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3.3 dose modifications 3.3.1 lmb-100

Table 12 below provides a guideline on how to manage certain toxicities which are expected with LMB-100 based on preclinical studies and previous clinical experience with molecules in the same class  
| Table 12. Guidelines for Managing Specific LMB-100 Adverse Events  Event Action to Be Taken  IRR/hypersensitivity reaction If an IRR/hypersensitivity develops, the infusion of LMB-100  should be temporarily slowed down or interrupted. The patient  should be monitored until complete resolution of the symptoms  and treated as clinically indicated. Treatment or concomitant  medication may include acetaminophen, antihistamine, IV  saline, oxygen, bronchodilators, corticosteroids, and  vasopressors depending on the symptoms.  If the infusion is interrupted:  o In the event of IRR CTCAE Grade 1, upon resolution of  symptoms, the infusion will resume at the same rate (the  rate being used at the time that the IRR occurred).  o In the event of IRR Grade 2 or 3, upon resolution of  symptoms, the infusion will resume at one-half the  previous rate. The infusion can be re-escalated to initial  rate if considered well tolerated after 1 hour of infusion.  o In the event of IRR CTCAE Grade 3, or CTCAE Grade 4  (which may include pulmonary or cardiac events) or an  anaphylactic reaction:  ƒ The infusion must be stopped and the patient should  receive aggressive treatment  o Patients experiencing IRR CTCAE Grade 4 or  anaphylaxis must be permanently discontinued from  LMB-100 treatment   |
|---|  
| Event                  | Action to Be Taken                     |    |    |                                                          |
|------------------------|----------------------------------------|----|----|----------------------------------------------------------|
| Vascular leak syndrome | In the event of Grade •2 CTCAE vascular leak syndrome  (medical intervention indicated):  o Delay LMB-100 administration until complete resolution  of the event  o For hypotension minimize fluid resuscitation to avoid  fluid overload Minimize crystalloid solutions (e.g., saline)  o Vasopressor support (e.g., phenylephrine) if indicated to  stabilize blood pressure  o Administer colloidal solutions (e.g., albumin) if there is a  clinically significant and persistent systolic blood  pressure drop, and the patient is symptomatic, or urine  output declines  o For pulmonary congestion provide diuretic and/or  albumin treatment in case of hypoalbuminemia as  appropriate  o Progressive shortness of breath may require in addition  endotracheal intubation or drainage of a pleural effusion  o For oliguria and /or rising serum creatinine level delay  LMB-100 if Grade C3 urine output (<10 mL/hr)  o Use fluids judiciously if increase in urine output is  required  o Use dopamine if patient is unresponsive to or unable to  tolerate fluids Monitor serum albumin levels prior to each  LMB-100 treatment cycle  o In the event of Grade •2 CTCAE pericardial effusion  (asymptomatic effusion small to moderate size), consider  delaying LMB-100 administration. In the event of Grade  •3 CTCAE pericardial effusion (effusion with  physiologic consequences) stop LMB-100 treatment until  full resolution                                        |    |    |                                                          |
| Inflammatory           | reactions                              | to | o  | Hydrocortisone (200 mg IV) or equivalent dose of another |
| serosal membranes      | corticosteroid as clinically indicated |    |    |                                                          |
| o                      | In the event of Grade 2 CTCAE pericardial effusion  (asymptomatic effusion small to moderate size), consider  delaying LMB-100 administration. In the event of Grade  •3 CTCAE pericardial effusion (effusion with  physiologic consequences) stop LMB-100 treatment until  full resolution                                        |    |    |                                                          |  
| Event                                                                                                      | Action to Be Taken  o In the event of pleuritis resulting in mild to severe pleuritic pain, treat with analgesics or steroids as clinically  indicated  o For patients who have previously experienced pleuritis  consider administration of a tapering course of prednisone  for 7 days starting with the next LMB-100 infusion   |
|------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Renal Toxicity                                                                                             | Periodic monitoring of renal function and serum electrolytes  IV fluids 0.9 NaCl may be administered after LMB-100  infusion if clinically indicated because of increasing serum  creatinine or decreased urine output.                                                                                                            |
| IRR = infusion related reaction; IV = intravenous; CTCAE = Common Terminology Criteria for  Adverse Events |                                                                                                                                                                                                                                                                                                                                    |
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3.3.2 sel-110

Table 13 below provides a guideline on how to manage certain toxicities which are expected with SEL-110 based on preclinical studies and previous clinical experience with molecules in the same class  
| Event      | Action to Be Taken                                                                                              |                                                                                                                                                                                                                                                                                                                                                                            |
|------------|-----------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Leukopenia | o                                                                                                               | Leukopenia has been reported in patients taking oral  rapamycin. Whether the cause of the leukopenia is a direct  relation to the rapamycin exposure, precedes or is due to  the development of an opportunistic infection is unknown.  Resolution of the leukopenia occurred in cases without  subsequent infection with the stoppage of Sirolimus  (Rapamycin) exposure. |
| o          | The risk of leukopenia and infection will be addressed in  as follows:  ƒ The study excluded subjects with any evidence of  infection or developing infection by evaluating  their vital signs, WBC count and differential.  ƒ All subjects were instructed to avoid anyone who  has an active infection either bacterial or viral.  Subjects also had a WBC performed on day 3, 7,  14, 21 and 30 post exposure.                                                                                                                 |                                                                                                                                                                                                                                                                                                                                                                            |
| o          | Observation. WBC counts have returned to baseline when  rapamycin does have been separated by at least 21 days. |                                                                                                                                                                                                                                                                                                                                                                            |
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table 13. guidelines for managing

