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Version Date: *05.10.2022* Abbreviated Title: QuICC Trial NIH Protocol \#: 20C0138 Version Date: May 10, 2022 IBC Registration Number: RD-19-IX-01 NCT Number: NCT04491955 Title: Phase II Trial of Combination Immunotherapy in Subjects with Advanced Small Bowel and Colorectal Cancers NCI Principal Investigator: Julius Strauss, MD
Laboratory of Tumor Immunology and Biology (LTIB) Center for Cancer Research (CCR) National Cancer Institute (NCI) 10 Center Drive Building 10, Room 13N240A Bethesda, MD 20892 Phone: 240-858-3999 Email: julius.strauss@nih.gov
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investigational agents

| Drug Name:    | MSB0011359C (M7824)                                     | N-803                 | NHS-IL12 (M9241)   | CV301   |
|---------------|---------------------------------------------------------|-----------------------|--------------------|---------|
| IND Number:   | 19660                                                   | 19660                 | 19660              | 19660   |
| Sponsor:      | Center for Cancer  Center for Cancer  Center for Cancer | Center for Cancer     |                    |         |
| Research, NCI | Research, NCI                                           | Research, NCI         | Research, NCI      |         |
| Manufacturer: | EMD Serono, Inc. ImmunityBio, Inc. EMD Serono, Inc.     | Bavarian Nordic, Inc. |                    |         |
| Supplier:     | EMD Serono, Inc. ImmunityBio, Inc. EMD Serono, Inc.     | Bavarian Nordic, Inc. |                    |         |  
Commercial Agents: None 1
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precis background objectives age >

Metastatic or refractory/recurrent small bowel and colorectal cancers are incurable and poorly palliated by standard therapies. There is an unmet need for active treatments for these tumors.  
To date immunotherapies including anti PD-1 or anti PD-L1 inhibitors have proven largely ineffective for the vast majority of these cancers.  
o In microsatellite stable (MSS) colorectal cancer (>95% of these cancers) the response rate to checkpoint inhibitors has been <5%.  
o Preclinical studies suggest that the use of different combinations of multiple immunotherapy agents may improve anti-tumor efficacy. These studies have employed (1) a vaccine targeting a tumor associated antigen, (2) an IL-15 superagonist (N-803, also known as ALT-803), (3) an anti-PD-L1 MAb or a bifunctional fusion protein targeting PD-L1 and TGFβ (M7824), and (4) a tumor targeted immunocytokine (NHS-IL12).  
To evaluate the objective response rate (ORR) according to Response Evaluation Criteria
(RECIST 1.1) of the combination of (1) CV301, a poxviral based vaccine targeting CEA and MUC1, (2) N-803 and (3) M7824; and of the combination of (1) CV301, (2) N-803, (3) M7824 and (4) NHS-IL12 (M9241) in subjects with advanced checkpoint naïve MSS small bowel and colorectal cancers.  
Subjects with cytologically or histologically confirmed locally advanced or metastatic small bowel or colorectal adenocarcinomas.  
Prior first line systemic therapy is required unless the participant declines standard treatment after appropriate counseling has been provided.  
Subjects must have measurable disease.  
This is a phase II trial of combination immunotherapy, with a brief dose escalation portion for Arm 2.  
The trial will be conducted using a Simon optimal two-stage design in each Phase II Arm.  
Participants will be enrolled on the following arms in sequential order: (1) Arm 1: CV301
+ M7824 + N-803, (2) Arm 2A and Arm 2B: CV301 + M7824 + N-803 + NHS-IL12; NHS-IL12 dose level will be evaluated in Arm 2A prior to further enrollment in Arm 2B.  
The first six participants on arm 1 will be evaluable for dose limiting toxicities (DLTs)
and accrual will only continue to 9 participants on that arm if less than 2 out of the first 6 participants experience a DLT.  
In Arm 2B, participants will receive 4 drug treatments (CV301 + M7824 + N-803 +
NHS-IL12), but the dose level of NHS-IL12 will first be determined during a dose escalation portion, Arm 2A. Following determination of the MTD or highest safe dose Eligibility:
evaluated, the 6 participants at that dose level will be included among the initial 9 participants for the first stage of that arm.  
If two or more out of nine participants have objective responses on a given arm that arm will be expanded to enroll 20 evaluable participants.  
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| TABLE OF CONTENTS                                                                                                                                              |                                                                                                                                                            |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------|
| PRÉCIS                                                                                                                                                         |                                                                                                                                                            |
| TABLE OF CONTENTS ..............................................................................................................................4              |                                                                                                                                                            |
| STATEMENT OF COMPLIANCE                                                                                                                                        |                                                                                                                                                            |
| 1.                                                                                                                                                             | INTRODUCTION .                                                                                                                                             |
| 1.1                                                                                                                                                            | Study Objectives .                                                                                                                                         |
| 1.2                                                                                                                                                            | Background and Rationale .............................................................................................................8                    |
| 2                                                                                                                                                              | ELIGIBILITY ASSESSMENT AND ENROLLMENT ..................................................................29                                                 |
| 2.1                                                                                                                                                            | Eligibility Criteria ...................................................................................................................................29 |
| 2.2                                                                                                                                                            | Screening Evaluation .......................................................................................................................32             |
| 2.3                                                                                                                                                            | Participant Registration and Status Update Procedures                                                                                                      |
| 2.4                                                                                                                                                            | Baseline Evaluation                                                                                                                                        |
| 3                                                                                                                                                              | STUDY IMPLEMENTATION ................................................................................................................34                    |
| 3.1                                                                                                                                                            | Study Design                                                                                                                                               |
| D Drug Administration ......................................................................................................................38                 |                                                                                                                                                            |
| 3.2                                                                                                                                                            |                                                                                                                                                            |
| 3.3                                                                                                                                                            | Study Intervention Compliance ..................................................................................................39                         |
| 3.4                                                                                                                                                            | Dose Modifications                                                                                                                                         |
| 3.5                                                                                                                                                            | Study Calendar                                                                                                                                             |
| Cost and Compensation ......................................................................................................................................52 |                                                                                                                                                            |
| 3.6                                                                                                                                                            |                                                                                                                                                            |
| 3.7                                                                                                                                                            | Criteria for Removal from Protocol Therapy and Off Study Criteria..................................52                                                      |
| 4                                                                                                                                                              | CONCOMITANT MEDICATIONS/MEASURES                                                                                                                           |
| The Following Treatments Should Not Be Administered During the Trial: ...................53                                                                    |                                                                                                                                                            |
| 4.1                                                                                                                                                            | N-803                                                                                                                                                      |
| 4.2                                                                                                                                                            |                                                                                                                                                            |
| S                                                                                                                                                              | CORRELATIVE STUDIES FOR RESEARCH / PHARMACOKINETICS STUDIES .....54                                                                                        |
| Biospecimen Collection .................................................................................................................................54     |                                                                                                                                                            |
| 5.1                                                                                                                                                            | Samples for Genetic/Genomic Analysis ................................................................................................56                    |
| 5.2                                                                                                                                                            |                                                                                                                                                            |
| 5.3                                                                                                                                                            | Sample Storage, Tracking and Disposition                                                                                                                   |
| 6                                                                                                                                                              | DATA COLLECTION AND EVALUATION .....................................................................................58                                     |
| DATA COLLECTION                                                                                                                                                |                                                                                                                                                            |
| 6.1                                                                                                                                                            |                                                                                                                                                            |
| 6.2                                                                                                                                                            | DATA SHARING Plans                                                                                                                                         |
| 6.3                                                                                                                                                            | Response Criteria .............................................................................................................................60          |
| 6.4                                                                                                                                                            | Toxicity Criteria                                                                                                                                          |  
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| Version Date: 05.10.2022 7 NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING PLAN...67 7.2 OHSRP Office of Compliance and Training / IRB Reporting 67 7.3 NCI Clinical Director Reporting 67 7.4 Institutional Biosafety Committee (IBC) Reporting Criteria 67 7.5 NIH Required Data and Safety Monitoring Plan 68 8 SPONSOR/PROTOCOL SAFETY REPORTING 69 8.1 Definitions 69 8.2 Assessment of Safety Events 71 8.3 Reporting of Serious Adverse Events 71 8.4 Waiver of Expedited Reporting to CCR 71 8.5 Safety Reporting Criteria to the Pharmaceutical Collaborators 72 8.6 Reporting Pregnancy 72 8.7 Regulatory Reporting for Studies Conducted Under CCR-Sponsored IND 72 8.8 Sponsor Protocol Deviation Reporting 73 9 CLINICAL MONITORING PLAN 73 10 STATISTICAL CONSIDERATIONS 74 10.1 Statistical Hypothesis 74 10.2 Sample Size Determination 74 10.3 Populations for Analyses 75 10.4 Statistical Analyses 75 11 COLLABORATIVE AGREEMENTS 77 11.1 Cooperative Research and Development Agreement (CRADA) 77 12 HUMAN SUBJECTS PROTECTIONS 77 12.1 Rationale For Subject Selection 77 12.2 Participation of Children 78 12.3 Participation of Subjects Unable to Give Consent 78 12.4 Risk/Benefit Assessment 78 12.5 Consent Process and Documentation 80 13 REGULATORY AND OPERATIONAL CONSIDERATIONS 81 13.1 Study Discontinuation and Closure 81 13.2 Quality Assurance and Quality Control 82 13.3 Conflict of Interest Policy 82   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
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| 13.4   | Confidentiality and Privacy 82             |
|--------|--------------------------------------------|
| 14     | PHARMACEUTICAL INFORMATION 83              |
| 14.1   | CV301 (IND # 19660) 83                     |
| 14.2   | M7824 (MSB0011359C) (IND # 19660) 86       |
| 14.3   | N-803 (IND # 19660) 89                     |
| 14.4   | NHS-IL12 (IND # 19660) 90                  |
| 15     | REFERENCES 92                              |
| 16     | APPENDICES 97                              |
| 16.1   | Appendix A: Performance Status Criteria 97 |  
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statement of compliance

The trial will be carried out in accordance with International Conference on Harmonisation Good Clinical Practice (ICH GCP) and the following:
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are responsible for the conduct, management, or oversight of NIH-funded clinical trials have completed Human Subjects Protection and ICH GCP Training. The protocol, informed consent form(s), recruitment materials, and all participant materials will be submitted to the Institutional Review Board (IRB) for review and approval. Approval of both the protocol and the consent form must be obtained before any participant is enrolled. Any amendment to the protocol will require review and approval by the IRB before the changes are implemented to the study. In addition, all changes to the consent form will be IRB-approved; an IRB determination will be made regarding whether a new consent needs to be obtained from participants who provided consent, using a previously approved consent form.
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1. introduction 1.1 study objectives

1.1.1 Primary Objective
To evaluate the objective response rate (ORR) according to Response Evaluation Criteria
(RECIST 1.1) of the combination of (1) CV301, a poxviral based vaccine targeting CEA and MUC1, (2) N-803 and (3) M7824; and of the combination of (1) CV301, (2) N-803, (3) M7824 and (4) NHS-IL12 in subjects with advanced checkpoint naïve MSS small bowel and colorectal cancers.  
1.1.2 Secondary Objectives
To evaluate the safety of the combination of (1) CV301, (2) N-803 and (3) M7824 in subjects with advanced small bowel and colorectal cancers.  
To evaluate the safety of the combination of (1) CV301, (2) N-803, (3) M7824 and (4)
NHS-IL12 in subjects with advanced small bowel and colorectal cancers.  
To assess progression-free survival time (PFS) according to RECIST 1.1 per treatment assignment (three or four drug combination).  
To assess overall survival (OS) per treatment assignment (three or four drug combination).  
To assess duration of response per treatment assignment (three or four drug combination).  
To assess ratio of participants that are hospitalized because of adverse events attributed to disease progression 1.1.3 Exploratory Objectives To conduct exploratory immunologic studies to understand and improve the administered treatment, including:
7 o peripheral immune subset analysis before and on treatment; o soluble factors circulation (e.g., sCD27 and sCD40 ligand) before and on treatment; o tumor tissue PD-L1 expression and immune infiltration before and after treatment.  
To assess responses to therapy using iRECIST per treatment assignment (three or four drug combination).  
To assess response to therapy using RECIST and iRECIST in checkpoint refractory participants (including participants with MSI disease)
To assess responses to therapy by RAS mutation status
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1.2 background and rationale 1.2.1

Metastatic colorectal cancer is characterized by poor outcomes. The statistics are discussed below and highlight the unmet need for effective treatments in this populations. In the face of the failures of the many tested treatment strategies for these patients, it is clear that innovative and bold approaches will be needed in order to develop treatment regimens that positively affect this population's prognoses.
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1.2.1.1 metastatic colon cancer

Each year, approximately 300,000 new cases of colon cancer are diagnosed in the United States and Europe. Following first-line treatment with 5-fluorouracil-based combination chemotherapy plus targeted therapy, median overall survival is approximately 2 years. Once a patient progresses on first-line treatment, overall survival is further diminished to 10-12 months. Oral salvage chemotherapy agents have received regulatory approval in recent years. However, the overall survival benefit seen in phase III studies with these agents is an additional 1-2 months [1-3]. With the exception of microsatellite unstable cases of mCRC, activity of ICI monotherapy is rare [4-6].
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1.2.2 rationale for combination of

