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|---|  
Abbreviated Title: Local LMB-100 + ipilimumab Version Date: 04/24/2023  
| Version Date: 04/24/2023                                                                                                                 |                                                                                                                                                   |
|------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------|
| 3.1.1                                                                                                                                    | SCHEMA ........................................................................................................................................34 |
| 3.1.2                                                                                                                                    | Dose Escalation .......................................................................................................................34         |
| 3.1.3                                                                                                                                    | Definition of the MTD ......................................................................................................35                    |
| 3.2                                                                                                                                      | Dose Limiting Toxicities ........................................................................................................35               |
| 3.3                                                                                                                                      | Drug Administration                                                                                                                               |
| 3.3.1                                                                                                                                    | LMB-100................................................................................................................................36         |
| 3.3.2                                                                                                                                    | Ipilimumab ..............................................................................................................................38       |
| 3.4                                                                                                                                      | Dose Modification                                                                                                                                 |
| LMB-100.3.............................................................................................................................38 |                                                                                                                                                   |
| 3.4.1                                                                                                                                    |                                                                                                                                                   |
| 3.4.2                                                                                                                                    | Ipilimumab ...........................................................................................................................41          |
| 3.5                                                                                                                                      | On Assessments Performed Outside of the NIH Clinical Center.................................41                                                    |
| Study Calendar .....................................................................................................................43   |                                                                                                                                                   |
| 3.6                                                                                                                                      | Cost and Compensation                                                                                                                             |
| 3.7                                                                                                                                      |                                                                                                                                                   |
| 3.7.1                                                                                                                                    | Costs .................................................................................................................................48         |
| 3.7.2                                                                                                                                    | Compensation                                                                                                                                      |
| Reimbursement..............................................................................................................48            |                                                                                                                                                   |
| 3.7.3                                                                                                                                    |                                                                                                                                                   |
| 3.8                                                                                                                                      | Criteria for Removal from Protocol Therapy and Off Study Criteria .......................48                                                       |
| 3.8.1                                                                                                                                    | Criteria for removal from protocol therapy................................................................48                                      |
| OFF-Study Criteria ...........................................................................................................48         |                                                                                                                                                   |
| 3.8.2                                                                                                                                    |                                                                                                                                                   |
| 3.8.3                                                                                                                                    | Lost to Follow-up..............................................................................................................49                 |
| 4                                                                                                                                        | CONCOMITANT MEDICATIONS/MEASURES ..................................................................49                                             |
| 4.1.1                                                                                                                                    | Permitted Therapy ..............................................................................................................49                |
| 4.1.2                                                                                                                                    | Prohibited Therapy ............................................................................................................49                 |
| s                                                                                                                                        | CORRELATIVE STUDIES FOR RESEARCH/PHARMACOKINETIC STUDIES..........50                                                                              |
| 5.1                                                                                                                                      | Biospecimen Collection ........................................................................................................................50 |
| 5.1.1                                                                                                                                    | Pharmacokinetic Assessments                                                                                                                       |
| Assessment of anti-drug antibodies (ADAs)                                                                                                |                                                                                                                                                   |
| 5.1.2                                                                                                                                    |                                                                                                                                                   |
| 5.1.3                                                                                                                                    | Retrospective Analysis of Tumor Mesothelin Expression ..........................................52                                                |
| 5.1.4                                                                                                                                    | Mesothelin and Megakaryocyte Potentiating Factor (MPF) Serum Samples: ........53                                                                  |
| Gene Expression-Based Characterization of the Immune Landscape Before and                                                                |                                                                                                                                                   |
| 5.1.5                                                                                                                                    | After Treatment with LMB-100 and Ipilimumab .............................................................53                                       |
| Tumor Microenvironment Studies Using Multiplex Staining Technologies ..........54                                                        |                                                                                                                                                   |
| 5.1.6                                                                                                                                    |                                                                                                                                                   |
| 5.1.7                                                                                                                                    | Assessment of plasma cytokine levels ....................................................................................54                       |  
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| G$>$> | K4W+72+ PW+1/$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$N                                                                                                                     |                                                                                                        |
| %     | &+70-52 K4W+72+ PW+1/ ^&KP_$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$N                                                                                                                     |                                                                                                        |  
| Version Date: 04/24/2023                                                                                                                              |                                                                                                                                                          |
|-------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------|
| 8.1.3                                                                                                                                                 | Life-threatening                                                                                                                                         |