| Version date: 10/01/18  Event                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Action to Be Taken  A complete blood count should be performed in patients  where leukopenia is observed. They should also avoid  other patients or family members in whom an active  infection exists. If the leukopenia resolves, patients have  been received additional doses of rapamycin.  o As of 30 November 2017, no SAEs or study drug  discontinuations involving leukopenia have been  reported.   |       |            |           |              |         |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------|------------|-----------|--------------|---------|
| Metabolic disruptions  (hyperglycemia, insulin  resistance,  hypertriglyceridemia and  hypercholesterolemia)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   | o                                                                                                                                                                                                                                                                                                                                                                                                              | Metabolic disruptions (hyperglycemia, insulin resistance,  hypertriglyceridemia and hypercholesterolemia) have  been reported in post-transplant patients who have been  exposed to rapamycin.(31, 32) The occurrence of posttransplant diabetes mellitus (PTDM) has been recognized  for many years as a consequence of solid organ transplant  immunosuppression.(33) Dyslipidemia is a wellrecognized side effect of rapamycin therapy.(34)       |            |           |              |         |
| o                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | The                                                                                                                                                                                                                                                                                                                                                                                                            | exact | mechanisms | of        | rapamycin    | induced |
| hyperglycemia, insulin resistance and its lipid effects are  unclear at this time. It has been shown that rapamycin can  diminish ȕ-cell proliferation in hyperglycemic states  thereby inhibiting the natural cellular response of  neogenesis, proliferation, hypertrophy and a reduction in  apoptosis.(35) Additionally, rapamycin has been shown to  inhibit phosphorylation of IRS-1 and IRS-2 in human  adipocytes mimicking changes seen in type 2 diabetes and  in human peripheral blood monocytes associated with  insulin resistance.(36) Rapamycin has also been shown to  increase basal lipolysis and reduce lipid storage.(36) |                                                                                                                                                                                                                                                                                                                                                                                                                |       |            |           |              |         |
| o                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Patients                                                                                                                                                                                                                                                                                                                                                                                                       | who   | experience | metabolic | disturbances |         |
| (increased glucose, triglyceride and LDL cholesterol  levels) should be treated at the discretion of the  investigator according to their clinical judgement.  Preliminary analyses of final safety data in the clinically  complete Phase I study indicate no TEAEs involving  metabolic disorders or lipid profiles in subjects who  received SEL-212 (combination of SEL-110 and SEL037).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |                                                                                                                                                                                                                                                                                                                                                                                                                |       |            |           |              |         |  
| Version date: 10/01/18  Event   | Action to Be Taken  o As of 30 November 2017, no SAEs or study drug  discontinuations involving metabolic disorders or changes  in lipid levels have been reported.                                                                                                                                                                                                                         |                                                                                                                                                                                                                              |
|---------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Hypophosphatemia                | o                                                                                                                                                                                                                                                                                                                                                                                           | The mechanism of hypophosphatemia is not known, but it  has been seen in patients that have received mTOR  inhibitors such as rapamycin.(37)                                                                                 |
| o                               | Preliminary analyses of final safety data in SEL-212/101  Phase I study indicate no TEAEs involving  hypophosphatemia in subjects who received SEL-212  (combination of SEL- 110 and SEL-037).                                                                                                                                                                                              |                                                                                                                                                                                                                              |
| o                               | As of 30 November2017, no SAEs or study drug  discontinuations involving hypophosphatemia have been  reported                                                                                                                                                                                                                                                                               |                                                                                                                                                                                                                              |
| Stomatitis                      | o                                                                                                                                                                                                                                                                                                                                                                                           | The mechanism of stomatitis is not known, but has been  reported in patients that have received mTOR inhibitors  such as rapamycin as early as 7 days after treatment and  responds to locally applied Clobetasol cream.(37) |
| o                               | Analyses of final safety data in the Phase I SEL-212/101  study indicate that SAEs of stomatitis in 2 subjects who  received SEL-110 at the highest dose (0.5 mg/kg) were  characterized as related to study drug. Both subjects  recovered from the events. As a result of these two SAEs,  the Sponsor did not dose patients at the planned highest  dose of SEL-212 (0.5 mg/kg SEL-110 + 0.4 mg/kg SEL037).                                                                                                                                                                                                                                                                                                                                                                                             |                                                                                                                                                                                                                              |
| o                               | Patients who experience early signs of stomatitis should  treat the local lesion with Clobetasol gel or cream directly  to the lesion. Initially the appearance is thought to be that  of an aphthous ulcer. Early application of the steroid  treatment usually results in resolution. Interestingly these  lesions don't usually recur after resolution and continued  rapamycin therapy. |                                                                                                                                                                                                                              |
| o                               | As of 30 November2017, no SAEs or study drug  discontinuations involving metabolic disorders or changes  in lipid levels have been reported.                                                                                                                                                                                                                                                |                                                                                                                                                                                                                              |
| Immunologic Responses           | o                                                                                                                                                                                                                                                                                                                                                                                           | The risk of infusion reactions are addressed as follows:  ƒ Subjects with known allergy to PEGylated products  and history of anaphylactic reactions to recombinant                                                                                                                                                                                                                              |  
| Event   | Action to Be Taken  protein or hypersensitivity to PEG are excluded from  study.  ƒ Measurements of anti-PEG antibodies will be taken as  a baseline upon pre-dose and at end of study.  ƒ Each subject will be observed for infusion reactions  after dosing of study drug in the clinic for 9 hours.  Subjects will be instructed on the signs or symptoms of  infusion reaction and told to notify the PI immediately  if they feel they are experiencing one.  ƒ SEL-110 will be administered via syringe pump to  control the infusion rate of the small volume of  material.  ƒ As of 30 November 2017, SAEs characterized as  related to study drug have involved anaphylactic  reactions or infusion related reactions in 7 subjects that  occurred with temporal proximity to initiation of the  second dose of either SEL-037 or SEL-212 (1 subject  at 0.1 mg/kg SEL-110 + 0.2 mg/kg SEL-037), and at  0.1 mg/kg SEL-110 + 0.4 mg/kg SEL-037) and with  temporal proximity to initiation of the first dose of  SEL-212 in Cohort 6 (1 subject at 0.08 mg/kg SEL-110  + 0.4 mg/kg SEL-037). All patients were treated with  antihistamines, bronchodilators, and/or corticosteroids  and all patients were reported as having recovered from  the events.  Two withdrawals due to non-severe, non-serious  adverse events of infusion reactions (other than SAEs)  have been reported, one each in Cohort 6 (0.08 mg/kg  SEL-110 + 0.4 mg/kg SEL-037) and Cohort 10 (0.125  mg/kg SEL-110 + 0.4 mg/kg SEL-037). Six additional  non-severe, non-serious adverse events of infusion  reactions were reported by 5 subjects in Cohort 3 (1  subject at 0.05 mg/kg SEL-110 + 0.2 mg/kg SEL037), Cohort 5 (1 subject at 0.08 mg/kg SEL-110 + 0.2  mg/kg SEL-037), Cohort 6 (1 subject at 0.08 mg/kg  SEL-110 + 0.4 mg/kg SEL-037), and Cohort 7 (2  subjects at 0.1 mg/kg SEL-110 + 0.2 mg/kg SEL-037)  which did not result in withdrawal of study drug. Only  two subjects required treatment with antihistamines  and corticosteroids, and all subjects were reported as  having recovered from the events.   |
|---------|---|  
| Version date: 10/01/18  Event   | Action to Be Taken                                                                                                                                                                                                                                                                                                                                                                                                                                                               |                                                                                                                                                                                                                                                                                                    |                                                    |
|---------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------|
| Reproductive                    | System                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | o                                                                                                                                                                                                                                                                                                  | Oligo/azoospermia has been seen in some male renal |
| Disruptions                     | transplant patients taking an oral form of SEL-110  (rapamycin) administered chronically on a daily or three  times weekly basis for the prevention of transplant  rejection when treated for a period greater than 6 months.  The mechanism for this effect is not known. In those  patients where oligo/azoospermia has been seen partial to  full reversibility of sperm production following cessation  of treatment with the oral form of rapamycin has been  demonstrated. |                                                                                                                                                                                                                                                                                                    |                                                    |
| o                               | Nonclinical data from three repeat dosing of 6 mg/kg  SEL-110 in male rats showed return of spermatogenesis  and normal levels of sperm in many rats, suggesting  recovery of the original testicular effects, while in some  rats the presence of atrophic tubules at the end of the  recovery period may have represented partial recovery or  may have been related to normal senescence.                                                                                     |                                                                                                                                                                                                                                                                                                    |                                                    |
| o                               | Male patients should be informed that their fertility may  be affected temporarily or permanently after being given  SEL-110.                                                                                                                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                    |                                                    |
| o                               | In patients prescribed chronic daily Rapamune® (same  active ingredient as SEL-110, rapamycin) cessation of  rapamycin has resulted in some of the cases experiencing  a partial or complete resolution to their oligospermia. No  information on recovery of patients taking SEL-110 is  currently available.                                                                                                                                                                   |                                                                                                                                                                                                                                                                                                    |                                                    |
| Fetal Development               | o                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | In preclinical animal studies performed with an oral form  of the drug to be administered in this study, SEL-110 (a  component of SEL-212) showed adverse effects when  given to pregnant rats. These effects included fetal death,  reduced fetal weights, and delays in the formation of  bones. |                                                    |
| o                               | It is not known whether these effects would also occur  humans, a similar risk should be considered possible until  such studies are performed.                                                                                                                                                                                                                                                                                                                                  |                                                                                                                                                                                                                                                                                                    |                                                    |  
| 3.4 STUDY CALENDAR                         | 1 cycle =21 days                | Screening assessments must occur within 28 days prior to enrollment unless otherwise noted. If screening assessments are performed   | within 3 days prior to dosing, the assessments do not need to be repeated on C1D1 unless otherwise indicated (see ECG and pregnancy  test below).   | Assessments after C1D1 may be performed up to 3 days prior to indicated time unless otherwise indicated.   | Dosing cycles after cycle 1 may be delayed for up to two weeks to accommodate schedule conflicts, Federal holidays and inclement  weather, etc.   | Procedure   |
|--------------------------------------------|---------------------------------|--------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------|-------------|
| Cycle 1                                    | Scree                           | ning                                                                                                                                 |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| Long-Term Follow  Up  (Optional)14         | X                               |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| Follow-Up Visit (6- 8 weeks after          | completion of study  therapy)13 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| End of Treatment  Visit  (Cycle 4, Day 21) |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| Cycles 2 - 4                               | X                               | X                                                                                                                                    | X                                                                                                                                                   |                                                                                                            |                                                                                                                                                   |             |
| X                                          |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| X                                          | X                               | X                                                                                                                                    | X X X X                                                                                                                                             |                                                                                                            |                                                                                                                                                   |             |
| X3 X X X X X3 X                            |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
|                                            | ay  15                          |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | ay  8                           |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | ay  5                           |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | ay  3                           |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | ay  1                           |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | ay  15                          |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          |                                 | y  8                                                                                                                                 |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
|                                            | a                               | y  5                                                                                                                                 |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | a                               |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          | a                               | y  3                                                                                                                                 |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| D                                          |                                 | y  1                                                                                                                                 |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
|                                            | a                               | C2                                                                                                                                   | onl                                                                                                                                                 | y                                                                                                          |                                                                                                                                                   |             |
| X X X                                      | C2                              | onl                                                                                                                                  | y                                                                                                                                                   |                                                                                                            |                                                                                                                                                   |             |
| X X X                                      |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| X X X X                                    |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| X X X  X                                   | X                               | X                                                                                                                                    |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| X X X X                                    | X X X X                         | X X X X                                                                                                                              |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| X X X                                      | X                               | X                                                                                                                                    | X                                                                                                                                                   | X                                                                                                          | X 4                                                                                                                                               |             |
| History and PE X                           | Vital signs1 X                  | X                                                                                                                                    | Labs2 X                                                                                                                                             | X                                                                                                          | HLA Typing  (Class I and  Class II)                                                                                                               |             |
| Performance  Score                         |                                 |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| LMB-100                                    | Urinalysis                      |                                                                                                                                      |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |
| SEL-110                                    | Weight                          | Height                                                                                                                               |                                                                                                                                                     |                                                                                                            |                                                                                                                                                   |             |  
65  
| 1 At screening: heart rate, blood pressure, body temperature, pulse oximetry. During the infusions of all study medication in Cycles 1 and 2,   | vital signs (heart rate, blood pressure, body temperature) have to be monitored pre-infusion and every 15 minutes (± 5 minutes) during the   |                          |                        |         |    |
|-------------------------------------------------------------------------------------------------------------------------------------------------|----------------------------------------------------------------------------------------------------------------------------------------------|--------------------------|------------------------|---------|----|
| Long-Term Follow  Up  (Optional)14                                                                                                              | X11 X11 X                                                                                                                                    | X11 X11 X                |                        |         |    |
| Follow-Up Visit (6- 8 weeks after                                                                                                               | completion of study  therapy)13                                                                                                              |                          |                        |         |    |
| End of Treatment  Visit  (Cycle 4, Day 21)                                                                                                      |                                                                                                                                              |                          |                        |         |    |
| Cycles 2 - 4                                                                                                                                    | X                                                                                                                                            | X                        |                        |         |    |
| Please see section 5.2                                                                                                                          | Please see section 5.2                                                                                                                       |                          |                        |         |    |
|                                                                                                                                                 | ay  15                                                                                                                                       |                          |                        |         |    |
| D                                                                                                                                               | ay  8                                                                                                                                        |                          |                        |         |    |
| D                                                                                                                                               | ay  5                                                                                                                                        |                          |                        |         |    |
| D                                                                                                                                               | ay  3                                                                                                                                        |                          |                        |         |    |
| D                                                                                                                                               | ay  1                                                                                                                                        |                          |                        |         |    |
| D                                                                                                                                               | ay  15                                                                                                                                       |                          |                        |         |    |
| D                                                                                                                                               |                                                                                                                                              |                          |                        |         |    |
| D                                                                                                                                               |                                                                                                                                              | y  8                     |                        |         |    |
|                                                                                                                                                 | a                                                                                                                                            | y  5                     |                        |         |    |
| D                                                                                                                                               | a                                                                                                                                            |                          |                        |         |    |
| D                                                                                                                                               | a                                                                                                                                            | y  3                     |                        |         |    |
| D                                                                                                                                               |                                                                                                                                              | y  1                     |                        |         |    |
|                                                                                                                                                 | a                                                                                                                                            | Monitored continuously   | Monitored continuously |         |    |
| X X X                                                                                                                                           |                                                                                                                                              |                          |                        |         |    |
| C3                                                                                                                                              | on                                                                                                                                           | ly1 0                    |                        |         |    |
| X                                                                                                                                               | Every 6 weeks ± 7 days                                                                                                                       | Every 6 weeks ± 7 days   | X X X                  |         |    |
| Cycle 1                                                                                                                                         | Scree                                                                                                                                        | ning Procedure           | 6                      |         |    |
| X                                                                                                                                               | X 8                                                                                                                                          | X 9                      |                        |         |    |
| Anti HIV, anti  HCV, HBSAg X  Urine or serum  hCG in women                                                                                      | of childbearing                                                                                                                              | potential5               |                        |         |    |
| X                                                                                                                                               | X                                                                                                                                            | X                        | X                      | ECG12 X | X  |
| Confirmation of                                                                                                                                 | dx7                                                                                                                                          | CT CAP and/or  MRI       | Adverse Events         |         |    |
| NIH Advance  Directives  Form                                                                                                                   | Echocardiogra m                                                                                                                              | Concomitant  Medications |                        |         |    |
| Correlative  Research  Studies                                                                                                                  |                                                                                                                                              |                          |                        |         |    |
| Biopsy  (optional)                                                                                                                              | FDG-PET                                                                                                                                      |                          |                        |         |    |
| PK                                                                                                                                              |                                                                                                                                              |                          |                        |         |    |  
66 infusion and then every 30 minutes (± 10 minutes) from the end of the infusion until the infusion line is removed. From Cycle 3 onwards, vital signs have to be monitored only pre and post infusion if study medication has been tolerated well in previous cycles.  
2 CBC with differential, Acute Care Panel, Hepatic Panel, Mineral Panel, Lipid Panel, creatine kinase, C-reactive protein, PT, PTT, fibrin degradation products. On day 1 of each cycle, labs for lactate dehydrogenase (LDH), uric acid and CA125 will also be drawn. 3 Day 15 labs may be performed outside of NIH 4 May be performed after study consent is signed but prior to treatment initiation (baseline) 5 Required in women of childbearing potential; i.e. premenopausal women and women  2 years after menopause (menopause is defined as amenorrhea for > 2 years. 6 Only required if more than 14 days have passed since screening.7 May be performed at any time prior to enrollment. Please see section 2.2 for tissue requirements 8 As indicated in section 10.3, all subjects will be offered the opportunity to complete an NIH advance directives form. This should be done preferably at baseline but can be done at any time during the study as long as the capacity to do so is retained. The completion of the form is strongly recommended, but is not required. 9 To be performed at baseline - any time after patient has signed the study consent, but before study therapy initiation. 10 To be performed after the completion of 2 cycles of study therapy. 11 Performed only if patient removed from study therapy for reason other than progressive disease 12 Single 12-lead ECG will be recorded at screening, then pre- and end of LMB-100 infusion for first 3 cycles and at the follow-up visit. Preinfusion at all other study drug administrations. Additional unscheduled ECG assessments should be performed if cardiovascular symptoms or abnormalities occur.13 The assessments listed refer to those that will be performed if the patient is seen in clinic 6- 8 weeks **after the last dose of study drug**. If the patient is unable to return to the clinic for the follow up visit, an adverse event assessment will be performed by telephone.14 Study visits after safety follow up visit will be encouraged but not required. Only patients who are removed from study therapy for reasons other than disease progression will be invited (approximately every 6 weeks) for the indicated scans and labs until disease progression.
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3.5 criteria for removal from

Prior to removal from study, effort must be made to have all subjects complete a safety visit approximately 30 days following the last dose of study therapy.  
3.5.1 Criteria for removal from protocol therapy  
x Progressive disease x Participant has completed 4 cycles of study therapy x Participant requests to be withdrawn from active therapy x Positive pregnancy test x Unacceptable Toxicity as defined in sections 3.1.1 and 3.3 x Requirement for any of the prohibited medications listed in section 4.1.2 x Investigator discretion 3.5.2 Off-Study Criteria x Completed study follow-up period x Decision to end the study x Participant requests to be withdrawn from study x 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 web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be completed and sent via encrypted email to: NCI Central Registration Office ncicentralregistrationl@mail.nih.gov.
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4 concomitant medications/measures 4.1.1 permitted

Concomitant therapy includes any medication (e.g., prescription drugs, over-the-counter (OTC) drugs, approved dietary and herbal supplements, nutritional supplements) used by a patient from the screening period until the follow-up visit. If any treatment is given within 4 weeks prior to screening this should be reported to the investigator and recorded in the eCRF. All therapy and/or medication administered to manage adverse events should be recorded on the Adverse Event eCRF. Supportive care may be administered according to NIH CC Pharmacy Guidelines unless otherwise specified in section 3.3.
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4.1.2 prohibited therapy

Patients should be treated for all concomitant conditions and adverse events according to accepted standards of medical care at the discretion of the investigator. The following treatments are not permitted during the study:
x Any other investigational therapy x Cytotoxic chemotherapy agents other than study agents x Radiotherapy. Note: palliative 8Gy radiotherapy is allowed.  
x Strong inhibitors or inducers of CYP3A4 (as can be found here: Flockhart Table or in another frequently updated source)
x Drugs known to interact with Rapamune such as cyclosporine, diltiazem, erythromycin, ketoconazole (and other antifungals), nicardipine (and other calcium channel blockers), rifampin, verapamil x Any medications or treatments that may adversely affect the immune system such as allergy injections, immune globulin, interferon, immunomodulators, cytotoxic drugs, or systemic corticosteroids (oral or injectable)
x Other systemic anti-neoplastic agents and targeted therapies If any anti-neoplastic or investigational therapies listed above are needed, the patient will be considered to have evidence of progressive neoplastic disease and have experienced treatment failure with study treatment and should be withdrawn from study treatment. All concomitant treatments must be documented in the eCRF.
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5 biospecimen collection 5.1 correlative