The vast majority of human carcinomas are characterized as "cold" tumors in that they do not respond to checkpoint MAb therapy. Preclinical studies are now revealing that an effective immuno-oncology strategy for so-called "cold" tumors such as colon carcinoma (MSS) is the use of multiple immune-mediating agents, each targeting different components of the immune system.  
These include: (a) induction of an immune response via vaccination directed against tumorassociated antigens, (b) potentiation of the systemic immune response by the use of immunocytokines (such as the N-803, an IL-15 superagonist fusion protein) to enhance both NK and CD8+ T-cell responses, (c) potentiation of the immune response in the tumor microenvironment (TME) by the use of the tumor targeting NHS-IL12 immunocytokine, and (d) reduction of immunosuppressive entities in the TME by the use of anti-PD1/PDL1 MAb checkpoint inhibitors, and/or reduction of immunosuppressive cytokines such as TGF-β with the use of a bifunctional anti-PDL1/TGF-β2 "Trap" designated M7824. The LTIB, in collaboration with the GMB, has been able to develop and/or co-develop these agents via a series of CRADAs. Each has been interrogated in a series of preclinical studies and in Phase I/II clinical studies in the CCR as well as by other investigators. Preclinical studies and early clinical studies are demonstrating the relative lack of additional toxicities with enhanced clinical benefit employing combinations of 2 of these agents. Preclinical studies are now demonstrating that the combined use of agents from each of the immune-mediating categories described above elicits the most immune-mediated anti-tumor activities.
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avelumab (anti-pd-l1) and m7824 (anti-pd-l1/tgf-

Studies in the LITB were the first to describe [7, 8] avelumab, a fully human anti-PD-L1 IgG1 MAb, and its ability to mediate ADCC for a range of human carcinoma cells employing NK cells as effectors. Avelumab (Bavencio) has since been approved by the FDA for the therapy of Merkel cell carcinoma (the first drug approved for this indication) and second line urothelial carcinomas. We have also shown that endogenous IL-12 will enhance avelumab-mediated NK lysis, thus forming the basis for the combined use of avelumab or M7824 with NHS-IL12. The first-in-human clinical study of avelumab with over 1,700 patients was led by Gulley with the dose escalation and initial PK and PD done entirely within the CCR [8]. Because of the activity this study was amended to include multiple expansion cohorts internationally. Because PD-L1 is also expressed on some immune cell subsets, and because avelumab can mediate ADCC there was initial concern that Avelumab may lead to depletion of PD-L1 expressing immune cells. Our finding [9] that there were no adverse events in the patients treated with avelumab above that seen with other anti-PDL/PD-L1 MAbs (which did not mediate ADCC) was important for planning further studies with avelumab or M7824. TGF-β is a well-known inhibitor of immune cell function, especially in the TME [10-15]. Prior studies have indicated the advantage in the use of a TGF-β inhibitor in combination with checkpoint therapy [16, 17] In collaboration with our CRADA partner EMD Serono, we have codeveloped a bifunctional fusion protein aimed at bringing a TGF-β TRAP to tumor cells via binding to PD-L1. M7824 is a novel fusion protein consisting of avelumab linked to the extracellular domain of two TGF-βR2 (serving as a TGF-β TRAP) **(Figure 1)**. We were the first to report [18, 19] that M7824 (a) mediates ADCC, (b) increases tumor cell gene expression of molecules involved in T-cell trafficking to the tumor, (c) enhances TRAIL- and antigen-specific CD8+ T-cell lysis of tumor cells, and (d) reduces TGF-β‒induced immunosuppressive activity.  
We have also recently demonstrated [20] in in vivo preclinical murine carcinoma models
(Figure 2A and B) that M7824 has the ability to decrease TGF-β‒ induced signaling in the TME.  
  
Specifically, phosphorylation of SMAD2 was significantly decreased in tumors following M7824 treatment, and not with an M7824(mut) molecule, devoid of the PD-L1 binding site **(Figure 2C)**. In both breast and colon carcinoma murine models, M7824 decreased tumor burden and increased survival, which required both CD8+ and NK cell activity **(Figure 2D)**. Two recent studies [21, 22] demonstrated the advantage in anti-tumor activity in the use of the bifunctional agent vs. the use of a PD-1/PD-L1 checkpoint in combination with a systemic TGF-β inhibitor. TGFβ is also known to alter human carcinoma cells from a more epithelial to a more mesenchymal phenotype and such tumor cells are more resistant to a range of therapies **(Figure 3)**. In LTIB studies, TGF-β‒induced mesenchymalization of carcinoma cells was shown [23] to be reversed by M7824, rendering tumor cells more susceptible to chemotherapy and immune-mediated killing [18, 20, 23].  
  
  
The first-in-human trial of M7824 (anti-PD-L1/TGF-ßR2) was conducted at the CCR. Nineteen heavily pretreated patients with solid tumors (non-melanoma) were treated; the MTD was not reached. M7824 was shown to saturate peripheral PD-L1 and sequester all released (acid released)
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plasma TGFβ1, -β2, and -β3 throughout the dosing period at >1 mg/kg (recommended phase 2 dose is 1200mg or about 10 mg/kg). There were signs of clinical efficacy across all dose levels (Figure 4, Figure 5), including one ongoing CR (cervical cancer), two durable PRs (pancreatic and anal cancers), one near PR (cervical) and two cases of prolonged stable disease [ 24 ]. In the Phase I study and a subsequent Phase II study, greater than 30–40% of patients with HPV+ malignancies showed evidence of clinical response to M7824 therapy. Prior studies by others have shown approximately 15-20% patient responses in this population employing checkpoint inhibition therapy.
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n-803 (il-15 superagonist)

IL-15 is a well-studied Th1 cytokine. Prior studies by others [25-28] have shown, in both preclinical and clinical studies, the ability of prokaryotic rec. IL-15 protein to enhance the level of both NK and CD8+ T cells. Limitations in the use of rec. IL-15 center around issues of pharmacokinetics and toxicity, and the lack of the IL-15/IL-15R complex for optimal activity. Our interest in IL-15 was also piqued by the ability of avelumab and M7824 to mediate ADCC. N-803 is an IL-15/IL-15Rα-Fc superagonist fusion protein developed by our CRADA partner ImmunityBio, Inc. (formerly Altor Bioscience and NantCell, Inc.). In a series of studies, we have shown [19, 29, 30] that N-803 can (a) significantly increase cytotoxic NK cells, showing enhanced NK lysis of tumor cells on a per-cell basis, (b) increase memory CD8+ T cells, (c) elicit anti-tumor effects in metastatic models of breast and colon carcinoma, and (d) inhibit TGF-β‒mediated reduced NK function, leading to increased NK lysis of a range of human carcinoma cell types. It has now been reported [31] that N-803 can re-induce objective responses to anti-PD-1 immunotherapy after treatment relapse or failure. Historically, about 8% of patients with NSCLC treated past progression had partial responses with continued PD-1 monoclonal antibodies treatment. The objective responses to N-803-nivolumab combination treatment after PD-1 treatment failure coincided directly with initiation of N-803 after progression in patients with relapsed disease treated with uninterrupted nivolumab [31]. Moreover, partial responses were seen in 3 out of 10 (30%) patients whose tumor lacked PD-L1 expression and in 3 out of 11 (27%) patients who had relapsed or refractory disease after previous anti-PD-1 immunotherapy. The level of toxicity observed in the combination was similar to (and perhaps less than) that observed with PD-1/PD-L1 monotherapy. These data suggest that N-803 represents a novel immunotherapeutic agent that could augment the anti-tumor activity of checkpoint inhibitors in several treatment settings.
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vaccines

Both CEA and MUC-1 have been reported as relevant immunologic targets in colon cancer. Earlier efforts to generate efficient cancer immunotherapy were directed towards the development of PANVAC, a prime and boost approach based on the administration of a replicating-competent Vaccinia-based delivery vector followed by a Fowlpox vector. Both vectors encoded the transgenes for B7.1, ICAM-1 and LFA-3, together with the CEA and MUC1. In order to establish its therapeutic potential, several preclinical studies were performed, showing that PANVAC activates antigen-specific human T cells *in vitro* [32], elicits antibody and cellular immune responses *in vivo,* and shows significant antitumor efficacy against tumors expressing either human CEA or MUC-1 in mice, resulting in programmed death ligand 1 (PDL1) up-regulation within the tumor microenvironment. Subsequently, the clinical development program continued with the design of several clinical trials to further confirm the efficacy and safety of this intervention. Overall, the results of Phase I and II clinical trials in different cancer populations employing PANVAC monotherapy or in combination with GM-CSF or docetaxel demonstrate a good safety profile accompanied by some hints of clinical benefits [33, 34]. A second generation cancer immunotherapy strategy was developed, giving rise to CV301 involving a modified vaccinia. CV301 is a recombinant non-replicating poxvirus based immunotherapy encoding the same 5 transgenes used in PANVAC (B7.1, ICAM-1, LFA-3, CEA and MUC-1) and thus designed to activate an antigen-specific response. Therefore, tumors expressing these antigens, including colon cancer, qualify as a potential indication for CV301.  
Given the potential risks associated with the replicating capacity of the vaccinia-based PANVACV construct, the next generation cancer immunotherapeutic candidate MVA-BN-CV301 was generated by Bavarian Nordic as part of a CRADA with the NCI (LTIB). It constitutes a recombinant non-replicating poxvirus- based immunotherapy derived from the MVA-BN construct. This novel viral vector was developed from the highly attenuated vaccinia virus known as MVA, which after more than 500 serial passages in chicken embryo fibroblasts lost approximately 15% of the original vaccinia genome. Furthermore, MVA-BN differs from other MVA strains in its extensive plaque purification and propagation in serum-free conditions, and has already undergone extensive investigation as a new smallpox vaccine. Within this comprehensive clinical development program, MVA-BN has been administered to more than 7,700 subjects without major safety concerns, hence exhibiting a robust safety profile. Accordingly, besides decreasing the risk of cardiac adverse events associated with earlier generation vaccinia-based strategies, the improved MVA-BN enables previously excluded segments of the general population, such as immunocompromised individuals and persons diagnosed with atopic dermatitis, to receive the potential benefits offered by this novel approach. Therefore, it embodies a highly novel approach and offers a reliable technological platform that enables the safe delivery of different transgenes to produce a tailored immune response against specific antigens. The new CV301 strategy encodes the same 5 transgenes expressed by the previous PANVAC vector: CEA, MUC-1, B7.1, ICAM-1 and LFA-3. However, these inserts encode each of the transgenes with amino acid sequences that are slightly different from the original vectors. In fact, MUC-1 has been modified with additional agonistic epitopes. Consequently, the CV301 construct is expected to promote an antigen-specific targeted immune response for tumors expressing these antigens. In addition, a change in biosafety also characterizes the new CV301 construct. Thus, whereas vaccinia possesses a BSL-2, MVA has been categorized as BSL1 in Europe. As well, similarly to the earlier PANVAC concept, CV301 also encompasses a heterologous prime-boost regimen employing an MVA-BN-CV301 priming dose followed by a Fowlpox-based FPV-CV301 boosting dose, thus replacing the former PANVAC-V and PANVAC-F components. Given the existing correspondences between the CV301 and PANVAC vectors, the clinical development program designed for CV301 will rely on the extensive nonclinical and clinical data currently available from PANVAC.
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clinical safety data

Analysis of safety data from a Phase 1/1b clinical trial of CV301 in 24 subjects showed no dose limiting toxicities at a dosage up to 1.6 × 109 Inf.U of MVA-BN-CV301.  
In both Phase 1b cohorts (CV301 plus nivolumab and CV301 plus pembrolizumab) the safety of the combination regimen was established. There was only one case of DLT reported due to immune mediated events in the nivolumab combination: one case of pneumonitis that further developed into a vasculitis, DIC and ultimately multi organ failure (fatal outcome). Overall, DLT and IMAE were below the pre-specified threshold to continue the trial based on the now established safety profile. In conclusion, there was no increased toxicity of the combination regimens CV301 plus pembrolizumab or nivolumab as compared to ICIs alone (per ICI prescribing information). The clinical safety data for the MVA-BN backbone vector and its recombinant products tested clinically to date are provided in Section 5.2 of CV301 IB v 5. In summary, no safety concerns, in particular no cardiac concerns have arisen from the development program of the MVA-BN platform, involving more than 51,000 subjects who have received MVA-BN and MVA-BN based recombinant products in completed and ongoing clinical trials. Six of the seven clinical trials with CV301's predecessor product PANVAC with data available have demonstrated an acceptable safety profile for the vaccines. Across these clinical trials, the most common treatment-related AEs were injection site reaction (including injection site erythema, injection site pain, and injection site swelling), myalgia, fatigue, vomiting, nausea, and abdominal pain. Most treatment-related AEs were Grade 1 or 2 in severity. SAEs related to study treatment, discontinuations due to AE, and deaths related to study treatment were rare (only 1 death due to Grade 5 pulmonary infiltrate was assessed as possibly related to study drug). Cardiac toxicity:
A detailed analysis of the TEAEs reported under the cardiac disorders SOC in clinical trial TBCPAN-003 and CTEP No 6977 were performed due to an imbalance of cardiovascular events reported in the PANVAC treatment arms. This detailed analysis concluded that for all reported cardiac SAEs and cases of pericardial effusion, alternative risk factors were present and causality with regard to PANVAC is unlikely. Importantly, there have been no reported observations of myocarditis or pericarditis in any of the PANVAC clinical trials. Based upon these data and the total clinical experience with poxvirus vectors for anticancer vaccines, including CV301's predecessor product PANVAC, a causal relationship of cardiotoxicity following treatment with CV301 and/or PANVAC is unlikely. Nonetheless, a proactive approach in pharmacovigilance will be applied prospectively, requesting from the investigators a deeper characterization of every case with a cardiac AE with the working hypothesis that myocarditis/pericarditis may be the underlying cause. Further toxicities monitored during clinical trials: Immune-Mediated Adverse Events: Autoimmune diseases and immune-mediated clinical syndromes, emerging since the initiation of trial product, will be reported as potential IMAEs. So far, no signal has emerged from the diverse poxvirus constructs studied in the clinic, but the theoretical possibility exists that breaking the immune tolerance to self-antigens may induce autoimmune phenomena. This possibility deserves close monitoring.
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cv-301 phase i experience