| 8.1.4                                                                                                                                                 | Severity                                                                                                                                                 |
| 8.1.5                                                                                                                                                 | Relationship to Study Product..................................................................................................70                        |
| 8.2                                                                                                                                                   | Assessment of Safety Events                                                                                                                              |
| 8.3                                                                                                                                                   | Reporting of Serious Adverse Events .................................................................................................71                  |
| Waiver of expedited reporting to CCR..........................................................................................71                      |                                                                                                                                                          |
| 8.4                                                                                                                                                   |                                                                                                                                                          |
| 8.5                                                                                                                                                   | Safety Reporting Criteria to the Pharmaceutical Collaborators ........................................71                                                 |
| 8.6                                                                                                                                                   | Reporting Pregnancy ..............................................................................................................................71     |
| Maternal exposure                                                                                                                                     |                                                                                                                                                          |
| 8.6.1                                                                                                                                                 |                                                                                                                                                          |
| 8.6.2                                                                                                                                                 | Paternal exposure                                                                                                                                        |
| 8.7                                                                                                                                                   | Regulatory Reporting for Studies Conducted Under CCR-Sponsored IND ...............72                                                                     |
| Sponsor Data and Safety Monitoring Board .......................................................................72                                    |                                                                                                                                                          |
| 8.8                                                                                                                                                   | Sponsor Protocol Deviation Reporting                                                                                                                     |
| 8.9                                                                                                                                                   |                                                                                                                                                          |
| 9                                                                                                                                                     | CLINICAL MONITORING                                                                                                                                      |
| STATISTICAL CONSIDERATIONS .                                                                                                                          |                                                                                                                                                          |
| 10                                                                                                                                                    | Statistical hypotheses .....................................................................................................................73           |
| 10.1                                                                                                                                                  |                                                                                                                                                          |
| 10.1.1                                                                                                                                                | Primary Objectives                                                                                                                                       |
| 10.1.2                                                                                                                                                | 10.1.2 Secondary Objectives                                                                                                                              |
| 10.2                                                                                                                                                  | Sample size determination                                                                                                                                |
| 10.3                                                                                                                                                  | Populations for Analyses..............................................................................................................74                 |
| 10.4                                                                                                                                                  | Statistical analysis ..........................................................................................................................74        |
| 10.4.1                                                                                                                                                | General Approach .....................................................................................................................................74 |
| Analysis of the Primary Endpoints                                                                                                                     |                                                                                                                                                          |
| 10.4.2                                                                                                                                                |                                                                                                                                                          |
| 10.4.3                                                                                                                                                | Analysis of the Secondary Endpoints                                                                                                                      |
| 10.4.4                                                                                                                                                | Se                                                                                                                                                       |
| 10.4.5                                                                                                                                                | Baseline Descriptive Statistics .................................................................................................75                      |
| 10.4.6                                                                                                                                                | Planned Interim Analyses .                                                                                                                               |
| 10.4.7                                                                                                                                                | HALTING RULES                                                                                                                                            |
| 10.4.8                                                                                                                                                | Sub-Group Analyses ........................................................................................................................75            |
| Tabulation of individual Participant Data ...............................................................................75                           |                                                                                                                                                          |
| 10.4.9                                                                                                                                                |                                                                                                                                                          |
| 10.4.10 Exploratory Analyses ......................................................................................................................75 |                                                                                                                                                          |
| 11                                                                                                                                                    | HUMAN SUBJECTS PROTECTIONS                                                                                                                               |
| 1.1                                                                                                                                                   | Rationale For Subject Selection ..................................................................................................76                     |  
7  
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|--------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 7      | &'()*+*,')*-. -/ 89:;4+)< =.':24 )- 0-.<4.)$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$56                                                                                      |
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| ##$>$7 | C<<4<<D4.) -/ &-)4.)*'2 ?*<@< '.3 B4.4/*)<$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$                                                                                                       |
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Abbreviated Title: Local LMB-100 + ipilimumab
Version Date:  04/24/2023 9
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untitled h1
1.2.5.4 clinical testing of lmb-100

The first in human study of LMB-100 was initiated by Roche (NCT02317419) and later on continued and completed at NCI (NCT02798536). Twenty-five patients received at least one infusion of LMB-100 and were evaluable for safety assessment ( Table 1 ). The median age of patients was 62.5 years and 14 were females. Seventeen patients had mesothelioma, 2 gastric cancer and 3 each ovarian and pancreatic cancer. Fifteen patients were treated on the multicenter Phase I conducted by Roche, and 10 on the NCI Phase I part of the study.  