All blood samples for PK assessment will be collected from an IV line different to that receiving the infusion to measure free and total concentrations for LMB-100 for all patients. The date and time of each sample collection will be recorded. If multiple samples are drawn at a given time point, the PK sample should take precedence. Free and total plasma concentrations of LMB-100 will be measured using validated ligand-binding assays. 5.1.1.1 Sample collection:
Blood will be collected in 2 mL K2EDTA tubes (purple top) at the times defined in section 5.2.  
Samples should be inverted 8 to 10 times after collection. Store on wet ice or at 4°C. Processing within 60 minutes of blood collection is highly preferred. 5.1.1.2 Sample processing Samples will be processed in the Clinical Pharmacology Program. Please e-mail Paula Carter pcartera@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact Paula Carter by e-mail or at 240-858-3191. Upon arrival in the CPP the following procedures should be followed:
1. Store on wet ice until centrifugation. 2. Centrifuge 1500xg for 10 minutes at 4°C within 60 minutes of blood collection. 3. Transfer plasma specimen to 2mL cryovials and store at -70°C.  
The analyses will be performed retrospectively in batched samples or at the end of the trial. 5.1.1.3 Sample Shipping Samples will be shipped by the CPP on dry ice to the below address for analysis.  
Leidos Biomedical, Inc. Attention: Ms. Yanyu Wang, Dr. Jon Inglefield Building 469, Room 120 Miller Drive Frederick, MD 21702 Phone: 301-846-6905/301-846-6865 5.1.1.4 Sample storage Samples will be stored in the CPP until shipment to the Leidos Biomedical Inc. Lab in Frederick.
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5.1.2 sel-110 pharmacokinetic assessments

Whole blood levels of rapamycin (SEL-110) will be measured using a validated LC/MS method. All blood samples for PK assessment will be collected from an IV line different to that receiving the infusion to measure concentrations for SEL-110 for all patients. The date and time of each sample collection will be recorded. If multiple samples are drawn at a given time point, the PK sample should take precedence.
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5.1.2.1 sample collection

Samples will be collected in 3.0 mL, K3EDTA tubes (purple top) at the times defined in section 5.2. Samples should be inverted 8 after collection. NOTE: Do not shake or centrifuge samples. Processing within 60 minutes of blood collection is highly preferred. 5.1.2.2 Sample Processing Samples will be processed in the Clinical Pharmacology Program. Please e-mail Paula Carter pcartera@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact Paula Carter by e-mail or at 240-858-3191. Upon arrival in the CPP, each sample should be processed in the following manner:
1. Divide whole blood into two 4.0 mL cryovial (at least 1.5 mL in cryovial A and the rest in cryovial B).  
2. Freeze upright at -80϶ C. The time between sample collections to placement in the freezer should not exceed 120 minutes
Do not Shake. Do not Centrifuge. 5.1.2.3 Sample Shipping Do NOT ship sample A and B together. Sample B should remain stored on site at -80º until sample received report is received for sample A Samples will be shipped by the CPP on dry ice along with sample manifest to Sannova Analytical Inc.  
Malleswar Kollu. Sannova Analytical Inc. 155 Pierce Street Somerset, NJ 08873 Phone No: 732-560-0066 Fax: 732-560-0266 Please send shipment notification to: Malleswar Kollu (kollu@sannova.net), Shalini Pasuparthy (shalini@sannova.net), Pinakin Patel (pinakin@sannova.net) 5.1.2.4 Sample Storage Samples will be stored in the CPP until shipment to Sannova Analytical Inc. 5.1.3 Assessment of LMB-100 anti-drug antibodies (ADAs) 5.1.3.1 Sample Collection Samples will be collected before LMB-100 administration on days 1 and 5 of each cycle (See section 5.2). Sample may be collected at the same time as the anti-PEG sample referenced in section 5.1.4.  
Draw 2mL into K2EDTA tube (purple top). Samples should be inverted 8 to 10 times after collection. Store on wet ice or at 4°C. Processing within 60 minutes of blood collection is highly preferred. 5.1.3.2 Sample Processing Samples will be processed in the Clinical Pharmacology Program. Please e-mail Paula Carter pcartera@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact Paula Carter by e-mail or at 240-858-3191. Upon arrival in the CPP, each sample should be processed in the following manner:
1. Store on wet ice until centrifugation. 2. Centrifuge 1500xg for 10 minutes at 4°C within 60 minutes of blood collection. 3. Transfer plasma specimen to 2mL cryovials and store at -70°C.  
Autoantibody levels will be retrospectively assessed. 5.1.3.3 Sample Shipping Samples will be shipped by the CPP on dry ice to the below address for analysis.  
Leidos Biomedical, Inc. Attention: Ms. Yanyu Wang, Dr. Jon Inglefield Building 469, Room 120 Miller Drive Frederick, MD 21702 Phone: 301-846- 6905 /301-846- 6865 5.1.3.4 Sample Storage Samples will be stored in the CPP until shipment to the Leidos Biomedical Inc. Lab in Frederick. 5.1.4 Assessment of anti-PEG antibodies 5.1.4.1 Sample Collection Samples will be collected before SEL-110 administration on day 1 of each cycle in which SEL110 is administered (See section 5.2)
Collect subject's venous blood contralaterally to the site of injection into a 5 mL SST Vacutainer. Invert and gently mix the SST Vacutainer 5 times. Place upright at room temperature until observe a clot (approximately 30 minutes).
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5.1.4.2 sample processing

Samples will be processed in the Clinical Pharmacology Program. Please e-mail Paula Carter pcartera@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact Paula Carter by e-mail or at 240-858-3191. Upon arrival in the CPP, each sample should be processed in the following manner: Centrifuge within one hour of collection by spinning SST Vacutainer at 1100 g for 15 minutes in a centrifuge with swinging buckets or 1100 g for 15 minutes in a fixed angle centrifuge. Remove from centrifuge and transfer plasma in approximately two equal volumes to two 2 mL cryovials, designated as primary sample A and sample B.  
Immediately freeze the plasma samples in -80oC freezer until shipped to TGA. Do NOT ship sample A and B together. Sample B should remain stored on site at -80oC until sample receipt at TGA is confirmed for sample A. 5.1.4.3 Sample Shipping Samples will be shipped by the CPP on dry ice to TGA Sciences Inc.  
TGA Sciences, Inc. Attn: Denise McSweeney (LMB) 47 Hall Street Medford, MA 02155 5.1.4.4 Sample Storage Samples will be stored in the CPP until shipment to TGA Sciences. 5.1.5 Mesothelin and Megakaryocyte Potentiating Factor (MPF) Serum Samples: The levels of serum mesothelin as well as megakaryocyte potentiating factor, which is released into serum from the processing of mesothelin precursor protein will be assessed in order to determine correlation with therapeutic response. 5.1.5.1 Sample Collection Samples will be obtained prior to the first LMB-100 dose of each cycle and at the end of treatment All blood samples will be taken by either direct venipuncture or an indwelling venous access. At each sample collection time, blood (2mL) will be drawn into a 3.5-mL serum separator tube labeled as follows:
- Subject ID Number - Study Number - Time and date of collection  
5.1.5.2 Sample Processing
Please e-mail Paula Carter pcartera@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact Paula Carter by e-mail or at 240-858-3191. Upon arrival in the CPP, each sample should be processed in the following manner: Allow blood to clot for 10 minutes and centrifuge to separate the serum within 30 minutes of collection. If unable to process within 30 minutes, then whole blood tubes may be stored upright in refrigerator (4-8qC) for up to 48 hours prior to processing. Processing of samples within 30 minutes is strongly preferred. Stability studies will establish if degradation of soluble mesothelin in whole blood during 0.5 to 48 hours is significant and therefore if the data from these samples should be included in the analysis. Transfer the serum into two pre-labeled cryotubes and immediately freeze by placing on dry ice.  
Transfer frozen serum samples into a - 80qC freezer for storage.
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5.1.5.3 sample storage

All serum samples will be stored by Dr. Figg's Clinical Pharmacology Program.
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5.1.6 retrospective analysis of mesothelin

IHC analysis will be performed by the Laboratory of Pathology at NCI to determine mesothelin expression within the tumor at any time after study enrollment. Leftover tissue from archival specimens or tumor biopsies obtained at screening or from optional collections at baseline or after cycle 2 may be used for this purpose. Specimens will be used to correlate treatment with response with mesothelin expression in an exploratory analysis.
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5.1.6.1 specimen collection

Collection of optional tumor biopsies should be guided by ultrasound, CT scan, or other method according to the location of the selected lesion using a  18-gauge needle to provide cores ideally of at least 20 mm in length or equivalent size. At least 2, ideally 4 core biopsies will be obtained at each time point (baseline and after cycle 2). Fine needle aspiration and biopsy of bone lesions are not acceptable. All biopsies collected under this protocol will undergo review in the NCI Laboratory of Pathology.
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5.1.7 cytokines for identification of

PE-based RITs cause dose-limiting CLS. At low doses CLS manifests as mild and transient weight gain, hypoalbuminemia, and peripheral or facial edema. At higher doses it can cause lifethreatening cardiopulmonary compromise. Previous studies in rats have indicated that pathological changes indicative of CLS onset occur within just two hours of toxin administration and even when the PE fragment lacks a targeting domain.(38) In vitro studies with cultured endothelial cells have demonstrated that super-physiologic doses of PE-based RITs cannot induce endothelial cell toxicity unless the cells express the RIT target.(39) Together these data suggest the hypothesis that PE-based RITs cause CLS by triggering release of vasoactive cytokines by specific immune cells rather than through direct damage to endothelial cells.  
5.1.7.1 Specimen collection To test this hypothesis, we will collect additional serum from participants in 4 mL SST tubes during each of LMB-100 therapy on:
x Days 1, 3, and 5 (Pre-dose)
x Day 8 (± 2 days)
5.1.7.2 Sample processing Please e-mail Paula Carter pcartera@mail.nih.gov at least 24 hours before transporting samples (the Friday before is preferred). For sample pickup, page 102-11964. For immediate help, call 240-760-6180 (main blood processing core number) or, if no answer, 240-760-6190 (main clinical pharmacology lab number). For questions regarding sample processing, contact Paula Carter by e-mail or at 240-858-3191. Cytokine levels will be retrospectively assessed. 5.1.8 Gene expression-based characterization of the immune landscape before and after treatment with LMB-100 As referenced above, optional tumor biopsy will be performed in consenting patients when deemed feasible at the following time points: before initiation of therapy (archival tissue may also be used) and after two cycles of therapy. We will evaluate tumor biopsies before and after treatment with LMB-100 (using samples referenced in section above) using a hybridization-based digital gene expression platform nCounter (NanoString Technologies). This platform allows for unbiased multiplexed quantification of RNA transcripts achieving sensitivity comparable to quantitative reverse-transcription polymerase chain reaction (Q-RT-PCR), without any enzymatic reaction involved in the process. We have expertise in the use of this technology for the characterization of purified cell subsets and also for the study of the changes that occur in human tumors, as a consequence of a given treatment, using tumor core biopsy tissues. This analysis can be performed on flash frozen biopsies without any further isolation or enrichment of specific cell types. For the present study, we will screen pre- and post-treatment samples for the expression of markers of immune cell subsets (CD3, CD8, CD4, etc.), local production of cytokines (interferon-gamma, tumor necrosis factor-alpha, etc.) and chemokines (CXCL13, CCL5, etc.), adhesion molecules and others. The purpose of this study is to characterize the molecular changes that occur within the tumors following treatment with LMB-100. The ultimate goal is to gain a better understanding of the mechanism of action of this treatment, and to identify molecular correlates of clinical outcomes such as objective responses and/or improved survival. In order to achieve these goals, flash frozen samples will be subjected to total RNA isolation followed by hybridization with capture and detection probes specific for 620 transcripts, including genes involved in the regulation of the immune function and also markers expressed by tumor cells and tumor stroma. To cover those target transcripts, a combination of a commercially available pre-designed probe set (GX Human Immunology v2, NanoString Technologies) will be used in combination with a custom-designed code set of thirty additional targets (Panel Plus, NanoString Technologies). Hybridization complexes will be quantified using a NanoString nCounter Analysis System, at the Genomics Core Facility of the Center for Cancer Research, NCI. Results obtained by this approach will be correlated with data obtained from immunohistochemistry of tumor biopsies as well as with data from analysis of peripheral blood populations, for a comprehensive study of the mechanism of action of LMB-100 in mesothelioma patients. Samples will be stored in the Laboratory of Dr. Raffit Hassan, Building 10, Room 3B51.
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5.1.9 tumor microenvironment studies using

As referenced above, optional tumor biopsy will be performed in consenting patients when deemed feasible at the following time points: before initiation of therapy (archival tissue may also be used) and after two cycles of therapy. Portions of the tumor tissue collected at both timepoints and stored in the Hassan lab (see section 5.1.8) will be provided to the CAT-I, the laboratory of Dr. Ronald Germain. The tissue will be analyzed for cancer associated immune biomarker alterations including the immune cell and tumor cell co-localization with confocal microscopy and histocytometry. The CAT-I lab will return confocal images and quantitative analyses of these images in figure format to the Hassan lab. Samples will be coded in the laboratory of Dr. Raffit Hassan and sent to CAT-I for imaging studies using multiplex staining technologies. The code key will be retained by individuals in the Hassan laboratory and will not be provided to members of the CAT-I lab.
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5.2 sample collection schedule