A phase I study was just completed at the NCI [35]. As expected, there were no grade 3 or greater toxicities reported in the study. There were no dose-limiting toxicities. Twelve patients enrolled on trial [dose level (DL) 1 = 3, DL2 = 3, DL3 = 6). Most side effects were seen with the prime doses and lessened with subsequent boosters. All treatment-related adverse events were temporary, self-limiting, grade 1/2, and included injection-site reactions and flu-like symptoms. Antigen-specific T cells to MUC1 and CEA, as well as to a cascade antigen, brachyury, were generated in most patients. Single-agent BN-CV301 produced a confirmed partial response (PR) in 1 patient and prolonged stable disease (SD) in multiple patients, most notably in *KRAS*-mutant gastrointestinal tumors. Furthermore, 2 patients with *KRAS*-mutant colorectal cancer had prolonged SD when treated with an anti-PD-L1 antibody following BN-CV301.
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nhs-il12 immunocytokine (m9241)

NHS-IL12 is a tumor targeting immunocytokine that binds to DNA-histone in necrotic areas of tumor. Studies by others have shown the ability of radiolabeled NHS-IL12 to target murine and human tumors **(Figure 6)**. Prior studies in the LTIB have shown the ability of this agent to elicit anti-tumor activity in multiple murine models, and in combination with anti-PD-L1 and with radiation and chemotherapy [36]. J. Strauss (LTIB), in collaboration with J. Gulley (GMB, CCR), conducted the Phase I dose escalation trial of the NHS-IL12 immunocytokine [36]. Due to known prior toxicities using a rec. IL-12 protein, multiple ascending dose levels were employed and the agent was administered every 4 weeks. Time-dependent increase in serum IFN-γ and subsequent rise in IL-10 increased with dose and varied greatly among patients **(Figure 7A)**. Increases in TCR diversity and TIL density in the TME following NHS-IL12 dosing were observed in those patients with elevated IFN-γ serum levels **(Figure 7B)**. Toxicity was acceptable with an MTD of 16.8 mcg/kg. Although no objective tumor responses were seen, of 30 patients with measurable disease, 15 had stable disease, with some durable (from 6‒30+  
  
months). Our recent preclinical studies (**Figure 8)** have also shown that there is enhanced anti-tumor effect of avelumab when used in combination with NHS-IL12 (**Figure 8**) and that this effect is mediated via an IFN-γ‒dependent mechanism. Studies in NSG-β2m‒/
‒ mice bearing a human carcinoma and reconstituted with human PBMC also showed the enhanced anti-tumor effect of the combination that coincided with increased NK and CD8+ in the TME. This further provided the rationale for an ongoing CCR led clinical study of avelumab in combination with NHS-IL12 (NCT02994953),
currently evaluating safety and efficacy of the combination. In addition to the combination being found to be safe and well-tolerated, evidence of clinical responses has been observed. As an example, a patient with checkpoint refractory metastatic urothelial cancer with a large sacral mass and retroperitoneal adenopathy at enrollment has had an ongoing complete response for 21+ months and a patient with rapidly progressive small cell bladder cancer with metastases to liver who progressed on standard therapy has an ongoing partial response for 15+ months.
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combination immunotherapies

As a consequence of the potential multi-functionality of M7824, we have conducted several combination studies employing this agent. We have previously shown [20] enhanced anti-tumor activity when M7824 is combined with vaccine in a metastatic carcinoma murine model **(Figure** 9). While M7824 can mediate ADCC for a range of human carcinoma cells, it is not as potent as Version Date: *05.10.2022* avelumab in this mechanism; the addition of N-803, however, enhanced the ADCC activity of both avelumab and M7824, but more importantly, increased the tumor lytic ability of M7824 to that equivalent of avelumab with N-803 [29] **(Figure 10)**. A series of preclinical studies have been carried out employing combinations of vaccine, M7824,  
  
N-803, and NHS-IL12. Combining M7824 with the NHS-IL12 molecule greatly enhanced antitumor activity **(Figure 11)**. Tumor challenge studies showed the presence of immune memory.  
This was shown in 3 different murine carcinoma models. Figure 8 Anti-tumor Activity of Immunocytokine NHS-IL12 + anti-PD-L1. **(A)** [37, 38] (B) Ongoing Trial: Avelumab + NHS-IL12 (Strauss et al, unpublished).  
  
  
  
Multimodal therapies were also carried out. Employing NSG- β 2m-/- mice bearing human carcinomas and reconstituted with human PBMC, the combination of vaccine, N-803, and M7824 resulted in the greatest level of anti-tumor activity compared to the use of individual agents (Figure 12 ). Employing the MC38 syngeneic murine colon carcinoma model the combination of vaccine, N-803, anti-PD-L1, and NHS-IL12 resulted in precipitous reduction of large tumors not seen with combinations of 3 of these agents (Figure 13). The use of all 4 agents also resulted in an intense influx of CD8+ T cells in tumors not seen with lesser combinations (Figure 14). Tumor challenge studies showed the presence of immune memory.  
  
  
  
1.2.3 Safety and Efficacy of Immunotherapy Combinations in Humans As detailed below **(Figure 15)**, evidence of clinical activity has been observed in MSS CRC patients who received anti-tumor vaccine, followed by ICI. These observations are particularly intriguing in the MSS colon cancer population, a group in which ICI activity has been rare [39]. Evidence of clinical activity has also been seen in a MSS, CRC patient who received the combination of M7824 and N-803 following a CEA/ MUC1 based vaccine regimen (Figure 16).  
  
Figure 15 (A) CEA (mcg/L) of a patient with KRAS mutant, MSS colorectal cancer. This patient enrolled on the phase 1 CV301 trial, had an unconfirmed partial response at the first retagging (6 weeks), then developed new mediastinal adenopathy at the 12-week restaging. Patient was then enrolled on a PD-L1 trial and experienced a subsequent decrease in her tumor markers as well as a radiographic response to treatment. Blue dotted line represents baseline CEA. (B) Unconfirmed PR on CV301 at 6 weeks on study. (C) Developed new mediastinal adenopathy (red arrows) at week 12 on CV301 trial, resulting in patient coming off trial for progressive disease. Patient was then started on another trial with a PD-L1 agent. After 3 months on the PD-L1 trial, mediastinal adenopathy had necrosed and tumor markers declined.  
  
This patient enrolled on the phase 1 trial of a CEA/MUC1based vaccine regimen, had evidence of disease progression, and switched over to another trial of M7824 plus N-803. Shortly after starting M7824 plus N-803 his tumor marker was found to drop precipitously. In addition, his first restaging scan showed a substantial partial response which was confirmed on his next scan. Many of these novel immunotherapy agents have been tested clinically in combination with other immunotherapy agents and demonstrated an acceptable safety profile (**Table 1**).
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table 1

| Nivolumab + N-803 [40]           | NCT02523469   |
|----------------------------------|---------------|
| Avelumab (anti-PD-L1) + NHS-IL12 | NCT02994953   |
| CV301 (Poxviral vaccine) + M7824 | NCT03315871   |
| N-803 + M7824                    | NCT03493945   |
| Poxviral vaccine + N-803 + M7824 | NCT03493945   |  
Safety data with the combination of Nivolumab and N-803 has been reported [31]. Twenty-three patients were enrolled and 21 patients treated at four dose levels of N-803 (6,10,15, and 20 mcg/kg) in combination with nivolumab at standard FDA approved dosing. No dose limiting toxicities were observed. And the maximum tolerated dose was not reached. The most common adverse events were injection site reactions (in 19 [90%] of 21 patients) and flu-like symptoms (in 15 [71%] of 21 patients). The most common grade 3 adverse events, occurring in two patients each were lymphopenia and fatigue. A grade 3 myocardial infarction occurred in one patient (only case of treatment discontinuation due to AE). No grade 4 or 5 adverse events were recorded. One case of grade 2 pneumonitis occurred which resolved without steroids. Otherwise no other notable autoimmune toxicity was observed.  
Thirty-three patients have been treated with the combination of avelumab (anti PD-L1) and NHSIL12. 26 patients in four dose levels of NHS-IL12 (4, 8, 12, or 16.8 mcg/kg) in combination with standard dosing of avelumab 10 mg/kg IV every 2 weeks and 7 additional patients in a fifth dose level which received NHS-IL12 at 16.8 mcg/kg in combination with avelumab 800 mg flat dosing weekly. One dose limiting toxicity occurred at DL3 (grade 3 autoimmune hepatitis). No dose limiting toxicities were observed at any other dose level. No grade 4 or 5 adverse events were recorded. The one case of grade 3 autoimmune hepatitis was the only notable autoimmune toxicity observed. Six patients have been treated with the combination of CV301, a poxviral vaccine, and M7824. No dose limiting toxicities have been observed. One patient did have a transient asymptomatic grade 3 lipase elevation which did not require treatment hold and self-resolved. No grade 4 or 5 adverse events were recorded. Aside from the one case of transient asymptomatic lipase elevation no other notable autoimmune toxicities were observed. Thirteen patients have been treated with the combination of two dose levels of N-803 (10 and 15 mcg/kg) and M7824 at 1200 mg flat dose. No dose limiting toxicities have been observed. One patient had grade 3 enterocolitis which resolved with steroid taper. No grade 4 or 5 adverse events were recorded. Aside from the one case of enterocolitis no other notable autoimmune toxicities were observed. Nine patients have been treated with the combination of the same poxviral vaccine vector employed in CV301 composed of an MVA component as four injections (4x108 IU/0.5 mL) each on day 1 and 15 followed by an FPV component (1x109 IU/0.5 mL), in addition to N-803 at 15 mcg and M7824 at 1200 mg flat dose. No dose limiting toxicities have been observed. The level of toxicity observed with all of these combinations were similar to (and perhaps less than) that observed with PD-1/PD-L1 monotherapy. 1.2.4 Clinical Rationale for using M7824 over other anti PD-L1 agents in Immunotherapy Combinations M7824 is being chosen over other anti PD-1/L1 agents as M7824 has been well tested in the CCR having had the first in human phase I trial done here and also having shown early promising efficacy in a number of tumor types often beyond the efficacy observed with avelumab or other anti PD-L1 agents. As an example in a subset analysis of patients treated within the dose-escalation cohort with human papillomavirus (HPV)-associated disease (n = 17), including patients with anal, cervical, and squamous cell carcinoma of the head and neck, there was an ORR of 35.3%, and an ORR of 41.7% in patients with known HPV-positive disease (n = 12) which exceeded the expected ORR of 15-20% expected with single agent PD-L1 inhibition [41]. In another cohort of patients with advanced NSCLC and PD-L1 expressing tumors the confirmed ORR was 40.7% in patients treated at the recommended phase II dose (1200 mg every 2 weeks) which also compared favorably to the 15-20% expected response rate with single agent PD-L1 inhibition. In patients with highPD-L1 expressing tumors, the ORR was 71.4% (n = 7) [42]. Based upon its potentially enhanced efficacy, M7824 is being used as the anti PD-1/L1 agent of choice in a number of combination trials either ongoing or planned in the CCR. In addition, once the safety profile of M6903 is well defined in combination with M7824 we plan to further expand on this combination by evaluating it in the context of additional IO agents such as vaccine therapies.
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1.2.5 dose rationale