| Table 1. Patient Demographics and Clinical Characteristics   |                   |    |
|--------------------------------------------------------------|-------------------|----|
| Characteristics                                              | Patients (n = 25) |    |
| Sex                                                          | Male              | 11 |
| Female                                                       | 14                |    |
| Age (years)                                                  |                   |    |
| Median (range)                                               | 62.5 (37-79)      |    |
| ECOG Performance Status                                      | 9                 |    |
| 0                                                            | 16                |    |
| Diagnosis                                                    |                   |    |
| Malignant Mesothelioma                                       | 17                |    |
| Gastric Cancer                                               | 2                 |    |
| Ovarian Cancer                                               | 3                 |    |
| Pancreatic Cancer                                            | 3                 |    |
| Phase I cohorts                                              |                   |    |
| Multicenter Phase I                                          | 15                |    |
| NCI Phase I                                                  | 10                |    |
| LMB-100 Treatment Cycles                                     |                   |    |
| Median (range)                                               | 2(1-7)            |    |  
Seven different dose levels of LMB-100 were evaluated ranging from 45 to 250 mcg/kg ( Table 2 ).  
On the multi-center part of the phase I study doses of 45, 65, 100, and 170 mcg/kg were evaluated before DLT (capillary leak syndrome, CLS) was observed in 2 of 4 patients treated at 250 mcg/kg. Subsequently, the dose was de-escalated, and 2 additional participants were enrolled at a 200 mcg/kg dose level. However, these two patients were not evaluable for DLT evaluation since they received only a single infusion of LMB-100 before the study was terminated. For the NCI part of the phase I study, treatment began at 170 mcg/kg and 3 of 3 patients experienced creatinine increase (grade 2) during the first cycle. This led to a delay in cycle 2 treatment, an investigatordefined DLT. Kidney function of all 3 participants recovered to baseline and they were able to
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1.2.5.4.2 pharmacokinetics of lmb-100

The change in LMB-100 exposure over time at the different dose levels during cycle 1 day 1 infusion is shown in Figure 3 A. There was a dose-proportional increase in both the C max and AUC INF from 45 mcg/kg to 250 mcg/kg (Figure 3B and C). In patients who were treated at the LMB-100 MTD of 140 mcg/kg, the mean C max was 1974 ng/ml, mean AUC INF 3709, mean halflife 0.87 hour (53 minutes), mean clearance 3.98 L/hour and the mean volume of distribution was 5.90 L. The C max of LMB-100 after day 1 infusion of LMB-100 during cycles 1, 2, 3 and 4 are shown in Figure 3D . In cycle 1 all patients had Cmax >100 ng/mL; in cycle 2, 13 of 21 (62%)
patients who received LMB-100 had C max >100 ng/mL; during Cycle 3 this was reduced to 2 of 1 (18%) patients. All 9 patients who received Cycle 4 had undetectable plasma drug concentration after LMB-100 infusion ( Figure 3D ).
untitled h1
1.2.5.4.3 human anti-lmb-100 antibodies

The presence of ADA was assessed retrospectively, and this information was not available to guide decisions concerning administration of LMB-100. Presence of ADA, of any titer, at baseline i.e.  
prior to receiving first cycle of LMB-100 did not affect the LMB-100 blood levels during cycle 1, since all 23 patients had LMB-100 C max levels ≥ 495 ng/ml on the day 1 infusion. During cycle 2, 13 of 21 patients who received LMB-100 achieved good blood levels (arbitrarily defined as levels
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|---|  
| International              | normalized                                  | ≤ 1.5 × ULN   unless   participant   is    receiving   |                                                |
|----------------------------|---------------------------------------------|--------------------------------------------------------|------------------------------------------------|
| ratio                      | (NR)                                        | OR                                                     | anticoagulant therapy as long as PT or aPTT is |
| prothrombin time (PT)      | within therapeutic range of intended use of |                                                        |                                                |
| Activated                  | partial                                     | anticoagulants                                         |                                                |
| thromboplastin time (aPTT) |                                             |                                                        |                                                |  
ALT (SGPT)=alanine aminotransferase (serum glutamic pyruvic transaminase);
AST (SGOT)=aspartate aminotransferase       (serum glutamic oxaloacetic transaminase); GFR=glomerular filtration rate; ULN=upper limit of normal.  
a.  
Criteria must be met without erythropoietin dependency and without packed red blood cell (pRBC) transfusion within last 2 weeks.
b.  
Creatinine clearance (CrCl) should be calculated per institutional standard.
2.1.1.10 Must have left ventricular ejection fraction >50%.  
2.1.1.11  The effects of LMB-100 on the developing human fetus are unknown. For this reason and because ipilimumab is a Category C agent, women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) while on study therapy and for four months after the last dose of study therapy. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately.  
2.1.1.12 Ability of subject to understand and the willingness to sign a written informed consent document.
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2.1.2 exclusion criteria

2.1.2.1 Is currently participating in or has participated in a study of an investigational agent or has used an investigational device within 3 weeks prior to initiation of study therapy.