Unless otherwise indicated, samples are collected at the times given below. For the timed samples (PKs) samples should be collected within ± 5 minutes of given time.  
| samples (PKs) samples should be collected within ± 5 minutes of given time.  SEL110 PKs  Serum  mesothelin  and MPF                                                                     | PE mediated  CLS  (Cytokines)  (5.1.7)   | Tumor  Samplea     |          |    |          |    |
|---------------------------------------------------------------------|------------------------------------------|--------------------|----------|----|----------|----|
| LMB-100  PKs                                                        | Anti PEG  antibodies                     |                    |          |    |          |    |
| ADA                                                                 |                                          |                    |          |    |          |    |
| (5.1.2)                                                             | (5.1.6,  5.1.8, 5.1.9)                   |                    |          |    |          |    |
| (5.1.3)                                                             |                                          |                    |          |    |          |    |
| (5.1.1)                                                             | (5.1.4)                                  | (5.1.5)            |          |    |          |    |
| 3mL  K3EDTA  tube                                                   | 5 mL SST                                 | 2 mL blood         |          |    |          |    |
| Vacutainer                                                          | in 3.5 mL  SST tube                      | 4 mL SST  tube     |          |    |          |    |
| 2 mL  K2EDTA  tube                                                  |                                          |                    |          |    |          |    |
| Cycle                                                               | Day                                      | 2 mL  K2EDTA  tube |          |    |          |    |
| (Times  relative  to start  of SEL110  infusion)                                                                     |                                          |                    |          |    |          |    |
| (Times  relative to  start of  LMB-100  infusion)                   | NA                                       |                    |          |    |          |    |
| Screening                                                           |                                          | Xa                 |          |    |          |    |
| Screening                                                           | period ± 3                               |                    |          |    |          |    |
| days                                                                | --                                       | Pre-dose  0.5      |          |    |          |    |
| --                                                                  | hours                                    |                    |          |    |          |    |
| Pre-dose                                                            | 1 hour                                   |                    |          |    |          |    |
| EOI                                                                 | --                                       |                    |          |    |          |    |
| 1 hour                                                              | 2 hours                                  |                    |          |    |          |    |
| 2 hours                                                             | 3 hours                                  |                    |          |    |          |    |
| 3 hours                                                             | 4 hours                                  |                    |          |    |          |    |
| 4 hours                                                             | 5 hours                                  |                    |          |    |          |    |
| 6 hours                                                             | 7 hours                                  |                    |          |    |          |    |
| 24 hours                                                            | 25 hours                                 | Pre-dose           | Pre-dose | X  | Pre-dose | Xb |
| 1                                                                   |                                          |                    |          |    |          |    |
| 1                                                                   | 3                                        | X                  | Pre-dose |    |          |    |
| --  --                                                              |                                          |                    |          |    |          |    |
| Pre-dose  EOI  1 hour  2 hours  3 hours  4 hours  6 hours  24 hours |                                          |                    |          |    |          |    |
| 5                                                                   | X                                        | Pre-dose           | Pre-dose |    |          |    |  
| Version date: 10/01/18                            | SEL110 PKs                        | Serum  mesothelin  and MPF   | PE mediated  CLS  (Cytokines)  (5.1.7)   | Tumor  Samplea   |          |
|---------------------------------------------------|------------------------|------------------------------|------------------------------------------|------------------|----------|
| LMB-100  PKs                                      | Anti PEG  antibodies   |                              |                                          |                  |          |
| ADA                                               |                        |                              |                                          |                  |          |
| (5.1.2)                                           | (5.1.6,  5.1.8, 5.1.9) |                              |                                          |                  |          |
| (5.1.3)                                           |                        |                              |                                          |                  |          |
| (5.1.1)                                           | (5.1.4)                | (5.1.5)                      |                                          |                  |          |
| 3mL  K3EDTA  tube                                 | 5 mL SST               | 2 mL blood                   |                                          |                  |          |
| Vacutainer                                        | in 3.5 mL  SST tube    | 4 mL SST  tube               |                                          |                  |          |
| 2 mL  K2EDTA  tube                                |                        |                              |                                          |                  |          |
| Cycle                                             | Day                    | 2 mL  K2EDTA  tube           |                                          |                  |          |
| (Times  relative  to start  of SEL110  infusion)                                                   |                        |                              |                                          |                  |          |
| (Times  relative to  start of  LMB-100  infusion) | NA                     |                              |                                          |                  |          |
| 8                                                 | Xc                     |                              | Xc                                       |                  |          |
| --                                                | Pre-dose  0.5          |                              |                                          |                  |          |
| --                                                | hours                  |                              |                                          |                  |          |
| Pre-dose                                          | 1 hour                 |                              |                                          |                  |          |
| EOI                                               | --                     |                              |                                          |                  |          |
| 1 hour                                            | 2 hours                |                              |                                          |                  |          |
| 2 hours                                           | 3 hours                |                              |                                          |                  |          |
| 3 hours                                           | 4 hours                |                              |                                          |                  |          |
| 4 hours                                           | 5 hours                |                              |                                          |                  |          |
| 6 hours                                           | 7 hours                |                              |                                          |                  |          |
| 24 hours                                          | 25 hours               |                              |                                          |                  |          |
| 3                                                 | X                      | Pre-dose                     |                                          |                  |          |
| 1                                                 | Pre-dose               | Pre-dose                     | X                                        | Pre-dose         |          |
| 2 -4                                              | 5                      | Pre-dose,  EOI               | X                                        | Pre-dose         | Pre-dose |
| 8                                                 | Xc                     |                              | Xc                                       |                  |          |
| At time of  Progression                           | X                      | X                            |                                          |                  |          |
| End                                               | of                     |                              |                                          |                  |          |
| Treatment                                         | X                      |                              |                                          |                  |          |
| Follow-up  Visit                                  |                        | X                            | X                                        |                  |          |  
ADA =anti-drug antibody; EOI =End of LMB-100 infusion; PK =pharmacokinetic; MDSC= myeloid derived suppressor cell a. Archival or if not available, a fresh Biopsy or Tumor Effusion (mandatory). Even if archival sample is available, patient may be asked for optional biopsy sample.  
b. Optional biopsies - collected at baseline (biopsy if collected at screening can be used as baseline sample) and at any time after the completion of 2 cycles of therapy.  
c. Performed on day 8 ± 2 days
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5.3 sample storage tracking and

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
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5.3.1 clinical pharmacology program

Upon arrival in the Clinical Pharmacology Program (CPP), OCD, CCR, NCI, all samples are barcoded, with data entered and stored in Patient Sample Data Management System (PSDMS), also known as *Labrador*, the system utilized by the CPP. This is a secure program, with access to the PSDMS system limited to defined CPP personnel, who are issued individual user accounts. PSDMS creates a unique barcode ID for every sample and sample box, which cannot be traced back to patients without PSDMS access. The data recorded for each sample includes the patient ID, name, trial name/protocol number, time drawn, cycle, time point, dose, material type, as well as box and freezer location. There are patient demographics that can be obtained to correlate with the samples through PSDMS. For each sample, there are notes associated with processing method (delay in sample processing, storage conditions on the ward, etc.) Barcoded samples are stored in barcoded boxes in a locked freezer at either -20°C or -80°C according to stability requirements. These freezers are located onsite in the CPP and offsite at NCI Frederick Central Repository Services in Frederick, MD. Samples will be stored until requested by the researcher assigned to the protocol. All requests are monitored and tracked in PSDMS. All researchers are required to sign a form stating that the samples are only to be used for research purposes associated with this trial (as per IRB approved protocol) and that any unused samples must be returned to the CPP. Following completion of this study, samples will remain in storage as detailed above. Access to these samples will only be granted following IRB approval of an additional protocol, granting the rights to use the material.
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5.3.2 leidos biomedical inc. lab

Blood and tissue collected during the course of this study will follow storage, handling and labeling procedures to ensure that security, confidentiality and sample integrity are maintained. All samples (blood or tissue) are tracked by distinct identification labels that include a unique patient identifier and date of specimen collection. Thus, samples will be coded, with access to the code key linking to personal data restricted to the study investigators. All cryopreserved samples are tracked for freezer location and storage criteria. All Samples are stored in a locked freezer at -70qC according to stability requirements. These freezers are located offsite at NCI-Frederick, at the Leidos Biomedical, Inc. Lab in Frederick, MD. Samples will be stored until requested by a researcher named on the protocol. All use and requests for use will be recorded by the Leidos Biomedical, Inc. Lab. Any unused samples must be returned. Some samples as indicated below may be stored in monitored freezers/refrigerators in the investigator's laboratory at specified temperatures with alarm systems in place. At the termination of this protocol, samples will remain in storage as detailed above. If additional studies are to be performed on any samples retaining patient identifiers, obtained during the conduct of this trial, a Request to Conduct Research for Stored Human Samples Specimens, or Data Collected in a Terminated NCI-IRB Protocol will be submitted. Otherwise, access to these samples will only be granted following IRB approval of an additional protocol, granting the rights to use the material. If specimens are to be discarded at any point, they will be disposed of in accordance with the environmental protection laws, regulations and guidelines of the Federal Government and the State of Maryland. 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, the samples will be destroyed (or returned to the patient, if so requested), and reported as such to the IRB.
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5.3.3 laboratory of dr. raffit

This study will follow storage, handling and labeling procedures to ensure that security, confidentiality and sample integrity are maintained. All samples (blood or tissue) are tracked by distinct identification labels generated by Labmatrix that include a unique patient identifier and date of specimen collection. Thus, samples will be coded, with access to the code key linking to personal data restricted to the study investigators. Depending on specimen type, samples are stored in liquid nitrogen, in monitored freezers/refrigerators at either -20 or -80qC according to stability requirements or in a slide cabinet in the research Laboratory of Dr. Raffit Hassan (Building 10, Room 3B51).
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5.3.4 nci laboratory of pathology

Tissues designated for clinical diagnostics are transported to the Laboratory of Pathology (LP) where they are examined grossly and relevant portions are fixed, embedded in paraffin and sectioned and stained for diagnostic interpretation. Unutilized excess tissue that is not placed in paraffin blocks is stored in formalin for up to three months, in accordance with College of American Pathologists/Joint Commission on Accreditation of Healthcare Organizations
(CAP/JCAHO) guidelines, and then discarded. Following completion of the diagnostic workup, the slides and tissue blocks are stored indefinitely in the LP's clinical archives. All specimens are catalogued and retrieved utilizing the clinical laboratory information systems, in accordance with CAP/JCAHO regulations. The use of any stored specimens for research purposes is only allowed when the appropriate IRB approval has been obtained. In some cases, this approval has been obtained via the original protocol on which the patient was enrolled.
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5.3.5 cat-i laboratory

The CAT-I laboratory (CAT-I) will obtain deidentified samples from the Hassan laboratory. Upon acquisition, members of the CAT-I laboratory will enter these samples into CEREBRO, an advanced sample labeling system that tracks each sample through every step of the workflow. To meet requirements for availability of primary data and for quality assurance checks, CAT-I will maintain a detailed inventory of the type (slide, paraffin block, tissue, frozen OCT block) and location of each sample in the laboratory. More specifically, paraffin blocks and accompanying slides will be maintained at room temperature in the CAT- I laboratory. Tissues provided by the Hassan laboratory will be fixed, frozen, and stored in the CAT-I's -80°C freezer. The CAT-I laboratory will be locked when CAT-I lab members are not present. Unprocessed samples will be held by the CAT-I or returned to the Hassan laboratory upon their request. Finally, CAT-I will comply with requirements for annual Biospecimen Reporting at the NIH.
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5.3.6 protocol completion/sample destruction

All specimens obtained in the protocol are used as defined in the protocol. Any specimens remaining at the completion of the protocol will be stored in the conditions described above. The study will remain open as long as sample or data analysis continues. Samples from consenting subjects will be stored until they are no longer of scientific value or until a subject withdraws consent for their continued use, at which time they will be destroyed. Once primary research objectives for the protocol are achieved, intramural researchers can request access to remaining samples, provided they have an IRB-approved protocol and patient consent or an exemption from OHSRP. The PI will report any loss or destruction of samples to the NCI IRB as soon as he/she is made aware of such loss. The PI will report destroyed samples to the IRB if samples become unsalvageable because of environmental factors such as a broken freezer or lack of dry ice in a shipping container, or if a patient withdraws consent. Samples will also be reported as lost if they are lost in transit between facilities or misplaced by a researcher. Freezer problems, lost samples, or other problems associated with samples will also be reported to the IRB, the NCI Clinical Director, and the office of the CCR, NCI.
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6 data collection and evaluation

The PI will be responsible for overseeing entry of data into an in-house password protected electronic system (C3D) 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 adverse events, including clinically significant abnormal findings on laboratory evaluations, regardless of severity, will be followed until return to baseline or stabilization of event. Patients will be followed for adverse events for a minimum of 30 days after removal from study treatment or until off-study, whichever comes first. Adverse events occurring more than 30 days after the last dose of study therapy are only required to be recorded only if they are considered to be serious and related to the investigational agent/intervention. An abnormal laboratory value will be recorded in the database as an AE **only** if the laboratory abnormality is characterized by any of the following:
x Results in discontinuation from the study  
x Is associated with clinical signs or symptoms x Requires treatment or any other therapeutic intervention x Is associated with death or another serious adverse event, including hospitalization.  
x Is judged by the Investigator to be of significant clinical impact x 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, the IRB will be notified.
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6.2 data sharing plans 6.2.1

I will share human data generated in this research for future research as follows:  
x Coded, linked data in an NIH-funded or approved public repository.  
x Coded, linked data in BTRIS (automatic for activities in the Clinical Center)
x Identified or coded, linked data with approved outside collaborators under appropriate agreements.
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how and where will the

x Data will be shared through:
x An NIH-funded or approved public repository. Insert name: clinicaltrials.gov.  
x BTRIS (automatic for activities in the Clinical Center)
x Approved outside collaborators under appropriate individual agreements.  
x Publication and/or public presentations.
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when will the data be

x Before publication.  
x At the time of publication or shortly thereafter.
6.2.2 Genomic Data Sharing Plan No large scale genomic data will be generated on this study; therefore, the NIH GDS policy does not apply.
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6.3 response criteria