In the phase I dose escalation trial of combination N-803 and M7824, escalating doses of N-803 were evaluated at 10 and 15 mcg/kg given with a standard flat RP2D of M7824 at 1200 mg. No DLTs were observed. Therefore, a dose of 15 mcg/kg of N-803 is being chosen for this trial for Arm 1 in combination with standard RP2D of M7824 at 1200 mg. In the phase I dose escalation trial of combination Avelumab (anti-PD-L1) + NHS-IL12, escalating doses of NHS-IL12 were evaluated at 8,12, and 16.8 mcg/kg given every 4 weeks in combination with standard dosing of Avelumab. The combination including NHS-IL12 at the highest dose evaluated (16.8 mcg/kg given every 4 weeks) was found to be well tolerated. The only DLT observed on the trial was a transient grade 3 AST/ALT elevation at NHS-IL12 at 12 mcg/kg but otherwise no other DLT was observed and the MTD was not reached. On another trial (20C0045) evaluating the combination of a therapeutic cancer vaccine plus NHS-IL12 at 16.8 mcg/kg and M7824 no DLTs were observed in the six participant lead in safety cohort, although the majority of original participants (11/19; 57.9%) treated on that trial needed dose reductions of NHS-IL12 when given in combination with the therapeutic cancer vaccine and M7824 due to grade 2 fever or flu like symptoms. After further evaluation a dose of NHS-IL12 at 8 mcg/kg was found to be very tolerable when combined with a therapeutic cancer vaccine and M7824 on that other trial. Therefore, based on that data we evaluated NHS-IL12 at a dose of 8 mcg/kg on both this study and the 20C0045 study. However, after evaluating a total of 39 patients on the 20C0045 study including 21 patients with starting dose of 16.8 mcg/kg and 18 patients with starting dose of 8 mcg/kg we observed what looks to be reduced efficacy in patients receiving 8 mcg/kg as a starting dose with only 3/18 patients responding with the 8 mcg/kg starting dose as compared to 11/21 with the 16.8 mcg/kg starting dose. Therefore, based on this observation that the possibility that a lowering starting dose of NHSIL12 may reduce efficacy in combination with vaccine and M7824, we are amending to allow treatment (effective with Protocol Amendment Version 10.20.2021) with a limited number of doses of NHS-IL12 at 16.8 mcg/kg (four doses total) before reducing NHS-IL12 to 8 mcg/kg on both this study and the 20C0045 study. This is based upon responding patients in the first 21 patients on the 20C0045 study which received anywhere between 1-4 doses of NHS-IL12 at 16.8 mcg/kg before dose reductions were made. Although N-803 and NHS-IL12 have potential overlapping toxicities (e.g., grade 1-2 flu like symptoms), it should be noted that no DLTs were observed in the six patient safety lead in combination of NHS-IL12 at 8 mcg/kg and N-803 at 10 mcg/kg. The NHS-IL12 and N-803 doses are being given on alternating schedules to minimize overlapping toxicities. Additionally, it was noted that 3/6 patients on this dose level (NHS-IL12 at 8 mcg/kg + N-803 10 mcg/kg in combination with vaccine and M7824) had bleeding events which did not meet DLT criteria but nonetheless limited patients' ability to receive further treatment with M7824 as part of this combination. Therefore, we are planning to dose reduce M7824 to 300 mg when evaluating the next and highest dose level on Arm 2A which also includes NHS-IL12 at 16.8 mcg/kg (for up to a total of 4 doses before reducing to 8 mcg/kg) + N-803 at 10 mcg/kg. A dose of M7824 at 300 mg has been found to be clinically active and anecdotally result in less bleeding.
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1.2.6 immune assays

Multiple immune assays have been developed in the LTIB to better define the mechanism(s) involved in the use of specific novel agents, as monotherapy or in combination therapies, both for preclinical and clinical studies (Section 5.1). In addition to analyses of biopsies, analyses of the peripheral immunome can provide valuable information in that multiple samples can be analyzed over the course of a given therapy vs. pre-therapy. The LTIB has now developed and employed
[8, 9, 24, 43] a flow cytometry‒based assay that can analyze 123 immune cell subsets in human PBMC from one vial of processed PBMC (approximately 10^7 cells). This assay will be used in this clinical trial to detect multiple subsets of CD4+ T cells (n=32), CD8+ T cells (n=29), Tregs
(n=7), B cells (n=5), NK (n=20), NKT (n=4), DC (n=10), and MDSC (n=16) to better understand the role of each agent. We also plan to evaluate changes in TCR clonal diversity both in biopsies and the periphery. One example involves an ongoing first-in-human trial of the NHS-IL12 tumortargeting immunocytokine. TCR diversity increased 6-14‒fold in biopsies of patients with a high or intermediate IFN-γ response but were unchanged or decreased with a low IFN-γ response. These findings also correlated with TIL in biopsies. We are also currently employing NanoString analyses to identify a gene signature in biopsies and PBMC, pre- and post-treatment. The GMB will conduct multiplexed, multispectral imaging of FFPE tissue to evaluate multiple immune parameters within the TME before and after treatment in patients with available tissue. 1.2.7 Summary We are proposing a novel immunotherapy combination to help overcome multiple barriers in an effective anti-tumor immune response.  
o (1) vaccines targeting tumor associated antigens to prime an anti-tumor immune response o (2) N-803 to expand the response and activate T effector cells and NKs o (3) NHS-IL12 and M7824 to enable activated immune cells to work better in the TME
Preclinical studies have shown that the addition of M7824 to vaccine therapy improves anti-tumor activity Preclinical studies have shown that the addition of N-803 to vaccine therapy and M7824 further improves anti-tumor activity Preclinical studies have shown that the addition of NHS-IL12 to vaccine therapy, N-803 and checkpoint therapy still further improves anti-tumor activity Clinical data suggests that M7824 is at least as effective if not more effective at producing anti-tumor responses than other standard anti PD-L1 agents in a number of tumor types Clinical data evaluating the safety of combination immunotherapy has shown multiple combinations of these agents to be safe and overall well tolerated including:
o Vaccine + M7824 o NHS-IL12 + Checkpoint therapy o N-803+ M7824 o Vaccine + N-803 + M7824 There has been anecdotal evidence of clinical activity with combination immunotherapy o Vaccine + anti PD-L1 o Vaccine + M7824 + N-803
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2 eligibility assessment and enrollment

2.1.1.1 Subjects with cytologically or histologically confirmed locally advanced or metastatic small bowel or colorectal adenocarcinoma 2.1.1.2 Subjects must have received two prior lines of systemic therapy unless the subject is not eligible to receive standard therapy or declines standard treatment 2.1.1.3 Subjects must have measurable disease 2.1.1.4 ECOG performance status < 2 (**Appendix A**: Performance Status Criteria) 2.1.1.5 Adequate hematologic function at screening, as follows:
Absolute neutrophil count (ANC) ≥1 x 109/L
Hemoglobin ≥ 9 g/dL
Platelets ≥ 75,000/microliter 2.1.1.6 Adequate renal and hepatic function at screening, as follows:
Serum creatinine ≤ 1.5 x upper limit of normal (ULN) OR
Measured or calculated creatinine clearance ≥ 40 mL/min for participant with creatinine levels > 1.5 X institutional ULN (GFR can also be used in place of creatinine or CrCl);
Bilirubin ≤ 1.5 x ULN OR in subjects with Gilbert's syndrome, a total bilirubin ≤ 3.0 x ULN
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 2.5 x ULN,
unless liver metastases are present, then values must be ≤ 3 x ULN)
2.1.1.7 The effects of the immunotherapies on the developing human fetus are unknown; thus, women of childbearing potential and men must agree to use highly effective contraception (hormonal or barrier method of birth control; abstinence) prior to study entry, for the duration of study treatment and up to two months after the last dose of study drug. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately.  
2.1.1.8 Participants serologically positive for HIV, Hep B, Hep C are eligible as long as the viral loads are undetectable by quantitative PCR. HIV positive participants must have CD4 count ≥ 200 cells per cubic millimeter at enrollment, be on stable antiretroviral therapy for at least 4 weeks and have no reported opportunistic infections or Castleman's disease within 12 months prior to enrollment.  
2.1.1.9 Ability of subject to understand and the willingness to sign a written informed consent document.
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2.1.2 exclusion criteria

2.1.2.1 Participants with prior investigational drug, chemotherapy, immunotherapy or any prior radiotherapy (except for palliative bone directed therapy) within the past 28 days prior to the first drug administration except if the investigator has assessed that all residual treatment-related toxicities have resolved or are minimal and feel the participant is otherwise suitable for enrollment. Additionally, current therapies (e.g., maintenance capecitabine) may be continued where in the opinion of the investigator stopping such therapies may increase the risk of disease progression. Also, participants may continue adjuvant hormonal therapy in the setting of a definitively treated cancer (e.g., breast).  
2.1.2.2 Participants with microsatellite unstable or mismatch repair deficient disease. 2.1.2.3 Major surgery within 28 days prior to the first drug administration (minimally invasive procedures such as diagnostic biopsies are permitted).  
2.1.2.4 Known life-threatening side effects resulting from prior checkpoint inhibitor therapy (e.g.,
colitis, pneumonitis, fulminant hepatitis which led to permanent discontinuation of prior checkpoint therapy). Autoimmune toxicity which was not life threatening (e.g., arthritis) or did not lead to discontinuation of prior checkpoint therapy is allowed.  
2.1.2.5 Known active brain or central nervous system metastasis (less than a month out from definitive radiotherapy or surgery), seizures requiring anticonvulsant treatment (<3 months) or clinically significant cerebrovascular accident (<3 months). In order to be eligible participants must have repeat CNS imaging at least a month after definitive treatment showing stable CNS disease. Participants with evidence of intratumoral or peritumoral hemorrhage on baseline imaging are also excluded unless the hemorrhage is grade ≤ 1 and has been shown to be stable on two consecutive imaging scans.  
2.1.2.6 Pregnant women are excluded from this study because these drugs have not been tested in pregnant women and there is potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with these immunotherapies, breastfeeding should be discontinued if the mother is treated on this protocol.  
2.1.2.7 Active autoimmune disease that might deteriorate when receiving an immunostimulatory agent with exception of:
Diabetes type I, eczema, vitiligo, alopecia, psoriasis, hypo- or hyperthyroid disease or other mild autoimmune disorders not requiring immunosuppressive treatment; Subjects requiring hormone replacement with corticosteroids are eligible if the steroids are administered only for the purpose of hormonal replacement and at doses ≤ 10 mg of prednisone or equivalent per day; Administration of steroids for other conditions through a route known to result in a minimal systemic exposure (topical, intranasal, intro-ocular, or inhalation) is acceptable; Subjects on systemic intravenous or oral corticosteroid therapy with the exception of physiologic doses of corticosteroids (≤ the equivalent of prednisone 10 mg/day) or other immunosuppressive agents such as azathioprine or cyclosporin A are excluded on the basis of potential immune suppression. For these subjects these excluded treatments must be discontinued at least 1 weeks prior to enrollment for recent short course use (≤ 14 days) or discontinued at least 4 weeks prior to enrollment for long term use (> 14 days). In addition, the use of corticosteroids as premedication for contrast-enhanced studies is allowed prior to enrollment and on study.  
2.1.2.8 Subjects with a history of serious intercurrent chronic or acute illness, such as cardiac or pulmonary disease, hepatic disease, bleeding diathesis or recent (within 3 months) clinically significant bleeding events or other illness considered by the Investigator as high risk for investigational drug treatment.  
2.1.2.9 Subjects unwilling to accept blood products as medically indicated.  
2.1.2.10 History of second malignancy within 3 years of enrollment except for the following:
adequately treated localized skin cancer, cervical carcinoma in situ, superficial bladder cancer, or other localized malignancy which has been adequately treated or malignancy which does not require active systemic treatment (e.g., low risk CLL).  
2.1.2.11 Subjects with a known severe hypersensitivity reaction to a monoclonal antibody (grade
≥ 3 NCI-CTCAE v5) will be evaluated by the allergy/immunology team prior to enrollment.  
2.1.2.12 Receipt of any organ transplantation requiring ongoing immunosuppression. 2.1.2.13 Receipt of prior lymphodepleting chemotherapy (e.g., cyclophosphamide or fludarabine at standard lymphodepleting doses).
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2.1.3 recruitment strategies

This study will be listed on www.clinicaltrials.gov. This study will be posted on NIH websites and on NIH social media forums. Participants will be recruited from the current participant population at NIH. Any recruitment materials will be submitted to the IRB for approval prior to distribution.
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2.2 screening evaluation

2.2.1 Screening activities prior to the obtaining informed consent Minimal risk activities that may be performed before the subject has signed a consent include the following:
Email, written, in person or telephone communications with prospective subjects  
Review of existing medical records to include H&P, laboratory studies, etc. Review of existing MRI, x-ray, or CT images Review of existing photographs or videos Review of existing pathology specimens/reports from a specimen obtained for diagnostic purposes 2.2.2 Screening activities performed after a consent for screening has been signed
The following activities will be performed only after the subject has signed the study consent or the consent for study \# 01C0129 (provided the procedures are permitted on that study) on which screening activities will be performed within 28 days prior to enrollment. Assessments performed at outside facilities or on another NIH protocol within the timeframes listed may also be used to determine eligibility once a participant has signed the consent.  
Complete medical history and physical examination (including height, weight, vital signs, and ECOG performance status).  
CT of chest, abdomen and pelvis or MRI, if clinically indicated.  
A brain CT scan in participants with known CNS disease as described in Section **2.1.2.5**
/ MRI scan if clinically indicated.
EKG.  
Clinical laboratory tests (within 16 days prior to enrollment).  
Chemistry: sodium, potassium, chloride, bicarbonate, calcium, glucose, BUN,
creatinine, ALT, AST, alkaline phosphatase, total protein, albumin, and total and direct bilirubin.  
Hematology: complete blood count (CBC) with differential.  
CD4 (if HIV positive).  
Coagulation panel: PT, INR, and PTT.  
Urine or serum pregnancy test (β-HCG) for females of childbearing-potential and women
< 12 months since the onset of menopause (within 16 days prior to enrollment).  
Urinalysis.  
HBV, HCV, HIV testing including viral load in positive participants (within 3 months prior to enrollment).
Histologic confirmation (at any time point prior to enrollment). If there is no available tumor sample or pathology report, a biopsy will be performed to confirm the diagnosis.
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2.3 participant registration and status