Note: Participants who have entered the follow-up phase of an investigational study may participate as long as it has been 3 weeks after the last dose of the previous investigational agent. Patients with active devices will be excluded from the study  
2.1.2.2 Has known active CNS metastases and/or carcinomatous meningitis. Participants with previously treated brain metastases may participate provided they are radiologically stable, i.e. without evidence of progression for at least 4 weeks by repeat imaging (note that the repeat imaging should be performed during study screening), clinically stable and without requirement of steroid treatment for at least 14 days prior to initiation of study therapy.  
2.1.2.3 2.1.2.4 Has active systemic issues as bleeding diathesis or active infections Presence of a clinically significant pericardial effusion 2.1.2.5 Has severe hypersensitivity ( ≥ Grade 3) anti-CTLA4 therapies and/or any of their excipients.  
2.1.2.6 Has received prior radiotherapy to the site of local administration 2.1.2.7 Subjects who have received LMB-100 previously
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longest diameter), be representative of all involved organs, but in addition should be those that lend themselves to reproducible repeated measurements. It may be the case that, on occasion, the largest lesion does not lend itself to reproducible measurement in which circumstance the next largest lesion which can be measured reproducibly should be selected. A sum of the diameters
(longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated and reported as the baseline sum diameters. If lymph nodes are to be included in the sum, then oly the short axis is added into the sum. The baseline sum diameters will be used as reference to further characterize any objective tumor regression in the measurable dimension of the disease. Non-target lesions. All other lesions (or sites of disease) including any measurable lesions over and above the 5 target lesions should be identified as non-target lesions and should also be recorded at baseline. Measurements of these lesions are not required, but the presence, absence, or in rare cases unequivocal progression of each should be noted throughout follow-up.  
6.3.1.2 Methods for Evaluation of Measurable Disease All measurements should be taken and recorded in metric notation using a ruler or calipers. All baseline evaluations should be performed as closely as possible to the beginning of treatment and never more than 4 weeks before the beginning of the treatment. The same method of assessment and the same technique should be used to characterize each identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam. Clinical lesions: Clinical lesions will only be considered measurable when they are superficial
(e.g., skin nodules and palpable lymph nodes) and ≥ 10 mm diameter as assessed using calipers
(e.g., skin nodules). In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the lesion, is recommended.  
Chest x-ray: Lesions on chest x-ray are acceptable as measurable lesions when they are clearly defined and surrounded by aerated lung. However, CT is preferable.  
Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. MRI is also acceptable in certain situations (e.g. for body scans).  
Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal resolution; however, there are many image acquisition variables involved in MRI, which greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable globally. As with CT, if an MRI is performed, the technical specifications of the scanning sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, as with CT, the modality used at follow-up should be the same as was used at baseline and the lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans should be performed with breath-hold scanning techniques, if possible.  
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c.  
FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in cases where a residual radiographic abnormality is thought to represent fibrosis or scarring. The use of FDG-PET in this circumstance should be prospectively described in the protocol and supported by disease-specific medical literature for the indication.  
However, it must be acknowledged that both approaches may lead to false positive CR due to limitations of FDG-PET and biopsy resolution/sensitivity.
Note: A 'positive' FDG-PET scan lesion means one which is FDG avid with an uptake greater than twice that of the surrounding tissue on the attenuation corrected image.  
6.3.1.3 RECIST version 1.1 Response Criteria 6.3.1.3.1   Evaluation of Target Lesions Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes
(whether target or non-target) must have reduction in short axis to <10 mm. Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking as reference the baseline sum of diameters.  
Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute increase of at least 5 mm. (Note: the appearance of one or more new lesions is also considered progressions).  
Stable Disease (SD):  Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum of diameters while on study.
untitled h1
6.3.1.3.2 evaluation of non-target lesions

Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor marker level. All lymph nodes must be non-pathological in size (<10 mm short axis).  
Note: If tumor markers are initially above the upper normal limit, they must normalize for a patient to be considered in complete clinical response.  
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor marker level above the normal limits. Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression of existing non-target lesions. Unequivocal progression should not normally trump target lesion status. It must be representative of overall disease status change, not a single lesion increase.  
Although a clear progression of "non-target" lesions only is exceptional, the opinion of the treating physician should prevail in such circumstances, and the progression status should be confirmed at a later time by the review panel (or Principal Investigator).
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6.3.1.3.3 evaluation of best overall

The best overall response is the best response recorded from the start of the treatment until disease progression/recurrence (taking as reference for progressive disease the smallest measurements  
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| 67@ ABB CDABEA@CF                                                                                                                                                                                                                              | 67            | 87@ CDABEA@CF      |
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