For the purposes of this study, patients should be re-evaluated for response every 6 weeks (2 cycles). In addition to a baseline scan, confirmatory scans should also be obtained no less than 4 weeks following initial documentation of objective response. Response and progression will be assessed by the investigator on the basis of physical examinations, computed tomography (CT) or Magnetic Resonance (MR) scans, and potentially other modalities according to standard of care. For peritoneal mesothelioma, the international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1)(40) will be used. Changes in the largest diameter (unidimensional measurement) of the tumor lesions and the shortest diameter in the case of malignant lymph nodes are used in the RECIST criteria. For pleural mesothelioma, modified RECIST for MPM (malignant pleural mesothelioma)(41) should be used as described in section 6.3.2.
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6.3.1 peritoneal mesothelioma

6.3.1.1 Disease Parameters Measurable disease: Measurable lesions are defined as those that can be accurately measured in at least one dimension (longest diameter to be recorded) as:
x By chest x-ray: >20 mm;  
x By CT scan:
o Scan slice thickness 5 mm or under: >10 mm o Scan slice thickness >5 mm: double the slice thickness x With calipers on clinical exam: >10 mm.
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). Malignant lymph nodes. To be considered pathologically enlarged and measurable, a lymph node must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended to be no greater than 5 mm). At baseline and in follow-up, only the short axis will be measured and followed. Non-measurable disease. All other lesions (or sites of disease), including small lesions (longest diameter <10 mm or pathological lymph nodes with 10 to <15 mm short axis), are considered non-measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and abdominal masses (not followed by CT or MRI), are considered as non-measurable. Note: Cystic lesions that meet the criteria for radiographically defined simple cysts should not be considered as malignant lesions (neither measurable nor non-measurable) since they are, by definition, simple cysts. 'Cystic lesions' thought to represent cystic metastases can be considered as measurable lesions, if they meet the definition of measurability described above. However, if non-cystic lesions are present in the same patient, these are preferred for selection as target lesions. Target lesions. All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, representative of all involved organs, should be identified as **target lesions** and recorded and measured at baseline. Target lesions should be selected on the basis of their size (lesions with the 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 only 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 t10 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. PET-CT: At present, the low dose or attenuation correction CT portion of a combined PET-CT is not always of optimal diagnostic CT quality for use with RECIST measurements. However, if the site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for RECIST measurements and can be used interchangeably with conventional CT in accurately measuring cancer lesions over time. Note, however, that the PET portion of the CT introduces additional data, which may bias an investigator if it is not routinely or serially performed. Ultrasound: Ultrasound is not useful in assessment of lesion size and should not be used as a method of measurement. Ultrasound examinations cannot be reproduced in their entirety for independent review at a later date and, because they are operator dependent, it cannot be guaranteed that the same technique and measurements will be taken from one assessment to the next. If new lesions are identified by ultrasound in the course of the study, confirmation by CT or MRI is advised. If there is concern about radiation exposure at CT, MRI may be used instead of CT in selected instances. Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor evaluation is not advised. However, such techniques may be useful to confirm complete pathological response when biopsies are obtained or to determine relapse in trials where recurrence following complete response (CR) or surgical resection is an endpoint. Tumor markers: Tumor markers alone cannot be used to assess response. If markers are initially above the upper normal limit, they must normalize for a patient to be considered in complete clinical response. Specific guidelines for both CA-125 response (in recurrent ovarian cancer) and PSA response (in recurrent prostate cancer) have been published.(42-44) In addition, the Gynecologic Cancer Intergroup has developed CA-125 progression criteria which are to be integrated with objective tumor assessment for use in first-line trials in ovarian cancer.(45) Cytology, Histology: These techniques can be used to differentiate between partial responses (PR) and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as germ cell tumors, where known residual benign tumors can remain).  
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens during treatment when the measurable tumor has met criteria for response or stable disease is mandatory to differentiate between response or stable disease (an effusion may be a side effect of the treatment) and progressive disease. FDG-PET: While FDG-PET response assessments need additional study, it is sometimes reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in assessment of progression (particularly possible 'new' disease). New lesions on the basis of FDG-PET imaging can be identified according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD
based on a new lesion.  
b. No FDG-PET at baseline and a positive FDG-PET at follow-up: If the positive FDGPET at follow-up corresponds to a new site of disease confirmed by CT, this is PD. If the positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, additional follow-up CT scans are needed to determine if there is truly progression occurring at that site (if so, the date of PD will be the date of the initial abnormal FDGPET scan). If the positive FDG-PET at follow-up corresponds to a pre-existing site of disease on CT that is not progressing on the basis of the anatomic images, this is not PD.  
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.  
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). 6.3.1.3.3 *Evaluation of Best Overall Response* 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 recorded since the treatment started). The patient's best response assignment will depend on the achievement of both measurement and confirmation criteria.  
| Target    | Non-Target             | New     | Overall   | Best Overall Response when   |
|-----------|------------------------|---------|-----------|------------------------------|
| Lesions   | Lesions                | Lesions | Response  | Confirmation is Required*    |
| CR        | CR                     | No      | CR        | >4 wks. Confirmation**       |
| CR        | NonCR/Non-PD                        | No      | PR        |                              |
| CR        | Not                    | No      | PR        |                              |
| evaluated | >4 wks. Confirmation** |         |           |                              |
| PR        | NonCR/NonPD/not  evaluated                        | No      | PR        |                              |  
| SD    | NonCR/NonPD/not  evaluated                                                                                                                                                                                                                                                                                                                              | No   | SD   | Documented at least once >4  wks. from baseline**   |
|-------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------|------|-----------------------------------------------------|
| PD    | Any                                                                                                                                                                                                                                                                                                                          | Yes  | or   | PD                                                  |
| No    |                                                                                                                                                                                                                                                                                                                              |      |      |                                                     |
| Any   | PD***                                                                                                                                                                                                                                                                                                                        | Yes  | or   | no prior SD, PR or CR                               |
| PD    |                                                                                                                                                                                                                                                                                                                              |      |      |                                                     |
| No    |                                                                                                                                                                                                                                                                                                                              |      |      |                                                     |
| Any   | Any                                                                                                                                                                                                                                                                                                                          | Yes  | PD   |                                                     |
| *     | See RECIST 1.1 manuscript for further details on what is evidence of a new lesion.                                                                                                                                                                                                                                           |      |      |                                                     |
| **    | Only for non-randomized trials with response as primary endpoint.                                                                                                                                                                                                                                                            |      |      |                                                     |
| ***   | In exceptional circumstances, unequivocal progression in non-target lesions may be accepted as  disease progression.                                                                                                                                                                                                         |      |      |                                                     |
| Note: | Patients with a global deterioration of health status requiring discontinuation of treatment without  objective evidence of disease progression at that time should be reported as "symptomatic  deterioration." Every effort should be made to document the objective progression even after  discontinuation of treatment. |      |      |                                                     |
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for patients with non-measurable disease

| Non-Target Lesions                                                                                                                                                                                                                             | New Lesions   | Overall Response   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------|--------------------|
| CR                                                                                                                                                                                                                                             | No            | CR                 |
| Non-CR/non-PD                                                                                                                                                                                                                                  | No            | Non-CR/non-PD*     |
| Not all evaluated                                                                                                                                                                                                                              | No            | not evaluated      |
| Unequivocal PD                                                                                                                                                                                                                                 | Yes or No     | PD                 |
| Any                                                                                                                                                                                                                                            | Yes           | PD                 |
| * 'Non-CR/non-PD' is preferred over 'stable disease' for non-target disease since SD is increasingly used as  an endpoint for assessment of efficacy in some trials so to assign this category when no lesions can be  measured is not advised |               |                    |
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6.3.2 pleural mesothelioma

Malignant pleural mesothelioma (MPM) lesions are difficult to measure reliably.(41) Therefore, modified criteria were defined in 2004 adjusting target lesion measurements to the specific needs of this disease. 6.3.2.1 Modified RECIST Criteria for MPM Target lesion: Measurable at baseline and defined as tumor thickness measurements perpendicular to the chest wall or mediastinum in two positions at three separate levels on transverse cuts of CT scan. The sum of those 6 measurements define a pleural unidimensional measure. For reproducibility of lesion identification in follow up scans, cuts were taken at least 1 cm apart and close to anatomical landmarks in the thorax. Reassessments should be done at same position at the same level and by the same reader. Nodal, subcutaneous, and other measurable lesion were measured as per RECIST criteria. All unidimensional measurements were added to obtain total tumor measurement. Evaluation of target lesions x Complete Response (CR): Disappearance of all target lesions with no evidence of tumor elsewhere.  
x Partial Response (PR): At least a 30% decrease in the total tumor measurement x Confirmed response (PR and CR): require a repeat scan at least 4 weeks apart x Progressive Disease (PD): At least a 20% increase in the total tumor measurement, taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest on study). (Note: the appearance of one or more new lesions is also considered progression).  
x Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as reference the smallest sum diameters while on study.  
6.3.2.2 Evaluation of Best Overall Response 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 recorded since the treatment started). The patient's best response assignment will depend on the achievement of both measurement and confirmation criteria.  
| Target   | Non-Target                                                                                                           | New       | Overall   | Best                                            | Response   | for   | this   |
|----------|----------------------------------------------------------------------------------------------------------------------|-----------|-----------|-------------------------------------------------|------------|-------|--------|
| Lesions  | Lesions                                                                                                              | Lesions   | Response  | Category Also Requires:                         |            |       |        |
| CR       | CR                                                                                                                   | No        | CR        | >4 wks. confirmation                            |            |       |        |
| CR       | Non-CR/NonPD                                                                                                                      | No        | PR        | >4 wks. confirmation                            |            |       |        |
| PR       | Non-PD                                                                                                               | No        | PR        |                                                 |            |       |        |
| SD       | Non-PD                                                                                                               | No        | SD        | documented at least once >4  wks. from baseline |            |       |        |
| PD       | Any                                                                                                                  | Yes or No | PD        |                                                 |            |       |        |
| Any      | PD*                                                                                                                  | Yes or No | PD        | no prior SD, PR or CR                           |            |       |        |
| Any      | Any                                                                                                                  | Yes       | PD        |                                                 |            |       |        |
| *        | In exceptional circumstances, unequivocal progression in non-target lesions may be accepted  as disease progression. |           |           |                                                 |            |       |        |  
Note: Patients with a global deterioration of health status requiring discontinuation of treatment without objective evidence of disease progression at that time should be reported as "*symptomatic deterioration"*. Every effort should be made to document the objective progression even after discontinuation of treatment.  
In some circumstances it may be difficult to distinguish residual disease from normal tissue. When the evaluation of complete response depends on this determination, it is recommended that the residual lesion be investigated (fine needle aspirate/biopsy) to confirm the complete response status.
6.3.3 Duration of Response Duration of overall response: The duration of overall response is measured from the time measurement criteria are met for CR or PR (whichever is first recorded) until the first date that recurrent or progressive disease is objectively documented (taking as reference for progressive disease the smallest measurements recorded since the treatment started). The duration of overall CR is measured from the time measurement criteria are first met for CR until the first date that progressive disease is objectively documented. Duration of stable disease: Stable disease is measured from the start of the treatment until the criteria for progression are met, taking as reference the smallest measurements recorded since the treatment started, including the baseline measurements.
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6.3.4 progression-free survival

Progression free survival (PFS) is defined as the duration of time from start of treatment to time of progression or death, whichever occurs first. 6.3.5 Objective Response Rate Objective response rate (ORR) is defined as the proportion of patients with partial response or complete response.
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6.4 toxicity criteria

The following adverse event management guidelines are intended to ensure the safety of each patient while on the study. The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site (http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm).
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7 safety reporting requirements/data and

7.1.1 Adverse Event Any untoward medical occurrence in a human subject, including any abnormal sign (for example, abnormal physical exam or laboratory finding), symptom, or disease, temporally associated with the subject's participation in research, whether or not considered related to the subject's participation in the research.
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7.1.2 suspected adverse reaction

Suspected adverse reaction means any adverse event for which there is a reasonable possibility that the drug caused the adverse event. For the purposes of IND safety reporting, 'reasonable possibility' means there is evidence to suggest a causal relationship between the drug and the adverse event. A suspected adverse reaction implies a lesser degree of certainty about causality than adverse reaction, which means any adverse event caused by a drug.
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7.1.3 unexpected adverse reaction

An adverse event or suspected adverse reaction is considered "unexpected" if it is not listed in the investigator brochure or is not listed at the specificity or severity that has been observed; or, if an investigator brochure is not required or available, is not consistent with the risk information described in the general investigational plan or elsewhere in the current application. "Unexpected" also refers to adverse events or suspected adverse reactions that are mentioned in the investigator brochure as occurring with a class of drugs or as anticipated from the pharmacological properties of the drug, but are not specifically mentioned as occurring with the particular drug under investigation.
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7.1.4 serious

An Unanticipated Problem or Protocol Deviation is serious if it meets the definition of a Serious Adverse Event or if it compromises the safety, welfare or rights of subjects or others.
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7.1.5 serious adverse event