Registration and status updates (e.g., when a participant is taken off protocol therapy and when a participant is taken off-study) will take place per CCR SOP ADCR-2, CCR Participant Registration & Status Updates found here.
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2.3.1 screen failures

Screen failures are defined as participants who consent to participate in the clinical trial but are not subsequently assigned to the study intervention or entered in the study. A minimal set of screen failure information is required to ensure transparent reporting of screen failure participants, to meet the Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to respond to queries from regulatory authorities. Minimal information includes demography, screen failure details, eligibility criteria, and any serious adverse event (SAE). Individuals who do not meet the criteria for participation in this trial (screen failure) because of a transient lab abnormality may be rescreened. 2.3.2 Treatment Assignment Procedures  
| Number   | Name     | Description                                                                                                         |
|----------|----------|---------------------------------------------------------------------------------------------------------------------|
| 1        | Cohort 1 | Subjects with small bowel or colon adenocarcinoma  receiving fixed doses of treatment.                              |
| 2        | Cohort 2 | Subjects with small bowel or colon adenocarcinoma  receiving quadruple therapy during dose escalation of  NHS-IL12. |
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arms

| Number         | Name    | Description                                                                                     |
|----------------|---------|-------------------------------------------------------------------------------------------------|
| 1              | Arm 1   | CEA/ MUC1 Vaccines + M7824 + N-803 (Triple  Therapy).                                           |
| 2              | Arm 2A  | CEA/ MUC1 Vaccines + M7824 + N-803 + NHS-IL12  (Quadruple Therapy); dose escalation of NHS-IL12 |
| 3              | Arm 2 B | CEA/ MUC1 Vaccines + M7824 + N-803 + NHS-IL12  (Quadruple Therapy); fixed dose of NHS-IL12      |
| Arm Assignment |         |                                                                                                 |  
Assignment of participants will be sequentially to arm 1, then 2A, then 2B as follows: Participants in Cohort 1 will be assigned to Arm 1 first. Then participants in Cohort 2 will be assigned to Arm 2A until the MTD or maximum safe dose of NHSIL12 has been determined in the quadruple combination. Then, following completion of Arm 2A, participants in Cohort 1 will be assigned to Arm 2B. If there is a pause in accrual to Arm 1 after the first Simon II stage step (due to pending clinical outcomes needed for the determination to expand Arm 1) accrual may continue to Arm 2A and 2B in the interim and be switched back to Arm 1 if and when the decision is made to expand Arm1.
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2.4 baseline evaluation

All subjects are required to complete baseline evaluations within one week prior to the first planned dosing of the study drug (any screening evaluation done within this time period can also serve for the baseline evaluation):
Physical exam including weight, ECOG performance status and vital signs.  
Concomitant Medications and Baseline Signs and Symptoms evaluation.  
Urine or serum pregnancy test (β-HCG) for females of childbearing-potential and women
< 12 months since the onset of menopause.  
Chemistry: sodium, potassium, chloride, bicarbonate, calcium, glucose, BUN, creatinine, ALT, AST, alkaline phosphatase, total protein, albumin, and total and direct bilirubin.  
ACTH, TSH, free T4, lipase, amylase, CRP.
Hematology: CBC with differential.
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3 study implementation 3.1 study

This is a phase II trial of combination immunotherapy, with a brief dose escalation portion for Arm 2.  
The trial will be conducted using a Simon optimal two-stage design in each Phase II Arm.  
Participants will be enrolled on the following two arms in sequential order: (1) CV301+
M7824 + N-803, (2) CV301 + M7824 + N-803 + NHS-IL12 (**Figure 17**).  
Given the known overlapping toxicities of NHS-IL12 and N-803 (e.g., flu like symptoms),
as of the amendment dated 10.20.2021 the second arm will evaluate the safety of the combination of standard dosing of vaccines and M7824 with N-803 at 10 mcg/kg and escalating doses of NHS-IL12 at 8 and 16.8 mcg/kg using a modified 3+3 design (six patients per dose level; if < 2/6 patients with DLTs may move up to higher dose level; if > 1/6 patients with DLTs may move to lower dose level). Dose level 1 on Arm 2A (including N-803 at 10 mcg/kg and NHS-IL12 at 8 mcg/kg) was found to be safe without any DLTs.  
Therefore, we plan to escalate to dose level 2 on Arm 2A evaluating the combination of N803 at 10 mcg/kg and NHS-IL12 at 16.8 mcg/kg (for up to 4 consecutive doses followed
by 8 mcg/kg thereafter) with standard dosed vaccine + M7824 at 300 mg). The maximum tolerated dose level deemed safe on Arm 2Awill be expanded to nine evaluable patients and used for the Simon optimal two-stage design. If dose level 2 on Arm 2A is determined to be the maximum tolerated dose and expanded to nine evaluable patients in Arm 2B as part of the Simon two stage design then dose level 1 on Arm 2A may also be expanded up to nine evaluable patients for further immune correlative assessments.  
The first six participants on arm 1 will be evaluable for dose limiting toxicities (DLTs) and accrual will only continue to 9 participants on that arm if less than 2 out of the first 6 pts experience a DLT.  
In Arm 2A, participants will receive the combination of 4 treatments, but the dose level of NHS-IL12will be determined during a dose escalation using a modified 3+3 design (six patients per dose level; if < 2/6 patients with DLTs may move up to higher dose level; if >
1/6 patients with DLTs may move to lower dose level). Following determination of the MTD or highest safe dose evaluated, the 6 participants at that MTD or highest safe dose level will be included among the initial 9 participants for the first stage of Arm 2B.  
There will be a minimum of 28 days between the sixth participant (last participant for determining safety) enrolled to Cohort 1 and assigned to Arm1 and the first participant enrolled on cohort 2 and assigned to Arm 2A
There will be a minimum of one week between the first three subjects enrolled in Arm 1 and for each dose level of Arm 2A. The fourth through sixth participant of Arm 1 or each dose level of Arm 2A may enroll no sooner than 48 hours after the most recent enrollee. Once a dosage combination has been determined to be safe in six participants further participants may enroll at any time to that dosage combination.  
In the second stage of the Simon optimal two-stage design, if two or more out of nine participants have objective responses on a given arm that arm will be expanded to enroll 20 evaluable participants
It is possible that the response rates observed with combination immunotherapy will be less in participants who have previously received checkpoint therapy and not be truly reflective of a population of participants who have not had prior checkpoint therapy. While checkpoint experienced participants will not be excluded from enrollment, the primary efficacy analyses will be limited to checkpoint naïve participants with MSS colon cancer and efficacy analyses in the checkpoint refractory participants will be only exploratory.  
Participants with small bowel cancers are being evaluated in this trial as well as participants with colorectal cancer but if efficacy is not observed in the first stage of the Simon II step design for either Arm 1 or Arm 2B than participants with small bowel cancer may be replaced with participants with colorectal cancer at the discretion of the investigator.  
| Arm 1                                                                                   | Vaccine Vaccine   | Vaccine                          | -------   | Vaccine   | -------        | Vaccine      |
|-----------------------------------------------------------------------------------------|-------------------|----------------------------------|-----------|-----------|----------------|--------------|
| ALT803                                                                                  | -------           | ALT803                           | -------   | ALT803    |                |              |
| -------                                                                                 | ALT803            | M7824                            |           |           |                |              |
| M7824  M7824                                                                            | M7824             | M7824                            | M7824     | M7824     | ✦ Up to a year |              |
| D15                                                                                     | D29               | D43                              | D71       | D85       |                |              |
| D1                                                                                      | D57               | Vaccine q 2 wks x 3 then q 4 wks |           |           |                |              |
| M7824 q 2 wks , ALT803 q 4 wks                                                          |                   |                                  |           |           |                |              |
| Arm 2A                                                                                  | Vaccine Vaccine   | Vaccine                          | -------   | -------   | Vaccine        | -------      |
| and 2B                                                                                  | ALT803  NHSIL12   | ALT803                           | NHSIL12   | ALT803    | NHSIL12        | ALT803       |
| M7824  M7824                                                                            | M7824             | M7824                            | M7824     | M7824     | M7824          | Up to a year |
| D1                                                                                      | D15               | D29                              | D43       | D57       | D71            | D85          |
| Vaccine q 2 wks x 3 then q 6 wks                                                        |                   |                                  |           |           |                |              |
| M7824 q 2 wks                                                                           |                   |                                  |           |           |                |              |
| ALT803/ NHSIL12 q 4 wks alternating                                                     |                   |                                  |           |           |                |              |
| Of note each Day # in the figure above has a corresponding Week # in the Study Calendar |                   |                                  |           |           |                |              |  
(1 = W1, D15 = W3, D29 = W5, etc.).  
| Dose Escalation Schedule   | MVA as 4       | N-803    | M7824    | NHS-IL12   |
|----------------------------|----------------|----------|----------|------------|
| Dose Level                 | injections 4 x |          |          |            |
| Arm l                      | 15 mcg/kg      | 1200 mg  |          |            |
| 10 8 IU/0.5                | n/a            |          |          |            |
| mL each) on                |                |          |          |            |
| Arm 2A, Dose Level  l      | 10 mcg/kg      | l 200 mg | 8 mcg    |            |
| D1 and D15,                |                |          |          |            |
| followed by                |                |          |          |            |
| Arm 2A, Dose Level 2       | 10 mcg/kg      | 300 mg   | 16.8 mcg |            |
| FV (1 x 10 9               |                |          |          |            |
| IU/ 0.5mL)                 |                |          |          |            |
| Arm 2B                     | 10 mcg/kg      | 300 mg   | MTD      |            |  
*Note: ALT803 is also known as N-803
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figure 17 3.1.1 dose limiting

Dose limiting toxicities (DLT) (For first 6 participants in Arm 1, and all participants during dose escalation in Arm 2A):
Dose-limiting toxicity (DLT) will be defined as any one of the following adverse events, possibly attributable to study drugs, that occur within 28 days of the start of therapy: Criteria are based on the NCI Common Terminology Criteria for Adverse Events, Version 5. Where clinically appropriate subjects on all arms will receive one year of treatment during which subjects will be followed with surveillance scans. On a case by case basis treatment beyond a year is allowed per investigator discretion. Subjects with evidence of disease progression after completing a year of treatment will be allowed retreatment on the same arm. Patents might be taken off treatment for disease progression prior to completing one year of treatment, but where clinically appropriate, treatment beyond radiographic progression is allowed if in the opinion of the investigator the subject is benefiting from treatment. Subjects will be taken off treatment if unacceptable toxicity. Both arms of this trial will be conducted using a Simon two-stage phase II trial design in which 9 evaluable participants will enroll and if 2 or more of the 9 have an objective response, then accrual would continue until a total of 20 evaluable participants have been treated on a given arm. If there are 5 or more of 20 (25.0%) who experience a response in a given arm, this would be sufficiently interesting to warrant further study. In the event that a participant develops a response (>30% decrease in target lesions as compared with baseline scan) following initial progression or "pseudo-progression", this response will be considered as an objective response in the determination to expand accrual.  
Any Grade 3 or greater adverse drug reactions (ADRs) as defined by CTCAE v5.0 and assessed as possibly attributed to an agent except for any of the following:
o Grade 3 flu-like symptoms or fever, as well as associated symptoms of fatigue, headaches, nausea, emesis which can be controlled with conservative medical management.  
o Tumor flare phenomenon defined as local pain, irritation, or rash localized at sites of known or suspected tumor.  
o Grade 3 Hgb decrease (< 8.0 g/dL) not attributed to grade 3 or greater bleeding events that is clinically manageable with blood transfusions or erythroid growth factor use does not require treatment discontinuation.  
o Grade 3 laboratory values laboratory values that are asymptomatic or resolve to Grade ≤ 1 or baseline grade within 14 days.  
o Grade 4 laboratory values that are asymptomatic and have no clinical correlate (e.g.,
lymphopenia).  
o Keratoacanthoma and squamous cell carcinoma of the skin. o Any endocrinopathy that can be medically managed with hormone replacement o Any grade 3 adverse drug reaction which can be medically managed with minimal risk to the participant (e.g., placement of a pleural catheter for recurrent inflammatory pleural effusions) and resolves to at least grade one or baseline grade within 14 days.
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3.2 drug administration 3.2.1 general

