1993  
15. Wilson WH, Grossbard ML, Alvarez M, et al: Dose-escalating EPOCH chemotherapy in
previously untreated large cell lymphoma. Proc Am Soc Oncol 17:65, 1998  
16. Cruczman MS, Grillo-Lopez AJ, White CA, et al: Treatment of patients with low-grade B-
cell lymphoma with the combination of chimeric anti-CD20 monoclonal antibody and CHOP
chemotherapy. J Clin Oncol 17:268,1999  
17. Stevenson GT, Stevenson FK: Antibody to molecularly defined antigen confined to a tumor
cell surface. Nature 1975, 254:714-6  
30  
18. Sirisinha S, Eisen HN: Autoimmune-like antibodies to the ligand-binding sites of myeloma
proteins. Proc Natl Acad Sci USA 68:3130-3135, 1971
19. Jorgensen T, Gaudernack G, Hannestad K: Immunization with the light chain and the VL
domain of the isologous myeloma protein 315 inhibits growth of mouse plasmacytoma
MOPC-315. Scand J Immunol 11:29-35, 1980
20. Daley MJ, Gebel HM, Lynch RG: Idiotype-specific transplantation resistance to MOPC-
315: Abrogation by post-immunization thymectomy. J Immunol 120:1620-1624, 1978
21. Bridges SH: Participation of the humoral immune system in the myeloma-specific
transplantation resistance. J Immunol 121:479-483, 1978
22. Freedman PM, Autry JR, Tokuda S, Williams RC, Jr: Tumor immunity induced by
preimmunization with BALB/c mouse myeloma protein. J Natl Cancer Inst 56:735-740,
1976
23. Sugai S, Palmer DW, Talal N, Witz IP: Protective and cellular immune responses to idiotypic
determinants on cells from a spontaneous lymphoma of NZB/NZWF1 mice. J Exp Med
140:1547-1558, 1974
24. Stevenson FK, Gordon J: Immunization with idiotypic immunoglobulin protects against
development of B lymphocytic leukemia, but emerging tumor cells can evade antibody attack
by modulation. J Immunol 130:970-973, 1983
25. Kaminski MS, Kitamura K, Maloney DG, Levy R: Idiotype vaccination against murine B
cell lymphoma. Inhibition of tumor immunity by free idiotype protein. J Immunol
138:1289-1296, 1987
26. Kwak LW, Campbell MJ, Czerwinski DK, et al: Induction of immune responses in patients
with B cell lymphoma against the surface immunoglobulin idiotype expressed by their
tumors. N Engl J Med 327:1209-1215, 1992
27. Kwak LW, Young HA, Pennington RW, Weeks SW: Vaccination with syngeneic,
lymphoma-derived immunoglobulin idiotype combined with granulocyte/macrophage
colony-stimulating factor primes mice for a protective T-cell response. Proc Natl Acad Sci
USA 93:10972, 1996
28. Sternas L, Janik JE, Duffey PL, et al: Early results of a clinical trial of therapeutic
vaccination with Ig idiotype antigen for de novo follicular lymphoma. Blood 88(Suppl
1):672a, 1996.
29. Bendandi M, Sternas L, Reynolds CW, Kwak LW: Induction of autologous lymphoma-
specific CD8+ T cells by patient-specific vaccination against follicular lymphoma in first
remission. Blood 90(Suppl :249a, 1997
30. Bendandi M, Gocke CD, Kobrin CB, et al: Complete molecular remissions induced by
patient-specific vaccination plus granulocyte-monocyte colony-stimulating factor against
lymphoma. Nature Med 5:1171-1177, 1999
31. Foran JM, Rohatiner AZS, Coiffier B, et al: Multicenter phase II study of fludarabine
phosphate for patients with newly diagnosed lymphoplasmacytoid lymphoma,
Waldenstrom's Macroglobulinemia, and mantle-cell lymphoma. J Clin Oncol 17:546, 1999
32. Qin et al., Nature Med 4:627-630, 1998.
33. Thall PF and Simon RM: Recent developments in design of phase II clinical trials. in Thall
PF ed. Recent advances in clinical trial design and analysis. Kluwer, pp 49-72, 1995.  