An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
x Death,  
x A life-threatening adverse drug experience x Inpatient hospitalization or prolongation of existing hospitalization x Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions x A congenital anomaly/birth defect.
x Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.  
7.1.6 Disability A substantial disruption of a person's ability to conduct normal life functions.  
7.1.7 Life-threatening adverse drug experience Any adverse event or suspected adverse reaction that places the patient or subject, in the view of the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it does not include a reaction that had it occurred in a more severe form, might have caused death.
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7.1.8 protocol deviation (nih definition)

Any change, divergence, or departure from the IRB-approved research protocol.  
7.1.9 Non-compliance (NIH Definition) The failure to comply with applicable NIH Human Research Protections Program (HRPP) policies, IRB requirements, or regulatory requirements for the protection of human research subjects.
7.1.10 Unanticipated Problem Any incident, experience, or outcome that:
x Is unexpected in terms of nature, severity, or frequency in relation to
(a) the research risks that are described in the IRB-approved research protocol and informed consent document; Investigator's Brochure or other study documents, and (b) the characteristics of the subject population being studied; AND
x Is related or possibly related to participation in the research; AND  
x Suggests that the research places subjects or others at a *greater risk of harm* (including physical, psychological, economic, or social harm) than was previously known or recognized.
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7.2 nci-irb and clinical director

7.2.1 NCI-IRB and NCI CD Expedited Reporting of Unanticipated Problems and Deaths The Protocol PI will report in the NIH Problem Form to the NCI-IRB and NCI Clinical Director:
x All deaths, except deaths due to progressive disease  
x All Protocol Deviations x All Unanticipated Problems
x All non-compliance Reports must be received within 7 days of PI awareness via iRIS. 7.2.2 NCI-IRB Requirements for PI Reporting at Continuing Review The protocol PI will report to the NCI-IRB:  
1. A summary of all protocol deviations in a tabular format to include the date the deviation occurred, a brief description of the deviation and any corrective action.  
2. A summary of any instances of non-compliance 3. A tabular summary of the following adverse events:
x All Grade 2 **unexpected** events that are possibly, probably or definitely related to the research; x All Grade 3 and 4 events that are possibly, probably or definitely related to the research; x All Grade 5 events regardless of attribution; x All Serious Events regardless of attribution.
NOTE: Grade 1 events are not required to be reported.
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7.2.3 nci-irb reporting of ind

Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported to the NCI IRB.
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7.3 ind sponsor reporting criteria

Starting from the initiation of study therapy and continuing through the first 30 days after the subject receives the last administration of the investigational agent/intervention, the investigator must immediately report to the sponsor, using the mandatory MedWatch form 3500a or equivalent, any serious adverse event, whether or not considered drug related, including those listed in the protocol or investigator brochure and must include an assessment of whether there is a reasonable possibility that the drug caused the event. For events that occur more than 30 days after the last administration of investigational agent/intervention, only report serious adverse events that have an attribution of at least possibly related to the agent/intervention. Required timing for reporting per the above guideline:
x Deaths (except death due to progressive disease) must be reported via email within 24 hours. A complete report must be submitted within one business day.  
x Other serious adverse events as well as deaths due to progressive disease must be reported within one business day Events will be submitted to the Center for Cancer Research (CCR) at: CCRsafety@mail.nih.gov and to the CCR PI and study coordinator.
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7.3.1 reporting pregnancy 7.3.1.1 maternal

If a patient becomes pregnant during the course of the study, the study treatment should be discontinued immediately and the pregnancy reported to the Sponsor. The potential risk of exposure of the fetus to the investigational agent(s) or chemotherapy agents (s) should be documented in box B5 of the MedWatch form "Describe Event or Problem". Pregnancy itself is not regarded as an SAE. However, as patients who become pregnant on study risk intrauterine exposure of the fetus to agents which may be teratogenic, the CCR is requesting that pregnancy should be reported in an expedited manner as Grade 3 "Pregnancy, puerperium
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and perinatal conditions - other

Congenital abnormalities or birth defects and spontaneous miscarriages should be reported and handled as SAEs. Elective abortions without complications should not be handled as AEs. The outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) should be followed up and documented. If any pregnancy occurs in the course of the study, then the investigator should inform the Sponsor within 1 day, i.e., immediately, but **no later than 24 hours** of when he or she becomes aware of it. The designated Sponsor representative will work with the investigator to ensure that all relevant information is provided to the Sponsor within 1 to 5 calendar days for SAEs and within 30 days for all other pregnancies. The same timelines apply when outcome information is available. 7.3.1.2 Paternal exposure Male patients should refrain from fathering a child or donating sperm during the study and for 90 days after the last dose of LMB-100. Pregnancy of the patient's partner is not considered to be an AE. However, the outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) occurring from the date of the first dose until 90 days after the last dose should, if possible, be followed up and documented.
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7.4 safety reporting criteria to

All events listed below must be reported in the defined timelines to CCRsafety@mail.nih.gov. The CCR Office of Regulatory Affairs will send all reports to the manufacturer as described below. All reports sent to the FDA will be sent concurrently to Selecta via email to Lloyd Johnston and Skip Sands: (LJohnston@selectabio.com and SSands@selectabio.com )
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7.5 data and safety monitoring

The clinical research team will meet on a regular basis when patients are being actively treated on the trial to discuss each patient. Decisions about dose level enrollment and dose escalation will be made based on the toxicity data from prior patients. All data will be collected in a timely manner and reviewed by the principal investigator or a lead associate investigator. Adverse events will be reported as required above. Any safety concerns, new information that might affect either the ethical and or scientific conduct of the trial, or protocol deviations will be immediately reported to the IRB using iRIS. The principal investigator will review adverse event and response data on each patient to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff.
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7.5.2 sponsor monitoring plan

As a sponsor for clinical trials, FDA regulations require the CCR to maintain a monitoring program. The CCR's program allows for confirmation of: study data, specifically data that could affect the interpretation of primary study endpoints; adherence to the protocol, regulations, and SOPs; and human subjects protection. This is done through independent verification of study data with source documentation focusing on:
x Informed consent process  
x Eligibility confirmation x Drug administration and accountability x Adverse events monitoring x Response assessment.
The monitoring program also extends to multi-site research when the CCR is the coordinating center. This trial will be monitored by personnel employed by an NCI contractor. Monitors are qualified by training and experience to monitor the progress of clinical trials. Personnel monitoring this study will not be affiliated in any way with the trial conduct.
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7.5.3 safety monitoring committee (smc)

This protocol will require oversight from the Safety Monitoring Committee (SMC). Initial review will occur as soon as possible after the annual NCI-IRB continuing review date. Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting schedule permits or more frequently as may be required by the SMC. For initial and subsequent reviews, protocols will not be reviewed if there is no accrual within the review period. Written outcome letters will be generated in response to the monitoring activities and submitted to the Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI.
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8 statistical considerations 8.1 statistical

The primary objective is to assess the safety and tolerability of LMB-100 in combination with SEL-110. Safety of the agent will be assessed as described in section 8.4.4. 8.1.2 Secondary endpoints: The secondary endpoints are whether patients will have detectable levels of LMB-100 in their blood during cycle 4 of treatment and to determine the effect of SEL-110 on LMB-100 pharmacokinetics and the objective response rate (CR+PR) of SEL-110 plus LMB-100.
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8.2 sample size determination

The primary objective of this pilot trial is to assess the safety and tolerability of LMB-100 in combination with SEL-110. An initial dose escalation phase will follow a modified 3 + 3 design as described in section **3.1.2**, originally planned to have LMB-100 at 140 mcg/kg along with SEL-110 at 0.15 mg/kg and then 0.30 mg/kg (dose levels 1 and 2 respectively). As it was determined that the LMB-100 dose at DL1 caused unacceptable toxicity, the option to enroll patients at dose level -1 with LMB-100 at 100 mcg/kg was exercised. As of Amendment C, dose level -1A was also added for possible exploration if toxicity acceptable at dose level -1 with LMB-100 at 100 mcg/kg and SEL-110 at 0 0.30 mg/kg. As only 3 subjects were enrolled at dose level 1 before de-escalation to dose level -1, this dose escalation phase should require no more than 12 to 15 evaluable patients to complete. (3 [DL1]+ 3 or 6 [DL-1]+up to 6 [DL-1A]+0 [DL2]). Once 6 patients have been safely treated at a single level (0-1 with DLTs at one of the dose levels explored), an additional 6 patients will be enrolled at that dose level. These 12 patients at the MTD will be evaluated for safety as described below. The dose escalation phase may require up to 15 patients, and since 6 of these are expected to have initially been enrolled in the efficacy evaluation, only 6 additional patients are expected to be required solely for the secondary efficacy evaluation. Thus, it is expected that up to 21 patients may be needed to conduct the safety and efficacy evaluations. It is anticipated that 8-10 patients per year may enroll onto this trial. Thus, it is expected that accrual may be completed in approximately 2 - 2.5 years. To allow for the possibility of needing to replace patients who are inevaluable for the efficacy evaluation, the accrual ceiling will be set at 23 patients.
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8.3 populations for analysis

Evaluable for toxicity: All patients will be evaluable for toxicity after receiving at least one dose of each study agent (LMB-100 and SEL-110) The dose determining population will consist of all patients evaluable for DLT. Patients are evaluable for DLT if they are evaluable for toxicity and discontinued earlier due to DLT or completed the DLT observation period and have undergone safety evaluations. Evaluable for pharmacokinetic analysis: All patients that are evaluable for toxicity will be included in the PK analysis population. Patients will be excluded from the PK analysis population if they significantly violate the inclusion or exclusion criteria, deviate from the protocol, or if data are unavailable or incomplete which may influence the PK analysis. Excluded cases will be documented with the reason for exclusion. Evaluable for objective response: Only those patients who have measurable disease present at baseline, and have received at least one dose of therapy.
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8.4 statistical analyses 8.4.1 general

Safety of the agent will be assessed by reporting the grade of adverse events noted in each patient, and reporting the fraction with grade 3 and grade 4 adverse events at each dose level. Levels of LMB-100 in the blood will be measured in cycle 4. The number of patients will be reported, and the fraction with detectable levels will be reported along with a 95% confidence interval. The effect of SEL-110 on LMB-100 pharmacokinetics and the anti-tumor efficacy of SEL-110 plus LMB-100 will also be reported.
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8.4.2 analysis of the primary

The primary objective is to assess the safety and tolerability of LMB-100 in combination with SEL-110. The safety of the agent will be assessed as described in section 8.4.4.
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8.4.3 analysis of the secondary

The six patients at the MTD will be evaluated for LMB-100 blood levels in cycle 4, along with 6 additional evaluable patients who will be enrolled at the same dose level to obtain the LMB-100 levels in 12 evaluable patients treated at a single dose level. If any of those 6 patients who were initially enrolled in the dose escalation phase are ineligible for the efficacy evaluation, they will be replaced to arrive at 12 patients who are evaluable for efficacy. The patients will be identified as having a detectable level of LMB-100 or not. The fraction of patients who have a detectable level in their blood will be determined and this fraction will be reported along with a 95% confidence interval. Obtaining 6 or more patients out of 12 with detectable levels of LMB-100 would be considered a desirable outcome and will be reported as such. Currently, approximately 60% of patients who are treated with LMB-100 have adequate blood levels of the treatment up through cycle 2 of treatment, but none have adequate blood levels in cycles 3 and 4. The goal will be to determine if the combination of LMB-100 and SEL-110 can result in 50% or greater of patients having measurable levels of LMB-100 in cycle 4. If 12 evaluable patients are enrolled into the efficacy evaluation portion, the following are the probabilities of obtaining 6 or more patients with detectable blood levels of LMB-100 as a function of the true probability of having a detectable blood level:  
| True prob. of detectable LMB-100   | Prob. of 6-12 out of 12 with detectable LMB-100   |
|------------------------------------|---------------------------------------------------|
| 0.70                               | 0.96                                              |
| 0.60                               | 0.84                                              |
| 0.40                               | 0.33                                              |  
$$0.12$$
0.30 0.12
$$0.02$$
0.20 0.02
Thus, if the true probability of having detectable LMB-100 levels is 60% or greater, there is an 84% probability or greater of having 6 or more out of 12 patients with detectable levels, while if the true probability of having detectable LMB-100 levels is 30% or less, the probability of observing 6 or more out of 12 patients with detectable levels is 12% or less. Thus, observing 6 or more out of 12 patients with detectable LMB-100 levels is more likely to be associated with a regimen that has a much higher probability of resulting in detectable LMB-100 levels vs. one with a lower probability of resulting in detectable LMB-100 levels. A 95% confidence interval will be formed about the observed proportion of patients who have detectable levels of LMB-100 in cycle 4. Where feasible, the following noncompartmental (NCA) pharmacokinetic parameters will be generated: maximum concentration (Cmax), half-life (T½), clearance (CL), volume of distribution
(Vz), the area under the concentration time curve from 0 to the last measurable concentration [AUC(0–t)] and from 0 to infinity [AUC(0–)], along with the percent extrapolated value (%Extrap).  
These will be reported using descriptive statistics primarily, while any statistical testing done will be exploratory in nature. The anti-tumor efficacy of SEL-110 plus LMB-100 will be reported by determining the fraction of patients who experience a clinical response to the combination. The fraction of patients with a PR or CR will be reported out of the 12 evaluable patients treated at the final dose of LMB-100 + SEL-110, along with an 80% and a 95% two-sided confidence interval.
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8.4.4 safety analyses