A window of +/- 14 days for a scheduled treatment is allowed in the event of scheduling issues (i.e., holiday, bad weather or other scheduling issues). The minimum time between administrations of a similar agent is 11 days. The CV301 vaccine regimen consists of MVA-BN-CV301 (priming vaccine) and FPV-CV301 (booster vaccine).  
MVA-BN-CV301 is administered as four subcutaneous injections (4 x 108 infectious units/0.5 mL
each) on D1 and D15. Starting on D29, FPV-CV301 (1 x 109 infectious units/ 0.5mL) is administered every 4 weeks on Arm 1 or every 6 weeks on Arm 2A and 2B for up to one year. MVA-BN-CV301 is administered as one injection in each of the following locations: upper left arm, upper right arm, upper left thigh and upper right thigh (i.e., four injection sites per dose). Alternate subcutaneous sites may be used with approval of the principle investigator. FPV-CV301 is administered as a subcutaneous injection preferably in the upper arm (i.e., one injection site per dose). An alternate subcutaneous site may be used with approval of the principle investigator. Subjects will receive M7824 via IV infusion over 1 hour (-10 minutes / +20 minutes, that is, over 50 to 80 minutes) once every 2 weeks. M7824 will be administered as a "flat" dose of either 300 mg or 1,200 mg independent of body weight depending on dose level. M7824 is administered as an intravenous infusion with a mandatory 0.2 micron in-line filter. In order to mitigate potential infusion-related reactions, premedication with an antihistamine and with acetaminophen (for example, 25-50 mg diphenhydramine and 500-650 mg acetaminophen within approximately 30 to 60 minutes prior to dosing of M7824 is optional and at the discretion of the Investigator. N-803 will be given via subcutaneous injection at a dose of 15 mcg/kg every four weeks on Arm 1 and 10 mcg/kg every four weeks on Arm 2A and Arm 2B. N-803 dosing will be calculated using a weight obtained within one week prior to the first dose. The dose will be re-calculated at the beginning of each subsequent cycle in the event of a 10% or greater weight change. If the weight at the beginning of each subsequent cycles is within 10%, the previous dose may be used or the dose may be re-calculated based on local site procedures. Injection should occur in the abdomen and injection sites should be rotated per institutional guidelines and each injection site separated by at least 1 inch. Depending on the injection volume required, the dose of N-803 may be administered as a single injection or multiple injections at the discretion of the investigator.
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3.2.5 nhs-il12 3.3 study intervention

NHS-IL12 will be administered at a dose of 8 or 16.8 mcg/kg by SC injection every 4 weeks on Arm 2A and Arm 2B depending on dose level assignment. The SC injection may be given in the upper arm, anterolateral thigh or abdomen and should preferably be at least 5 cm away from any other subcutaneous injection. The dose of NHS-IL12 will be calculated based on the weight of the subject determined within 72 hours prior to the day of drug administration. The dose of NHS-IL12 used for the previous administration can be repeated if the change in the subject's weight is 10% or less than the weight used for the last dose calculation. Note: Vital signs will be obtained prior to treatment and 30 minutes after administration of the last study drug. Participants should be observed for 30 minutes after the administration of the last study drug. All study drug administration will be given at NIH and documented in the electronic medical record. Treatment with individual agents will be discontinued in the case of:
Any Grade 4 or higher adverse drug reactions (ADRs) as defined by CTCAE v5.0 and assessed as possibly related to that agent by the Investigator, except for laboratory values that are asymptomatic or resolve to Grade ≤ 1 or baseline grade within 7 days without medical intervention".  
Any Grade 3 ADRs possibly attributed to an agent except for any of the following:
o Grade 3 flu-like symptoms or fever, as well as associated symptoms of fatigue, headaches, nausea, emesis which can be controlled with conservative medical management.  
o Tumor flare phenomenon defined as local pain, irritation, or rash localized at sites of known or suspected tumor.  
o Grade 3 Hgb decrease (< 8.0 g/dL) that is clinically manageable with blood transfusions or erythroid growth factor use does not require treatment discontinuation.  
o Grade 3 laboratory values that are asymptomatic or resolve to Grade ≤ 1 or baseline grade within 14 days.  
o Keratoacanthoma and squamous cell carcinoma of the skin.  
o Any endocrinopathy that can be medically managed with hormone replacement o Any grade 3 adverse drug reaction which can be medically managed with minimal risk to the participant (e.g., placement of a pleural catheter for recurrent inflammatory pleural effusions) and resolves to at least grade one or baseline grade within 14 days.  
Individual agents should be withheld for any Grade 2 or 3 ADR possibly attributed to that agent until resolution to Grade ≤ 1 unless the ADR in the opinion of the investigator is not clinically relevant or can be medically managed with minimal risk to the participant. Should a clinically relevant grade 2 or 3 ADR persist for more than 4 weeks, consideration should be given to discontinuing treatment with that individual agent at the discretion of the investigator. For non-medical logistical reasons, unrelated acute illnesses, or palliative radiation, scheduled assessments and dosing can be delayed up to 2 months. Where at all possible, dosing should be restarted to keep in line with the original treatment schedule. N-803 may be held or delayed on the day of a planned dose for either of the following situations:
the participant has a fever of > 101°F (38.3 °C);  
if in the opinion of the treating physician, holding would be of benefit to the participant; hypotension (systolic blood pressure < 90 mm Hg).
N-803 dosing should be held for hypotension (defined as systolic blood pressure less than 90 mm Hg) if in the presence of any clinically significant symptoms (in the opinion of the treating physician), until the systolic blood pressure reading is stable. If mild dehydration is suspected, an IV fluid bolus may be used per standard of care.
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3.4.3 dose modification

Participants with dose modifications or skipped doses within DLT period (for first 6 participants in Arm 1 and all participants during dose escalation in Arm 2A) for reasons other than a DLT (e.g., logistical reasons) who do not experience a DLT within the DLT window will not be evaluable for DLTs and will be replaced for the DLT assessment. Participants who have dose modifications or skipped doses within the DLT period for logistical reasons and nevertheless experience a DLT within the DLT period will be considered DLT evaluable. CEA/ MUC1 vaccines: Vaccine doses will not be modified but doses may be skipped per investigator discretion. N-803: Doses may be reduced to 4, 6 or 8 mcg/kg dose or doses may be skipped. On Arm1, if participants do not tolerate N-803 at 15 mcg/kg every 4 weeks, N-803 may be given on an alternative treatment schedule at lower doses every 2 weeks per investigator discretion. M7824: Doses may be reduced to a 200 or 300 mg flat dose or doses may be skipped. NHS-IL12: Doses may be reduced to a 4,6, 8 or 12 mcg/kg dose or doses may be skipped. Stopping Rule: Any death at least possibly related to study regimen will prompt a suspension of accrual and reassessment of available safety information prior to reopening study to accrual. As a general rule consideration should be given to holding doses of drugs when a toxicity greater than grade 1 at least possibly attributed to a given drug occurs until resolution of that toxicity to at least grade 1 or better. If this occurs with N-803 or NHS-IL12 than consideration should be given to restarting at a reduced dose when restarting treatment with those agents. On Arm1, N-803 may be restarted at any scheduled visit as long as there is at least 14 days between doses of this agent. Dose reductions for vaccine and M7824 are not allowed. If repeated grade 2 adverse events occur than consideration should be given to permanently discontinuing a given agent. 3.4.4 Guidelines for Management of Infusion Reactions
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(in addition to the below

| NCI-CTCAE Grade                                                                                                                                                                                         | Treatment Modification for Infused Agent  (M7824)                                                                                                                                                                     |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 1 - mild                                                                                                                                                                                          | Consider decreasing the infusion rate of the  particular agent by 50% and monitoring closely  for any worsening.                                                                                                      |
| Mild transient reaction; infusion interruption not  indicated; intervention not indicated. Grade 2 - moderate                                                                                           | Consider temporarily discontinuing infusion of  the particular agent.                                                                                                                                                 |
| Therapy or infusion interruption indicated but  responds promptly to symptomatic treatment (e.g.,  antihistamines, NSAIDs, narcotics, i.v. fluids);  prophylactic medications indicated for ≤ 24 hours. | Consider resuming infusion of the particular agent  at 50% of previous rate once infusion related  reaction has resolved or decreased to at least  Grade 1 in severity, and monitor closely for any  worsening.       |
| Grade 3 or Grade 4 - severe or life-threatening                                                                                                                                                         | Stop the infusion immediately and disconnect  infusion tubing from the subject.                                                                                                                                       |
| Grade 3: Prolonged (e.g., not rapidly responsive  to symptomatic medication and/or brief  interruption of infusion); hospitalization indicated  for clinical sequelae.                                  | For grade 3 events: Consider withdrawing  immediately from treatment with that particular  agent and not offering any further treatment with  that agent based upon if the clinical condition can  be safely managed. |
| Grade 4: Life-threatening consequences; urgent  intervention indicated.                                                                                                                                 | For grade 4 events: Withdraw immediately from  treatment and do not offer further treatment with  that agent.                                                                                                         |  
If the infusion rate of M7824 has been decreased by 50% or interrupted due to an infusion reaction, keep it decreased for the next scheduled infusion. If no infusion reaction is observed in the next scheduled infusion, the infusion rate may be returned to baseline at the subsequent infusions based on investigator's medical judgment. If hypersensitivity reaction occurs, the subject should be treated according to the best available medical practice.
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(in addition to the below