18. Sirisinha S, Eisen HN: Autoimmune-like antibodies to the ligand-binding sites of myeloma
proteins. Proc Natl Acad Sci USA 68:3130-3135, 1971  
19. Jorgensen T, Gaudernack G, Hannestad K: Immunization with the light chain and the VL
domain of the isologous myeloma protein 315 inhibits growth of mouse plasmacytoma
MOPC-315. Scand J Immunol 11:29-35, 1980  
20. Daley MJ, Gebel HM, Lynch RG: Idiotype-specific transplantation resistance to MOPC-
315: Abrogation by post-immunization thymectomy. J Immunol 120:1620-1624, 1978  
21. Bridges SH: Participation of the humoral immune system in the myeloma-specific
transplantation resistance. J Immunol 121:479-483, 1978  
22. Freedman PM, Autry JR, Tokuda S, Williams RC, Jr: Tumor immunity induced by
preimmunization with BALB/c mouse myeloma protein. J Natl Cancer Inst 56:735-740,
1976  
23. Sugai S, Palmer DW, Talal N, Witz IP: Protective and cellular immune responses to idiotypic
determinants on cells from a spontaneous lymphoma of NZB/NZWF1 mice. J Exp Med
140:1547-1558, 1974  
24. Stevenson FK, Gordon J: Immunization with idiotypic immunoglobulin protects against
development of B lymphocytic leukemia, but emerging tumor cells can evade antibody attack
by modulation. J Immunol 130:970-973, 1983  
25. Kaminski MS, Kitamura K, Maloney DG, Levy R: Idiotype vaccination against murine B
cell lymphoma. Inhibition of tumor immunity by free idiotype protein. J Immunol
138:1289-1296, 1987  
26. Kwak LW, Campbell MJ, Czerwinski DK, et al: Induction of immune responses in patients
with B cell lymphoma against the surface immunoglobulin idiotype expressed by their
tumors. N Engl J Med 327:1209-1215, 1992  
27. Kwak LW, Young HA, Pennington RW, Weeks SW: Vaccination with syngeneic,
lymphoma-derived immunoglobulin idiotype combined with granulocyte/macrophage
colony-stimulating factor primes mice for a protective T-cell response. Proc Natl Acad Sci
USA 93:10972, 1996  
28. Sternas L, Janik JE, Duffey PL, et al: Early results of a clinical trial of therapeutic
vaccination with Ig idiotype antigen for de novo follicular lymphoma. Blood 88(Suppl
1):672a, 1996.  
29. Bendandi M, Sternas L, Reynolds CW, Kwak LW: Induction of autologous lymphoma-
specific CD8+ T cells by patient-specific vaccination against follicular lymphoma in first
remission. Blood 90(Suppl :249a, 1997  
30. Bendandi M, Gocke CD, Kobrin CB, et al: Complete molecular remissions induced by
patient-specific vaccination plus granulocyte-monocyte colony-stimulating factor against
lymphoma. Nature Med 5:1171-1177, 1999  
31. Foran JM, Rohatiner AZS, Coiffier B, et al: Multicenter phase II study of fludarabine
phosphate for patients with newly diagnosed lymphoplasmacytoid lymphoma,
Waldenstrom's Macroglobulinemia, and mantle-cell lymphoma. J Clin Oncol 17:546, 1999  
32. Qin et al., Nature Med 4:627-630, 1998.  
33. Thall PF and Simon RM: Recent developments in design of phase II clinical trials. in Thall
PF ed. Recent advances in clinical trial design and analysis. Kluwer, pp 49-72, 1995.  
31
13. appendices
13.1 appendix 1 procedures for

NOTE: See Section 5.2 for more information on request and use of stored specimens.  
13.1.1 Apheresis Products, Tissue, and Serum Specimens
The Clinical Support Laboratory, Leidos Biomedical Research, Inc., processes and cryopreserves
samples in support of IRB-approved, NCI clinical trials. All laboratory personnel with access to
patient information annually complete the NIH online course in Protection of Human
Subjects. The laboratory is CLIA certified for CD4 immunophenotyping and all laboratory areas
operate under a Quality Assurance Plan with documented Standard Operating Procedures that are
reviewed annually. Laboratory personnel are assessed for competency prior to being permitted
to work with patient samples. Efforts to ensure protection of patient information include:  
The laboratory is located in a controlled access building and laboratory doors are kept
locked at all times. Visitors to the laboratory are required to be accompanied by
laboratory staff at all times.
Hard copy records or electronic copies of documents containing patient information are
kept in the locked laboratory or other controlled access locations.
An electronic database is used to store information related to patient samples processed
by the laboratory.
The database resides on a dedicated program server that is kept in a central,
locked computer facility.
The facility is supported by two IT specialists who maintain up to date security
features including virus and firewall protection.
Program access is limited to specified computers as designated by the laboratory
director. Each of these computers has a password restricted login screen.
The database sample entry program itself is accessed through a password
protected entry screen.
The database program has different levels of access approval to limit
unauthorized changes to specimen records and the program maintains a sample
history.
Upon specimen receipt each sample is assigned a unique, sequential laboratory accession
ID number. All products generated by the laboratory that will be stored either in the
laboratory freezers or at a central repository facility are identified by this accession ID.
Beginning October 1, 2006 inventory information will be stored at the vial level and each
vial will be labeled with both a sample ID and a vial sequence number.
Vial labels do not contain any personal identifier information.
Samples are stored inventoried in locked laboratory freezers and are routinely transferred
to the NCI-Frederick repository facilities for long term storage.
Access to stored clinical samples is restricted. Investigators establish sample collections
under "Source Codes" and the investigator responsible for the collections, the protocol
Principal Investigator, specifies who has access to the collection. Beginning October 1,
2006 specific permissions will be required to view, input or withdraw samples from a
collection. Prior to that date sample input was not restricted and restrictions were limited
to specimen withdrawal.  