Safety of the agent will be assessed by reporting the grade of adverse events noted in each patient, and reporting the fraction with grade 3 and grade 4 adverse events at each dose level. Safety data will be presented in individual listings. Summaries will also be prepared. The safety data will consist of the reporting of all adverse events, vital signs, physical examination data, laboratory safety data and ECG data. 8.4.5 Baseline Descriptive Statistics Limited demographic and clinical characteristics of all patients will be reported. 8.4.6 Planned interim analyses None will be performed. 8.4.7 Subgroup analyses None will be performed. 8.4.8 Tabulation of individual participant data Toxicity data may be reported on a per-patient basis if adequate events are noted, or may be summarized.
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9 collaborative agreements

9.1 **COLLABORATIVE RESEARCH AND DEVELOPMENT AGREEMENT (CRADA)** This study is performed under a CRADA \#3157 between NCI and Selecta Biosciences, Inc.
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10 human subjects protections 10.1

LMB-100 is a mesothelin-targeted cFP and has shown preclinical dose-dependent activity in monotherapy and/or combination in xenografts representing MSLN-positive indications (NSCLC, mesothelioma, triple negative breast cancer, gastric cancer, pancreas, ovarian, potentially other tumor indications). The rationale to evaluate LMB-100 with SEL-110 in advanced/metastatic mesothelioma is to preliminarily assess the effect of SEL-110 on the pharmacokinetics of LMB100. All patients meeting the criteria listed in section 2.1 are eligible for enrollment.
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10.2 participation of children

There are no dosing or adverse event data are currently available on the use of LMB-100 with SEL-110 in patients <18 years of age; therefore, children are excluded from this study.
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10.3 participation of subjects unable

Adults unable to give consent are 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 10.5), 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 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 MAS Policy 87-4 and 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.
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10.4 evaluation of benefits and

Patient safety will be managed by careful proactive patient selection prior to study to exclude patients at risk from study treatment due to their pre-existing conditions. During the study, safety of patients will be proactively managed by protocol-mandated physical examinations, vital signs assessments, chest X-rays, ECGs, clinical laboratory assessments, and collection of adverse events and their assessment. The risks of the study include those associated with study agent as discussed in section 11.
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10.4.2 blood collection

Side effects of blood draws include pain and bruising, lightheadedness, and rarely, fainting.
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10.4.3 image guided biopsy collection

The risks of the research biopsies collected at baseline and after 2 cycles include pain, bleeding and infection at the biopsy site. In addition, as the biopsies may be collected under CT guidance, subjects in this study may be exposed to approximately 1.6 rem. This amount is below the guideline of 5 rem per year allowed for adult research subjects by the NIH Radiation Safety Committee.
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10.5 risks/benefits analysis

Patients with advanced and/or metastatic mesothelioma are in continuous need of improved therapy options. This is especially true for patients where no standard therapy exists such as the patient population that will be eligible for this trial. Preclinical data has demonstrated promising anti-tumor efficacy of LMB-100 in xenograft models in monotherapy and combination therapy. Laboratory studies have further demonstrated that SEL-110 inhibits the development of antibodies against LMB-100. Therefore, LMB-100 + SEL-110 may improve clinical outcome of patients with mesothelioma. A number of clinically appropriate strategies to minimize risk to patients have been built into the protocol through the means of inclusion/exclusion criteria, monitoring strategies, and management guidelines. Overall, the potential benefits of mesothelin targeted cFP for mesothelioma patients, those able to consent and those who lose the capacity to do so during the course of the trial, outweigh the risks associated with the proposed entry-into-human trial with LMB-100 + SEL-110.
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10.6 consent process and documentation

The procedures and tests involved in this study and the associated risks, discomforts and benefits of these processes, will be carefully explained to the patient or the patient's parents or guardian if he/she is a child, and a signed informed consent document will be obtained prior to entry onto the study. Consent for the optional biopsies performed on this study will be obtained at the time of the procedure. If the patient refuses the optional biopsy at that time, the refusal will be documented in the medical record and in the research record. 10.6.1 Telephone consent and re-consent Re-consent in all cases as well as initial consent for screening, but not for treatment may be obtained by telephone using the following procedure: 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. A witness to the subject's signature will sign and date the 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 on a progress note by the consenting investigator.  
10.6.2 Informed consent of non-English speaking subjects If there is an unexpected enrollment of a research participant for whom there is no translated extant IRB approved consent document, the principal investigator and/or those authorized to obtain informed consent will use the Short Form Oral Consent Process as described in MAS Policy M772, OHSRP SOP 12, 45 CFR 46.117 (b) (2), and 21 CFR 50.27 (b) (2). The summary that will be used is the English version of the extant IRB approved consent document. Signed copies of both the English version of the consent and the translated short form will be given to the subject or their legally authorized representative and the signed original will be filed in the medical record. Unless the PI is fluent in the prospective subject's language, an interpreter will be present to facilitate the conversation (using either the long translated form or the short form). Preferably someone who is independent of the subject (i.e., not a family member) will assist in presenting information and obtaining consent. Whenever possible, interpreters will be provided copies of the relevant consent documents well before the consent conversation with the subject (24 to 48 hours if possible).  
We request prospective IRB approval of the use of the short form process for non-English speaking subjects and will notify the IRB at the time of continuing review of the frequency of the use of the Short Form.
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11 pharmaceutical information 11.1 lmb-100

LMB-100 was transferred to the NIH CC Pharmacy by Roche, the drug manufacturer. For this trial, the drug will be supplied by the NIH CC Pharmacy.
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11.1.2 toxicity

Information in this section is based on preclinical studies with LMB-100, and clinical studies of the cytolytic fusion protein SS1-P. Patients should receive a full dose of LMB-100 unless a DLT and/or a treatment limiting toxicity is observed. In case of DLT and/or treatment limiting toxicities, treatment with LMB-100 will be stopped until resolution of toxicity to NCI CTCAE Grade d2 hematological toxicities or Grade d1 non-hematological toxicities. A delay of LMB-100 administration for up to three weeks of the planned schedule will be acceptable to allow for resolution of toxicity to NCI CTCAE Grade d2 hematological toxicities or Grade d1 nonhematological toxicities. If toxicity does not resolve to NCI CTCAE Grade d2 hematological toxicities or Grade d1 non-hematological toxicities and the patient is unable to resume treatment with LMB-100 after this time, no additional doses will be administered and the patient will be withdrawn from study treatment.
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11.1.2.1 infusion-related reactions and hypersensitivity

LMB-100 administration may cause infusion-associated symptoms such as fever, chills, hypotension, shortness of breath, skin rash, headache, nausea, and/or vomiting. Such reactions typically occur during or shortly after an infusion, predominantly the first infusion. Patients may also develop IgE-mediated hypersensitivity reactions to LMB-100. IRRs may be indistinguishable from an anaphylactic reaction. Patients should receive full supportive care to treat IRRs or anaphylaxis according to institutional practice. If infusion-associated signs or symptoms occur, patients should be monitored until complete resolution. In vitro data suggest that the risk for the release of pro-inflammatory cytokines upon first administration of LMB-100 to humans is low (human whole blood assay, see section 1.2.3.3.3). Past experience with monoclonal antibodies that demonstrated a risk in the whole blood assay has shown that this risk could be effectively managed in the clinic with appropriate risk-minimization measures. The release of pro-inflammatory cytokines is believed to be partially responsible for the occurrence of IRRs.
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11.1.2.2 risk of immunogenicity and

LMB-100 may cause the formation of ADAs. These may trigger hypersensitivity reactions or immune complex-mediated responses. The development of ADAs to LMB-100, an improved cytolytic fusion protein with a humanized targeting moiety directed against mesothelin and a dehumanized, truncated Pseudomonas exotoxin A is expected to be less likely than SS1P. Clinical trials with SS1P have led to the development of neutralizing ADAs in 75% and 88% of patients after 1 cycle of therapy, in the IV bolus and continuous infusion trials respectively.(12) Patients will be monitored at regular intervals for the development of ADAs and cytokines. In particular, any clinical signs and symptoms suggestive of a hypersensitivity reaction and/or an immune complex-mediated reaction possibly due to ADA formation will be carefully investigated.
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11.1.2.3 risk of inflammatory reactions

LMB-100 administration may cause inflammatory reactions to serosal membranes including pleuritis, characterized by pleuritic chest pain, dyspnea, and hypoxia and pericarditis, characterized by precordial chest pain, congestive heart failure, hypotension, and uremia. Clinical trials with SS1P monotherapy have led to reversible pleuritis and pericarditis. Patients who develop symptoms of serosal inflammation should be closely monitored and receive standard treatments which may include corticosteroids. 11.1.2.4 Risk of Vascular Leak Syndrome LMB-100 administration may cause VLS characterized by hypotension, hypoalbuminemia, edema, weight gain, and hemoconcentration. Clinical trials with SS1P monotherapy have led to the development of reversible VLS. Patients will be monitored with frequent assessments of chest xrays, weight, edema, blood pressure, and serum albumin levels prior to and during treatment.  
Patients who develop symptoms of VLS should be closely monitored and receive standard symptomatic treatments.
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11.1.2.5 risk of renal toxicity

LMB-100 administration may cause renal toxicity characterized by increased creatinine, BUN, and proteinuria. In preclinical cynomolgus monkey studies, LMB-100 has shown increases in creatinine and histological changes including regenerative and degenerative changes to the tubular epithelium. Hemolytic uremic syndrome has been reported for other cytolytic fusion antibodies in development. Patients should be monitored with renal laboratory assessments including creatinine, BUN, and urinalysis.
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11.1.2.6 injection site reactions

LMB-100 administration may cause adverse reactions at the infusion site characterized by pain, swelling, induration, and nodules. In preclinical NHP studies for both SS1P and LMB-100 reddening and swelling of the infusion site were noted. Patients who develop symptoms of infusion site reactions can be administered pain relieving medication (analgesic) as required, and rotation of infusion sites is recommended.
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11.1.3 formulation and preparation

LMB-100 drug product (20 mg/20 mL) is provided for syringe infusion as a sterile, colorless to brownish, preservative-free liquid in single-use, 20 mL vials. The nominal fill volume is 20 mL
and the approximate concentration of LMB-100 recombinant fusion protein in the vials is 1 mg/mL.
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11.1.4 stability and storage

Chemical and physical in-use stability for undiluted LMB-100 drug product in syringes has been demonstrated for 24 hours at 2-8 °C and 24 hours at ambient temperature.  
Storage conditions should generally be at 2-8qC, but syringes may be held at room temperature for up to a maximum of 4 hours. 11.1.5 Administration procedures Please refer to section 3.2.2.
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11.1.6 incompatibilities

Pharmacodynamic drug interaction studies have not been conducted. LMB-100 is contraindicated in subjects with a history of severe allergic anaphylactic reactions to humanized, chimeric or mouse peptides/antibodies or to any components of the product.
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11.1.6.1 mechanism of action

LMB-100 is a novel recombinant anti-mesothelin targeted cytolytic fusion protein (cFP) developed for the treatment of patients with solid tumors that express the mesothelin protein. Mesothelin is a suitable candidate for targeted therapy due to its very limited expression in normal/non-malignant tissue and its high expression in several tumor entities including mesothelioma, ovarian cancer, pancreatic cancer, gastric cancer, breast cancer, and lung cancer. To target mesothelin, a humanized Fab fragment of the anti-mesothelin antibody SS1 is linked to a truncated and de-immunized recombinant 24 kD fragment of Pseudomonas exotoxin (PE24). After binding to mesothelin, the complex is internalized by endocytosis and kills cells by inhibition of eukaryotic elongation factor 2 (eEF2), leading to arrest of protein synthesis and secondarily triggering cell death by apoptosis or necrosis. 11.1.6.2 Molecular Weight: approximately 73 kDa  
 11.1.6.3 Chemical Structure
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11.2.2 toxicity