Version Date: *05.10.2022*  
| Gastrointestinal irAEs                                                                                                                                                                                                                                        |                                                                                                                                                                                                     |                                                                                                                                                                                 |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Severity of Diarrhea/Colitis (NCI-CTCAE v5)                                                                                                                                                                                                                   | Initial Management                                                                                                                                                                                  | Follow-up Management                                                                                                                                                            |
| Grade 1 Diarrhea: < 4 stools/day over Baseline Colitis: asymptomatic                                                                                                                                                                                          | Consider continuing M7824  Symptomatic treatment (e.g.  loperamide)                                                                                                                                 | Consider close monitoring for  worsening symptoms Consider educating subject to  report worsening immediately If worsens: Treat as Grade 2, 3 or 4.                             |
| Grade 2  Diarrhea: 4 to 6 stools per day over  Baseline; IV fluids indicated < 24  hours; not interfering with ADL Colitis: abdominal pain; blood in stool                                                                                                    | Consider withholding M7824                                                                                                                                                                          | If improves to Grade ≤ 1:                                                                                                                                                       |
| Symptomatic treatment                                                                                                                                                                                                                                         | Consider resuming therapy If persists > 7 days or recurs: Consider treating as Grade 3 or 4.                                                                                                        |                                                                                                                                                                                 |
| Grade 3 to 4 Diarrhea (Grade 3): ≥ 7 stools per day  over Baseline; incontinence; IV fluids  ≥ 24 h; interfering with ADL Colitis (Grade 3): severe abdominal  pain, medical intervention indicated,  peritoneal signs Grade 4: life-threatening, perforation | Consider withholding or permanently  discontinuing M7824 for Grade 3  events based upon if the clinical  condition can be safely managed. For  grade 4 events permanently  discontinue treatment.   | If improves:  Consider continuing steroids  until Grade ≤ 1, then tapering  over at least 1 month; consider  resuming therapy following  steroids taper (for initial Grade  3). |
| Consider 1.0 to 2.0 mg/kg/day  prednisone IV or equivalent                                                                                                                                                                                                    | If worsens, persists > 7 days, or  recurs after improvement: Consider adding infliximab  5mg/kg (if no contraindication).  Note: infliximab should not be  used in cases of perforation or  sepsis. |                                                                                                                                                                                 |
| Consider adding prophylactic  antibiotics for opportunistic  infections  Consider lower endoscopy                                                                                                                                                             |                                                                                                                                                                                                     |                                                                                                                                                                                 |  
3.4.5 Guidelines for Management of Immune-Mediated Adverse Reactions Version Date: *05.10.2022*  
| Dermatological irAEs                                                                              |                                                                                                                                                                                                                                                                                                               |                                                                                                                                                           |
|---------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade of Rash                                                                                     |                                                                                                                                                                                                                                                                                                               |                                                                                                                                                           |
| (NCI-CTCAE v5)                                                                                    | Initial Management                                                                                                                                                                                                                                                                                            | Follow-up Management                                                                                                                                      |
| Grade 1 to 2                                                                                      | Consider continuing M7824                                                                                                                                                                                                                                                                                     |                                                                                                                                                           |
| Covering ≤ 30% body surface area                                                                  | If persists > 1 to 2 weeks or  recurs:  Consider withholding M7824 and  OX40 therapy  Consider skin biopsy                                                                                                                                                                                                    |                                                                                                                                                           |
| Consider symptomatic therapy (for  example, antihistamines, topical  steroids)                    | Consider 0.5-1.0 mg/kg/day  prednisone or equivalent. Once  improving, consider tapering  steroids over at least 1 month,  consider prophylactic antibiotics  for opportunistic infections, and  consider resuming M7824  therapy following steroids taper. If worsens:  Consider treating as Grade 3 to 4.   |                                                                                                                                                           |
| Grade 3 to 4 Grade 3: Covering > 30% body  surface area;  Grade 4: Life threatening  consequences | Consider withholding or permanently  discontinuing M7824 for Grade 3  events based upon if the clinical  condition can be safely managed. For  grade 4 events permanently  discontinue treatment. Consider skin biopsy  Consider dermatology consult  Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent | If improves to Grade ≤ 1:  Consider tapering steroids over at  least 1 month; consider resuming  therapy following steroids taper  (for initial Grade 3). |
| Consider adding prophylactic  antibiotics for opportunistic  infections  Pulmonary irAEs          |                                                                                                                                                                                                                                                                                                               |                                                                                                                                                           |
| Grade of Pneumonitis (NCI-CTCAE v5)                                                               | Initial Management                                                                                                                                                                                                                                                                                            | Follow-up Management                                                                                                                                      |
| Grade 1                                                                                           | Consider withholding M7824                                                                                                                                                                                                                                                                                    |                                                                                                                                                           |
| Radiographic changes only                                                                         | Consider Pulmonary and Infectious  Disease consults                                                                                                                                                                                                                                                           | Consider re-assessing at least  every 3 weeks If worsens:  Consider treating as Grade 2 or  Grade 3 to 4.                                                 |
| Grade 2                                                                                           | Consider withholding M7824                                                                                                                                                                                                                                                                                    | If improves:                                                                                                                                              |
| Mild to moderate new symptoms                                                                     |                                                                                                                                                                                                                                                                                                               |                                                                                                                                                           |  
Version Date: *05.10.2022*  
| Version Date: 05.10.2022                                                                     | Consider pulmonary and Infectious  Disease consults Consider monitoring symptoms  daily; consider hospitalization  Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent Consider adding prophylactic  antibiotics for opportunistic  infections  Consider bronchoscopy, lung biopsy                                                                                                                                                                | When symptoms return to Grade  ≤ 1, consider tapering steroids  over at least 1 month, and then  consider resuming therapy  following steroids taper  If not improving after 2 weeks or  worsening:  Consider treating as Grade 3 to 4.                                  |
|----------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 3 to 4 Grade 3: Severe new symptoms;  New/worsening hypoxia; Grade 4: Life-threatening | Consider withholding or permanently  discontinuing M7824 for Grade 3  events based upon if the clinical  condition can be safely managed. For  grade 4 events permanently  discontinue treatment. Consider hospitalization. Consider pulmonary and Infectious  Disease consults. Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent  Consider adding prophylactic  antibiotics for opportunistic  infections  Consider bronchoscopy, lung biopsy | If improves to Grade ≤ 1:  Consider tapering steroids over at  least 1 month  If not improving after 48 hours or  worsening:  Consider adding additional  immunosuppression (for  example, infliximab,  cyclophosphamide, IV  immunoglobulin, or  mycophenolate mofetil) |
| Hepatic irAEs                                                                                |                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                                          |
| Grade of Liver Test Elevation (NCI-CTCAE v5)                                                 | Initial Management                                                                                                                                                                                                                                                                                                                                                                                                                                    | Follow-up Management                                                                                                                                                                                                                                                     |
| Grade 1 Grade 1 AST or ALT > ULN to 3.0 x  ULN and/or Total bilirubin > ULN to  1.5 x ULN    | Consider continuing M7824                                                                                                                                                                                                                                                                                                                                                                                                                             | Consider continued liver function  monitoring  If worsens:   Consider treating as Grade 2 or 3  to 4.                                                                                                                                                                    |
| Grade 2 AST or ALT > 3.0 to ≤ 5 x ULN  and/or total bilirubin > 1.5 to ≤ 3 x  ULN            | Consider withholding M7824                                                                                                                                                                                                                                                                                                                                                                                                                            | If returns to Grade ≤ 1: Consider resuming therapy. If elevation persists > 7 days or  worsens:  Consider treating as Grade 3 to 4.                                                                                                                                      |
| Grade 3 to 4 AST or ALT > 5 x ULN and/or total  bilirubin > 3 x ULN                          | Consider withholding or permanently  discontinuing M7824 for Grade 3  events based upon if the clinical  condition can be safely managed. For  grade 4 events permanently  discontinue treatment.                                                                                                                                                                                                                                                     | If returns to Grade ≤ 1:  Consider tapering steroids over at  least 1 month  If does not improve in > 7 days,  worsens or rebounds:                                                                                                                                      |  
Version Date: *05.10.2022*  
| Version Date: 05.10.2022                                                                | Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent Consider adding prophylactic  antibiotics for opportunistic  infections  Consider consulting  gastroenterologist/ hepatologist Consider obtaining MRI/CT scan of  liver and liver biopsy if clinically  warranted                                                                                                                                                                                                                                                                                             | Consider adding mycophenolate  mofetil 1 gram (g) twice daily  If no response within an  additional 7 days, consider other  immunosuppressants per local  guidelines.   |
|-----------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Renal irAEs                                                                             |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                         |
| Grade of Creatinine Increased  (NCI-CTCAE v5)                                           | Initial Management                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Follow-up Management                                                                                                                                                    |
| Continue renal function monitoring If worsens: Consider treating as Grade 2 to 3 or  4. |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                         |
| Grade 1 Creatinine increased > ULN to 1.5 x                                             | Consider continuing M7824                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |                                                                                                                                                                         |
| ULN                                                                                     | If returns to Grade ≤1: Consider tapering steroids over at  least 1 month, and consider  resuming therapy following  steroids taper. If worsens:  Treat as Grade 4.                                                                                                                                                                                                                                                                                                                                                                                                   |                                                                                                                                                                         |
| Grade 2  Creatinine increased > 1.5 and ≤ 6 x  ULN                                      | Consider withholding M7824  Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent. Consider adding prophylactic  antibiotics for opportunistic infections Consider renal biopsy Consider withholding or permanently  discontinuing M7824 for Grade 3  events based upon if the clinical  condition can be safely managed. For  grade 4 events permanently  discontinue treatment. Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent. Consider adding prophylactic  antibiotics for opportunistic infections Consider renal biopsy Consider Nephrology consult | If returns to Grade ≤1: Consider tapering steroids over at  least 1 month.                                                                                              |
| Grade 3-4 Creatinine increased > 6 x ULN                                                |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       |                                                                                                                                                                         |  
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| Cardiac irAEs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                 |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Myocarditis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Initial Management                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Follow-up Management                                                                                                                                                                                                                                                                                            |
| New onset of cardiac signs or  symptoms and / or new laboratory  cardiac biomarker elevations (e.g.  troponin, CK-MB, BNP) or cardiac  imaging abnormalities suggestive of  myocarditis.                                                                                                                                                                                                                                                                                                                                                                                                                                                                 | Consider withholding or permanently  discontinuing M7824 based upon if  the clinical condition can be safely  managed. Consider hospitalization In the presence of life threatening  cardiac decompensation, consider  transfer to a facility experienced in  advanced heart failure and  arrhythmia management. Consider cardiology consult to  establish etiology and rule-out  immune-mediated myocarditis.  Consider myocardial biopsy if  recommended per cardiology consult. | If symptoms improve and  immune-mediated etiology is  ruled out, consider re-starting  therapy. If symptoms do not  improve/worsen, viral  myocarditis is excluded, and  immune-mediated etiology is  suspected or confirmed following  cardiology consult, consider  managing as immune-mediated  myocarditis. |
| Immune-mediated myocarditis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Consider withholding or permanently  discontinuing M7824 based upon if  the clinical condition can be safely  managed. Consider guideline based supportive  treatment as appropriate as per  cardiology consult. Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent Consider adding prophylactic  antibiotics for opportunistic  infections.                                                                                                                                  | Once improving, consider  tapering steroids over at least 1  month. If no improvement or worsening,  consider additional  immunosuppressants (e.g.  azathioprine, cyclosporine A).                                                                                                                              |
| *Local guidelines, or eg. ESC or AHA guidelines  ESC guidelines website: https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines AHA guidelines website:  http://professional.heart.org/professional/GuidelinesStatements/searchresults.jsp?q=&y=&t=1001 Endocrine irAEs Endocrine Disorder Initial Management Follow-up Management Grade 1 or Grade 2  endocrinopathies (hypothyroidism,  hyperthyroidism, adrenal  insufficiency, type I diabetes  mellitus) Consider continuing M7824  Consider endocrinology consult if  needed Consider continuing hormone  replacement/suppression and  monitoring of endocrine function  as appropriate. |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                 |  
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| Version Date: 05.10.2022                                                                                                                                                                                                                                                                                                      | Consider starting thyroid hormone  replacement therapy (for  hypothyroidism), anti-thyroid  treatment (for hyperthyroidism),  corticosteroids (for adrenal  insufficiency) or insulin (for Type I  diabetes mellitus) as appropriate.  Consider ruling-out secondary  endocrinopathies (i.e.  hypopituitarism / hypophysitis)                                                                                                                                                            |                                                                                                                                                                                                                                                                                                                                                               |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Grade 3 or Grade 4  endocrinopathies (hypothyroidism,  hyperthyroidism, adrenal  insufficiency, type I diabetes  mellitus)                                                                                                                                                                                                    | Consider withholding or  permanently discontinuing M7824  for Grade 3-4 events based upon if  the clinical condition can be safely  managed.  Consider hospitalization Consider endocrinology consult                                                                                                                                                                                                                                                                                    | Consider resuming therapy once  symptoms and/or laboratory tests  improve to Grade ≤ 1 (with or  without hormone  replacement/suppression). Consider continuing hormone  replacement/suppression and  monitoring of endocrine function  as appropriate.                                                                                                       |
| Consider starting thyroid hormone  replacement therapy (for  hypothyroidism), anti-thyroid  treatment (for hyperthyroidism),  corticosteroids (for adrenal  insufficiency) or insulin (for type I  diabetes mellitus) as appropriate.  Consider ruling-out secondary  endocrinopathies (i.e.  hypopituitarism / hypophysitis) |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |                                                                                                                                                                                                                                                                                                                                                               |
| Hypopituitarism/Hypophysitis                                                                                                                                                                                                                                                                                                  | If secondary thyroid and/or adrenal                                                                                                                                                                                                                                                                                                                                                                                                                                                      |                                                                                                                                                                                                                                                                                                                                                               |
| (secondary endocrinopathies)                                                                                                                                                                                                                                                                                                  | insufficiency is confirmed (i.e.  subnormal serum FT4 with  inappropriately low TSH and/or low  serum cortisol with inappropriately  low ACTH):  Consider referring to  endocrinologist for dynamic  testing as indicated and  measurement of other hormones  (FSH, LH, GH/IGF-1, PRL,  testosterone in men, estrogens  in women)   Consider hormone  replacement/suppressive therapy  as appropriate   Consider performing pituitary  MRI and visual field  examination as indicated | Consider resuming therapy once  symptoms and hormone tests  improve to Grade ≤ 1 (with or  without hormone replacement). In addition, for hypophysitis  with abnormal MRI, consider  resuming M7824 only once  shrinkage of the pituitary gland  on MRI/CT scan is documented.  Consider continuing hormone  replacement/suppression therapy  as appropriate. |
| If hypophysitis confirmed:                                                                                                                                                                                                                                                                                                    |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |                                                                                                                                                                                                                                                                                                                                                               |  
Version Date: *05.10.2022*  
| Version Date: 05.10.2022                                                       |                                                                                                                                                                                                                                                                         | Continue M7824 if mild  symptoms                                                                                             |
|--------------------------------------------------------------------------------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------|
|                                                                               | Consider withholding M7824  and if moderate, severe or lifethreatening symptoms of  hypophysitis. Consider  hospitalization. Consider  initiating corticosteroids (1 to 2  mg/kg/day prednisone or  equivalent) followed by  corticosteroids taper during at  least 1 month.                                                                                                                                                                                                                                                                          |                                                                                                                              |
|                                                                               | Consider adding prophylactic  antibiotics for opportunistic  infections.                                                                                                                                                                                                 |                                                                                                                              |
| Other irAEs (not described above)                                              |                                                                                                                                                                                                                                                                          |                                                                                                                              |
| Grade of other irAEs                                                           | Initial Management                                                                                                                                                                                                                                                       | Follow-up Management                                                                                                         |
| (NCI-CTCAE v5)                                                                 |                                                                                                                                                                                                                                                                          |                                                                                                                              |
| Grade 2 or Grade 3 clinical signs or  symptoms suggestive of a potential  irAE | Consider withholding M7824                                                                                                                                                                                                                                               | If irAE is ruled out, consider                                                                                               |
| pending clinical investigation                                                 | managing as appropriate  according to the diagnosis and  consider re-starting therapy If irAE is confirmed, consider  treating as Grade 2 or 3 irAE.                                                                                                                     |                                                                                                                              |
| Grade 2 irAE or first occurrence of                                            | Consider withholding M7824 based                                                                                                                                                                                                                                         |                                                                                                                              |
| Grade 3 irAE                                                                   | upon if the clinical condition can be  safely managed. Consider 1.0 to 2.0 mg/kg/day  prednisone or equivalent  Consider adding prophylactic  antibiotics for opportunistic  infections  Specialty consult as appropriate                                                | If improves to Grade ≤ 1:  Consider tapering steroids over  at least 1 month and resuming  therapy following steroids taper. |
| Recurrence of same Grade 3 irAEs                                               | Consider permanently discontinuing  M7824 based upon if the clinical  condition can be safely managed;  Consider 1.0 to 2.0 mg/kg/day prednisone or equivalent Consider adding prophylactic  antibiotics for opportunistic  infections  Specialty consult as appropriate | If improves to Grade ≤ 1:  Consider tapering steroids over  at least 1 month.                                                |  
Version Date: *05.10.2022*  
| Grade 4                                                                                                                                                            | Permanently discontinue M7824  Consider to 2.0 mg/kg/day prednisone or equivalent and/or  other immunosuppressant as needed Consider adding prophylactic  antibiotics for opportunistic  infections  Consider specialty consult as  appropriate   | If improves to Grade ≤ 1:  Consider tapering steroids over  at least 1 month   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------------|
| Requirement for 10 mg per day or  greater prednisone or equivalent  for more than 12 weeks for reasons  other than hormonal replacement  for adrenal insufficiency | Consider permanently discontinuing  M7824  Consider specialty consult as  appropriate                                                                                                                                                             |                                                                                |
| Persistent Grade 2 or 3 irAE  lasting 12 weeks or longer                                                                                                           |                                                                                                                                                                                                                                                   |                                                                                |  
Abbreviations: ACTH=adrenocorticotropic hormone; ADL=activities of daily living; ALT=alanine aminotransferase; AST=aspartate aminotransferase; BNP=B-type natriuretic peptide; CK-MB=creatine kinase MB; CT= computed tomography; FSH=follicle-stimulating hormone; GH=growth hormone; IGF-1=insulin-like growth factor 1; irAE=immune related adverse event; IV=intravenous; LH=luteinizing hormone; MRI=magnetic resonance imaging; NCI CTCAE=National Cancer Institute Common Terminology Criteria for Adverse Events; PRL=prolactin;T4=thyroxine; TSH=thyroid stimulating hormone; ULN=upper limit of normal  
| 3.5                                                                       | STUDY CALENDAR   | Safety                |               |      |        |
|---------------------------------------------------------------------------|------------------|-----------------------|---------------|------|--------|
| Procedure                                                                 | Screening1       | Baseline /            | Week  (2N+1)3 | EOT4 | follow |
| Week 12                                                                   | up5              | Long Term  follow up6 |               |      |        |
| Treatment3                                                                | X                | X                     |               |      |        |
| NIH Advance Directives Form7                                              | X                |                       |               |      |        |
| Medical History                                                           | X                |                       |               |      |        |
| Height                                                                    | X                |                       |               |      |        |
| History (e.g., bleeding history) and  physical exam, weight, vital signs, | X                | X                     | X             | X    | X      |
| ECOG  HIV, HCV, HepB                                                      | X                |                       |               |      |        |
| EKG                                                                       | X                | X                     | X             | X    |        |
| CBC with differential                                                     | X                | X                     | X             | X    | X      |
| Biochemical profile8                                                      | X                | X                     | X             | X    | X      |
| Tumor Markers9                                                            | X                | X                     | X             |      |        |
| CD410                                                                     | X                | X                     | X10           | X    |        |
| ACTH, TSH, Free T4, lipase,  amylase, CRP                                 | X                | X11                   |               |      |        |
| Urinalysis                                                                | X                |                       |               |      |        |
| Urine or serum pregnancy testing in  women of childbearing potential (see | X                | X                     | X             |      |        |
| Section 2.2)  PT, INR, aPTT                                               | X                | X                     | X             | X    | X      |
| Tumor Evaluation (CT Scan /  MRI)12                                       | X                | X                     | X             |      |        |
| Brain CT / MRI 13                                                         | X                |                       |               |      |        |
| Concomitant Medications                                                   | X                | X                     | X             | X    |        |
| Adverse Events                                                            | X                | X                     | X             | X    |        |
| Optional biopsy for immune  analysis14                                    | X                | X                     |               |      |        |
| Research Blood15                                                          | X                | X                     | X             |      |        |
| Telephone Follow Up                                                       | X                | X                     |               |      |        |  
1. Screening evaluations performed within 28 days prior to the first drug administration, unless specified in Section 2.2. 2. Baseline evaluations performed within 1 week prior to the first drug administration. 3. Schedule of therapeutic agents administered will be as outlined in Section **3.2, Figure 17**, depending upon the arm of study participant has been assigned to. Of note each week in the study calendar above has a corresponding day \# in Figure 17 (W1 = D1, W3 = D15, W5 = D29, etc.). CV301 will be given every 2 weeks for the first 3 doses followed by every 4 weeks on Arm 1 and every 6 weeks on Arm 2A and 2B thereafter. M7824 infusion will be every two weeks for both arms. Subjects assigned to Arm 1 will receive N-803 every 4 weeks. Subjects assigned to Arm 2 will receive N-803 or NHS-IL12 on an alternating schedule every 2 weeks (each of these agents will be given individually every 4 weeks). Administration of study agents and indicated evaluations can be done up to 14 days earlier or delayed up to 14 days due to holidays, inclement weather, conflicts, or similar reasons. The timing of subsequent administrations is adjusted to maintain a minimum of 11 days between treatments of similar agents. Note: Vital signs will be obtained prior to treatment and 30 minutes after administration of the last study drug. Participants should be observed for 30 minutes after the administration of the last study drug. 4. EOT - End of treatment visit: Where feasible, on the day of or within 7 days of the decision to discontinue treatment prematurely before completion of one year of treatment. Does not need to be completed if drug is withheld after one year of treatment. 5. 28 days (+/- 7 days) after last treatment. If subjects are not willing to come to NIH for FU visit, they will be contacted by phone to assess adverse events. 6. Participants who have come off treatment for disease progression will be followed by phone annually for survival. Participants who have not progressed on treatment will continue to be followed and scanned per investigator discretion until progression. Those that completed one year of treatment will be invited for an additional year of treatment at the time of progression. Initial and follow up courses of treatment may extend beyond a year per investigator discretion. 7. As indicated in Section **12.3**, all subjects will be offered the opportunity to complete an NIH advanced directive 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 8. Biochemical profile: sodium, potassium, chloride, bicarbonate, calcium, glucose, BUN, creatinine, ALT, AST, alkaline phosphatase, total protein, albumin, and total and direct bilirubin. Serial Troponins and echocardiogram may also be added as clinically indicated if there is evidence or concern for myopericarditis. 9. Evaluate CEA, CA19-9, CA125 and CA15-3 at baseline and follow elevated values thereafter. 10. In HIV positive participants; Every 8 weeks
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11. every 8 weeks.