The laboratory is located in a controlled access building and laboratory doors are kept
locked at all times. Visitors to the laboratory are required to be accompanied by
laboratory staff at all times.  
Hard copy records or electronic copies of documents containing patient information are
kept in the locked laboratory or other controlled access locations.  
An electronic database is used to store information related to patient samples processed
by the laboratory.  
The database resides on a dedicated program server that is kept in a central,
locked computer facility.  
The facility is supported by two IT specialists who maintain up to date security
features including virus and firewall protection.  
Program access is limited to specified computers as designated by the laboratory
director. Each of these computers has a password restricted login screen.  
The database sample entry program itself is accessed through a password
protected entry screen.  
The database program has different levels of access approval to limit
unauthorized changes to specimen records and the program maintains a sample
history.  
Upon specimen receipt each sample is assigned a unique, sequential laboratory accession
ID number. All products generated by the laboratory that will be stored either in the
laboratory freezers or at a central repository facility are identified by this accession ID.  
Beginning October 1, 2006 inventory information will be stored at the vial level and each
vial will be labeled with both a sample ID and a vial sequence number.  
Vial labels do not contain any personal identifier information.  
Samples are stored inventoried in locked laboratory freezers and are routinely transferred
to the NCI-Frederick repository facilities for long term storage.  
Access to stored clinical samples is restricted. Investigators establish sample collections
under "Source Codes" and the investigator responsible for the collections, the protocol
Principal Investigator, specifies who has access to the collection. Beginning October 1,
2006 specific permissions will be required to view, input or withdraw samples from a
collection. Prior to that date sample input was not restricted and restrictions were limited
to specimen withdrawal.  
32  
Sample withdrawal requests submitted to approved laboratory staff by anyone other than
the repository source code owner are submitted to the source code owner for approval.
Beginning October 1, 2006 the repository facility will also notify the Source Code holder
of any submitted requests for sample withdrawal.
It is the responsibility of the Source Code holder (the NCI Principal Investigator) to
ensure that samples requested and approved for withdrawal are being used in a manner
consistent with IRB approval.
The Clinical Support Laboratory does perform testing services that may be
requested by clinical investigators including, but not limited to,
immunophenotyping by flow cytometry and cytokine testing using ELISA or
multiplex platforms.
When requests are submitted by the NCI investigator for shipment of samples outside of
the NIH it is the policy of the laboratory to request documentation that a Material
Transfer Agreement is in place that covers the specimen transfer. The laboratory does
not provide patient identifier information as part of the transfer process but may, at the
discretion of the NCI investigator, group samples from individual patients when that is
critical to the testing process.
The NCI investigator responsible for the sample collection is responsible for ensuring
appropriate IRB approvals are in place and that a Material Transfer Agreement has been
executed prior to requesting the laboratory to ship samples outside of the NIH.  
Sample withdrawal requests submitted to approved laboratory staff by anyone other than
the repository source code owner are submitted to the source code owner for approval.
Beginning October 1, 2006 the repository facility will also notify the Source Code holder
of any submitted requests for sample withdrawal.  
It is the responsibility of the Source Code holder (the NCI Principal Investigator) to
ensure that samples requested and approved for withdrawal are being used in a manner
consistent with IRB approval.  
The Clinical Support Laboratory does perform testing services that may be
requested by clinical investigators including, but not limited to,
immunophenotyping by flow cytometry and cytokine testing using ELISA or
multiplex platforms.  
When requests are submitted by the NCI investigator for shipment of samples outside of
the NIH it is the policy of the laboratory to request documentation that a Material
Transfer Agreement is in place that covers the specimen transfer. The laboratory does
not provide patient identifier information as part of the transfer process but may, at the
discretion of the NCI investigator, group samples from individual patients when that is
critical to the testing process.  
The NCI investigator responsible for the sample collection is responsible for ensuring
appropriate IRB approvals are in place and that a Material Transfer Agreement has been
executed prior to requesting the laboratory to ship samples outside of the NIH.
13. appendices
13.1.2 bloods for pharmacokinetic analysis

The blood that was collected for PK analysis is currently stored as plasma in screw-capped
polypropylene vials in a -70°C degree freezer which is located in a common freezer room in the
1W lab area of the Pediatric Oncology Branch. The freezer temperature is continuously
monitored for +/- temperature differences of 10 degrees C. Samples are stored by patient initials
as well as date and time of sample in individual boxes within this freezer. Records of samples
stored are catalogued in a Filemaker database which is maintained by Pharmacology and
Experimental Therapeutics research nurses and is password protected SO that only members of
the section have access to patient sample information. Results from the analyses of drug levels
from these samples are maintained in an Excel database maintained on a password-protected
computer in the laboratory of Dr. Frank Balis. Both computers containing patient sample
information are backed on a regular (at least one time per week) basis.  
NOTE: These analyses are no longer ongoing. Accordingly, Dr. Balis no longer involved in the
study; however, his name is retained for historical reasons.  
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