Consistent with ICH guidance, SEL-110 has been evaluated in nonclinical studies to support clinical study in humans, including safety pharmacology studies in rats and monkeys, as well as single and multiple dose toxicology studies in rats and monkeys. Immunotoxicology and local injection site reactions also were evaluated as a component of a repeat dose study in monkeys (Study 1933-004). Initial non-GLP dose finding studies of SEL-110 toxicity were completed in Sprague Dawley rats (Study 14-04312-N1) and cynomolgus monkeys (Study 14-04311-N1) in 8week studies (given biweekly five times by IV bolus). In the GLP repeated dose study of SEL-110 in rats (Study 1933-005), 1, 3 and 6 mg/kg were given as an intravenous slow bolus 3 times separated by 28 days. SEL-110 produced dose-dependent decreases in body weight and food consumption over the course of the study, primarily in the male animals that persisted for both sexes in the 6 mg/kg dose group through the end of the recovery period. Observation of reduced sizes of reproductive organs including testes and ovaries, as well as microscopic correlates, were observed at the 3 and 6 mg/kg dose levels. These changes are consistent with the known effect of rapamycin on the gonadotropin axis.(46) Microscopic changes were observed in the heart (mild cardiomyopathy) in males at the high dose 6.0 mg/kg group. At recovery, bilateral incipient cataracts were present in all male animals in the 6.0 mg/kg/dose group. Cataracts are a known toxicity of rapamycin in male rats, which is thought to be related to the development of hyperglycemia (Rapamune NDA 21-083). Based on the adverse findings observed at 3 and 6 mg/kg/dose including effects on the male reproductive system, 1 mg/kg/dose was identified as the No-Observed-Adverse-Effect-Level (NOAEL) for SEL-110 (rapamycin containing nanoparticle) when administered as a bolus intravenous injection on three occasions (Days 1, 29, and 57) in rats. In the multi-dose study of SEL-110 in cynomolgus monkeys (Study 1933-006), 0.3, 1.0 and 3.0 mg/kg were given as an intravenous slow bolus 3 times separated by 28 days. SEL-110 was well tolerated at all doses, although there were observations of inappetence, vomitus and watery feces in males and females at the 1.0 and 3.0 mg/kg doses. Additionally, consistent with the immunosuppressive action of rapamycin, test article related microscopic findings of minimal follicular lymphoid depletion in the spleen in males and females at all dose levels and lymph nodes (mandibular and mesenteric) in males and females at 1.0 and 3.0 mg/kg were observed, but were not severe enough to be considered adverse. The no-observed-adverse-effect level (NOAEL) for this study was 3.0 mg/kg for males and females, the highest dose level tested.  
Potential risks include those that have been identified in preclinical and clinical studies of SEL110 and SEL-212 (combination of SEL-110 and pegylated uricase for the treatment of severe gout)
as well as similar marketed products. These include 1) infusion reactions including anaphylaxis, 2) leukopenia and opportunistic infection, 3) metabolic disturbances (hyperglycemia, hypertriglyceridemia and hypercholesterolemia), 4) hypophosphatemia, 5) stomatitis, 6) oligo/azoospermia and 7) potential fetal development effects as seen in preclinical studies.  
Rare cases of anaphylaxis were reported in the Phase 3 trials of Sirolimus (Rapamune®) during its development. Identification of the reason for these reactions has not been made whether it be the rapamycin or other ingredients in the oral formulation. Subjects with a history of anaphylaxis, angioedema or previous infusion reactions will be excluded from the trial. Leukopenia has been reported in patients taking oral rapamycin. Whether the cause of the leukopenia is a direct relation to the rapamycin exposure, precedes or is due to the development of an opportunistic infection is unknown. Resolution of the leukopenia occurred in cases without subsequent infection with the stoppage of Sirolimus (Rapamycin) exposure. The current study will exclude subjects with any evidence of infection or developing infection by evaluating their WBC count and differential. Additionally, all subjects will be told to avoid anyone who has an active infection either bacterial or viral. Subjects will also have WBC evaluations performed during each treatment cycle per Study Calendar. In our single clinical study SEL-212/101 we have not seen this effect. (Data on file) Metabolic disruptions (hyperglycemia, insulin resistance, hypertriglyceridemia and hypercholesterolemia) have been reported in post-transplant patients who have been exposed to rapamycin.(31, 32) The occurrence of post-transplant diabetes mellitus (PTDM) has been recognized for many years as a consequence of solid organ transplant immunosuppression.(33) Dyslipidemia is a well-recognized side effect of rapamycin therapy.(34) In our single ascending dose clinical study SEL-212/101 we have not seen this effect. (Data on file) The exact mechanisms of rapamycin induced hyperglycemia, insulin resistance and its lipid effects are unclear at this time. It has been shown that rapamycin can diminish ȕ-cell proliferation in hyperglycemic states thereby inhibiting the natural cellular response of neogenesis, proliferation, hypertrophy and a reduction in apoptosis.(35) Additionally, rapamycin has been shown to inhibit phosphorylation of IRS-1 and IRS-2 in human adipocytes mimicking changes seen in type 2 diabetes and in human peripheral blood monocytes associated with insulin resistance.(36) Rapamycin has also been shown to increase basal lipolysis and reduce lipid storage.(36) Due to these, subjects who participate will have these specific laboratories (fasting glucose, triglyceride and cholesterol levels) monitored closely for significant changes during their participation. Subjects will be monitored during each treatment cycle per Study Calendar.  
The mechanism of hypophosphatemia is not known, but it has been seen in patients that have received mTOR inhibitors such as rapamycin.(37) And so, subjects will be monitored weekly during each treatment. The mechanism of stomatitis is not known, but it has been seen in patients that have received mTOR inhibitors such as rapamycin as early as 7 days after treatment and responds to locally applied Clobetasol cream.(37) And so, subjects will be monitored during each treatment cycle per Study Calendar Oligo/azoospermia has been seen in some male renal transplant patients taking an oral form of SEL-110 (rapamycin) administered chronically on a daily or three times weekly basis for the prevention of transplant rejection when treated for a period greater than six months. The mechanism for this effect is not known. In those patients where oligo/azoospermia has been seen partial to full reversibility of sperm production following cessation of treatment with the oral form of rapamycin has been demonstrated. Male patients should be informed that their fertility may be affected temporarily or permanently after being given SEL-110. In preclinical animal studies performed with an oral form of the drug to be administered in this study (rapamycin, which is the active substance in SEL-110) showed adverse effects when given to pregnant rats. These effects included fetal death, reduced fetal weights, and delays in the formation of bones. It is not known whether these effects would also occur humans, a similar risk should be considered possible until such studies are performed. Because of these potential adverse effects, all females who directly participate in this clinical study must be of no childbearing potential and all males with female partners with childbearing potential must agree to use effective contraception and agree to continue doing so for four months after study drug dosing. Childbearing potential is defined as: a) less than 6 weeks after surgical removal of ovaries, tubes with or without removal of the womb or (b) pre- or peri-menopausal (less than 24 months of being without a period naturally). SEL-110 was tested alone in the clinical study SEL-212/101 in an ascending single dose and also in combination with SEL-037 (pegsiticase, pegylated uricase). In the SEL-110 alone cohorts, two SAEs occurred at the highest dose (0.5 mg/kg) tested in this protocol. Both SAEs (stomatitis) resolved without any long-term consequences. Stomatitis is a known adverse event associated with rapamycin, the active ingredient in SEL-110. Data for this trial has been submitted to IND 124184. Additionally, the components of SEL-110 have been in previous clinical trials. The nanoparticles primarily consist of the class of biodegradable lactide polymers, part of the family of poly(lactide-co-glycolide) (PLGA) biodegradable polymers such as those found in the Food and Drug Administration (FDA) approved absorbable sutures Vicryl® and Dexon® and FDA approved products Zoladex®, Risperdal® Consta®, and Vivitrol®. Rapamycin (sirolimus) is the active ingredient in Rapamune, an FDA approved product for the prevention of organ rejection in kidney transplant patients. SEL-110 is currently being studied in combination with SEL-037 (pegsiticase, pegylated uricase) in an open label Phase 2 study where patients diagnosed with gout and hyperuricemia are given an IV infusion of SEL-110 followed immediately by an IV infusion of SEL-037 (SEL-212 combination drug). Cohorts included patients receiving SEL-037 alone, patients receiving 3 combination doses of SEL-110 plus SEL-037 each 28 days apart followed by two doses of SEL037 alone each 28 days apart and patients receiving 5 combination doses of SEL-110 plus SEL037 each 28 days apart In this study SEL-110 doses of 0.05, 0.08, 0.1, 0.125, and 0.15 mg/kg have been studied.  
Serious Adverse events in this study have primarily been related to infusion reactions to SEL-037 on repeat dosing in the control (no SEL-110 dose) or in the low dose SEL-110 plus SEL-037 arms. One SAE infusion reaction occurred during infusion of SEL-110, which appears to be related to the rate of infusion being above the specified rate. 11.2.3 Formulation and preparation 11.2.3.1 Formulation 11.2.3.1.1 Drug Product Presentation The SEL-110 nanoparticle is primarily composed of the biodegradable polymers PLA (poly(D,Llactide) and PLA-PEG (poly(D,L-lactide)-block-poly(ethylene-glycol)). PLA as a formulation excipient is part of the broader PLGA (poly(lactide-co-glycolide)) family of biodegradable polymers that have more than 30 years of clinical use and are formulation components in a number of approved products, including Zoladex®, Risperdal® Consta®, Vivitrol® and Lupron Depot®. PEG has also been widely studied in clinical trials and is also a formulation component in many approved biological products, including macugen® and Krystexxa®.
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11.2.3.1.2 composition

The SEL-110 drug product is a suspension of nanoparticles encapsulating rapamycin in phosphate buffered saline for intravenous administration. Table 14 lists the components of the SEL-110 drug product.  
| SEL-110         | Description and Function       | Nominal   |
|-----------------|--------------------------------|-----------|
| Component       | Formulation  Content           |           |
| Rapamycincontaining  nanoparticle                 | Drug substance carrier         | 2%        |
| Phosphate       | Isotonic vehicle at neutral pH | 98%       |
| Buffered Saline |                                |           |  
11.2.3.1.3 Investigational Drug Product SEL-110 is supplied as a frozen nanoparticle drug product suspension. SEL-110 is supplied as a frozen suspension of nanoparticles in PBS at a fill volume of 5 mL and a rapamycin content of 10 mg in a 10 mL Type 1 glass vial with a chlorobutyl stopper (gray, FluorTec® film on plug) and sealed with West 20 mm flip-off seals.  
| Investigational Product              |                                                                                           |
|--------------------------------------|-------------------------------------------------------------------------------------------|
| Product Name:                        | SEL-110                                                                                   |
| Dosage Form:                         | Frozen nanoparticle  suspension                                                           |
| Unit Dose                            | 10 mg / 5 ml in the thawed  state                                                         |
| Route of                             | IV infusion                                                                               |
| Administration  Physical Description | 10 mL borosilicate glass  vial with rubber stopper  and aluminum-plastic  combination cap |
| Manufacturer                         | Manufactured for Selecta  Biosciences by Emergent  BioSolutions                           |
| 11.2.3.2 Preparation                 |                                                                                           |  
Each vial of SEL-110 will be allowed to thaw at room temperature and brought to room temperature over an approximate 2-hour period. Each vial will be inverted 20 times slowly (do not shake). Thawed SEL-110 should be administered as soon as possible, however is stable at room temperature and normal light conditions for 24 hours. Study drugs will be dosed on a mg/kg basis according to the cohort the subject is assigned. More than one vial may be required depending on the subject's weight and mg/kg dose. 11.2.4 Stability and Storage Upon receipt of the SEL-110 vials at the clinical site, the vials should be stored in a secured way at -15 to -25 °C within the primary or secondary box container in order to protect the SEL-110 from long-term light exposure. 11.2.5 Administration procedures Please refer to section 3.2.1. 11.2.6 Incompatibilities Medications which are known CYP3A4 inhibitors or inducers incompatible with rapamycin. Patients taking medications that are known CYP3A4 inhibitors or inducers including natural products such as St. John's Wort or grapefruit juice may be included **ONLY** if they discontinue the medication 14 days before dosing and are able to remain off the medication for the duration of the study. Drugs known to interact with Rapamune such as cyclosporine, diltiazem, erythromycin, ketoconazole (and other antifungals), nicardipine (and other calcium channel blockers),
rifampin, verapamil must be stopped at least 2 weeks prior to starting the trial and will not be used during the trial.
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11.2.7 mechanism of action

SEL-110 drug product (DP) is a suspension of nanoparticles composed of PLA (poly(D,L-lactide)) and PLA-PEG (poly(D,L-lactide)-block-poly(ethylene-glycol)) encapsulating rapamycin in phosphate buffered saline for intravenous administration.  
Rapamycin acts on mTOR and has been used as an immunosuppressive drug and is approved as a daily to thrice weekly oral tablet for the prevention of organ rejection in kidney transplant patients. By encapsulating the rapamycin in the biodegradable nanoparticle, the action of rapamycin is concentrated on dendritic cells and in preclinical models has shown to induce antigen specific tolerance as opposed to immunosuppression achieved by systemic administration of rapamycin.,  
| Physical/Chemical Properties   | Description   |
|--------------------------------|---------------|
| pH                             | 7.4 ± 0.5     |
| 11.2.7.2 Chemical Properties   |               |  
Appearance White to off-white semi-transparent suspension Particle Size Monomodal nanoparticle size distribution; mean size 150 nm  
Chemical Abstract Service (CAS): 53123-88-9 IUPAC Name: (3S,6R,7E,9R,10R,12R,14S,15E,17E,19E,21S,23S,26R,27R,34aS)-
9,10,12,13,14,21,22,23,24,25,26,27,32,33,34,34a-hexadecahydro-9,27dihydroxy-3-[(1R)-2-[(1S,3R,4R)-4-hydroxy-3-methoxycyclohexyl]-1methylethyl]-10,21-dimethoxy-6,8,12,14,20,26-hexamethyl-23,27-epoxy-3Hpyrido[2,1-c][1,4]-oxaazacyclohentriacontine-1,5,11,28,29(4H,6H,31H)-
pentone Company or Laboratory Code Selecta Code: S-457 LSNE Code: BMTR0086 USAN Name: Sirolimus British Approved Name (BAN): Sirolimus Other Non-Proprietary Names: Rapamycin, RAPA
untitled h1
11.2.7.3 structural formula

The active pharmaceutical ingredient in SEL-110 is rapamycin, also known as sirolimus, a molecule with a molecular formula of C 51 H 79 NO 13 and a molecular weight 941.19 Da. The structure of rapamycin is in Figure 16 . Rapamycin is the active ingredient in Rapamune®, which is FDA approved for chronic daily oral administration for the prevention of organ rejection in kidney transplant patients. Figure 16. Structure of Rapamycin