12. Every 8 weeks. In the event of a PR or CR tumor imaging assessments may be performed every 3 months (+/- 2 weeks) at the discretion of the investigator. Tumor assessment should be continued beyond end of treatment in participants who have not experienced PD until they experience PD in order to assess PFS. MRI will be used when CT scan is not an option to follow the disease clinically. Gadolinium will be used only for clinically indicated MRIs. Bone scans and other imaging assessments may also be performed as clinically indicated. 13. In participants with known CNS disease as described in Section **2.1.2.5**. MRIs may be performed as clinically indicated in this population. 14. Optional biopsies at baseline and as close as possible to first imaging restaging. 15. Where feasible, research blood for all study assessments (see Section 4.2) will be collected at weeks 1, 3, 5, 7 and every 6 weeks thereafter in selected participants per PI discretion.
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3.6 cost and compensation 3.6.1

NIH does not bill health insurance companies or participants for any research or related clinical care that participants receive at the NIH Clinical Center. If some tests and procedures performed outside the NIH Clinical Center, participants may have to pay for these costs if they are not covered by insurance company. Medicines that are not part of the study treatment will not be provided or paid for by the NIH Clinical Center.
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3.6.2 compensation

There will be no compensation provided on this study. 3.6.3 Reimbursement The NCI will cover the costs of some expenses associated with protocol participation. Some of these costs may be paid directly by the NIH and some may be reimbursed to the participant/guardian as appropriate. The amount and form of these payments are determined by the NCI Travel and Lodging Reimbursement Policy.
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3.7 criteria for removal from

Regardless of reason for removal from study therapy, participants will be asked to have a 28 day follow up safety visit. Participants who refuse to return for this visit will be asked to review any safety concerns by phone within this time period. 3.7.1 Criteria for Removal from Protocol Therapy Clinical or radiographic progression of disease except when the investigator feels the subject is still benefiting from treatment. (It is generally preferable for participants to remain on treatment past initial radiographic progression in case there is pseudo - progression, except when the investigator feels that the clinical picture warrants changing therapy at initial progression).  
Unacceptable toxicity possibly attributed to all active therapies.  
Participant requests to be withdrawn from active therapy.  
Start of another systemic anticancer treatment (with the exception of continuation of maintenance therapy) or participation in another investigational therapeutic trial. Focal palliative radiotherapy, ablation, or surgery to a site of disease will not necessitate removal from protocol therapy. Investigator discretion.  
Positive pregnancy test.  
3.7.2 Off-Study Criteria Screen failure. PI decision to end the study.  
Participant requests to be withdrawn from study.  
Participant lost to follow up.
Investigator discretion. Death.  
3.7.3 Lost to Follow-up A participant will be considered lost to follow-up if he or she fails to return for 4 scheduled visits and is unable to be contacted by the study site staff. The following actions must be taken if a participant fails to return to the clinic for a required study visit:  
The site will attempt to contact the participant and reschedule the missed visit within the next two weeks and counsel the participant on the importance of maintaining the assigned visit schedule and ascertain if the participant wishes to and/or should continue in the study.  
Before a participant is deemed lost to follow-up, the investigator or designee will make every effort to regain contact with the participant (where possible, 3 telephone calls and, if necessary, an IRB approved certified letter to the participant's last known mailing address or local equivalent methods). These contact attempts should be documented in the participant's medical record or study file.
Should the participant continue to be unreachable, he or she will be considered to have withdrawn from the study with a primary reason of lost to follow-up.
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4 concomitant medications/measures

Any medications (other than those excluded by the clinical trial protocol) that are considered necessary to protect subject welfare or alleviate symptoms and will not interfere with the trial medication may be given at the Investigator's discretion. Palliative radiotherapy delivered in a normal organ-spearing technique may be administered during the trial. The assessment of PD will not be based on the necessity for palliative radiotherapy.
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4.1 the following treatments should

Other immunotherapies or immunosuppressive drugs (for example, chemotherapy or systemic corticosteroids except for prophylaxis or treatment of allergic reactions, endocrine replacement therapy at low dose prednisone [≤ 10 mg daily] or equivalent, for the treatment of irAEs, or for short courses (≤ 14 days) as appropriate medical therapy for unrelated medical conditions (e.g., asthma). Steroids with no or minimal systemic effect (topical, inhalation) are allowed.  
Prophylactic use of corticosteroids for infusion related reactions. Corticosteroid administration prior to CT scans in participants with intravenous contrast allergy is allowed.  
Any live vaccine therapies for the prevention of infectious disease. Administration of inactivated vaccines is allowed (for example, inactivated influenza vaccines or locally approved COVID vaccines).
Systemic anticancer treatment.
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4.2 n-803

Central nervous function may be affected with N-803. Caution should be used with psychotropic medications. Nephrotoxic, myelotoxic, cardiotoxic, or hepatotoxic medications should be avoided if possible as they may further increase toxicities that have been associated with N-803. Interferonalfa is prohibited while on study. Beta-blockers and other antihypertensives may potentiate the hypotension seen with N-803. Therefore, administration of these agents should be avoided during N-803 treatment period, unless clinically indicated. If a participant who is to receive N-803 is on a beta-blocker or other antihypertensive, that agent may be discontinued starting on the day of the first treatment with N-803, if the investigator determines that stopping the agent is safe. Antihypertensive management decisions will be made on a case by case basis. For example, an antihypertensive may be resumed or added at any point if the investigator believes it to be clinically indicated e.g., if a participant experiences uncontrolled hypertension while receiving N-803 treatment on study. For participants on antihypertensives at baseline, the agent will be resumed if clinically indicated by blood pressure readings in the days following N-803 treatment cessation. If a localized skin rash at the injection site occurs that is >6 cm and symptomatic, it may be treated with 0.05% clobetasol propionate or 0.1% triamcinolone cream or similar product at the discretion of the treating physician.
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5 correlative studies for research

| 5.1                                                            | BIOSPECIMEN COLLECTION  Volume                      | Type of tube a   | Collection point   | Location of specimen   |
|----------------------------------------------------------------|-----------------------------------------------------|------------------|--------------------|------------------------|
| Test/assay                                                     | (approx.) per                                       | analysis*        |                    |                        |
| Timepoint                                                      |                                                     |                  |                    |                        |
| Standard and 123  immune cell subsets  by FACS                 | See study calendar  3.5                             | LTIB             |                    |                        |
| Functional Analysis  of immune cell  subsets by FACS           | LTIB                                                |                  |                    |                        |
| 60-80 mL  blood for  PBMCs                                     | Sodium  heparin (green  top) tubes                  |                  |                    |                        |
| Antigen Specific  Immune Response  by cytokine staining  assay | LTIB LTIB and NCI  Frederick Genomic  Core Facility |                  |                    |                        |
| T cell clonality by  immunseq platform                         | LTIB and NCI  Frederick Genomic  Core Facility      |                  |                    |                        |
| RNA expression  level of 770 genes                             | 8 mL blood for                                      | SST              |                    |                        |
| Soluble Factors (to  include sCD27 and                         | serum                                               | LTIB             |                    |                        |  
| Volume                                 | Type of tube a   | Collection point   | Location of specimen                           |
|----------------------------------------|------------------|--------------------|------------------------------------------------|
| Test/assay                             | (approx.) per    | analysis*          |                                                |
| Timepoint                              |                  |                    |                                                |
| sCD40 ligand) by                       | 10 mL blood      | EDTA tube          |                                                |
| ELISA                                  | for plasma       |                    |                                                |
| Immune Markers                         | Tumor samples    | N/A                | GMB TIME Lab                                   |
| by IHC                                 | Tumor samples    | N/A                | LTIB and NCI  Frederick Genomic  Core Facility |
| RNA expression  level of 770 genes     | Tumor samples    | N/A                | LTIB and NCI  Frederick Genomic  Core Facility |
| T cell clonality by  immunseq platform |                  |                    |                                                |  
*Research blood samples will be sent to the Clinical Services Program - Leidos Biomedical Research, Inc. (CSP) (Section **5.3.1**) for barcoding, initial processing and storage. Tissue will be sent to the Laboratory of Pathology as described in Section **5.3.2**. From these facilities, coded, linked samples will be sent to the designated labs for analysis upon request.  
a Please note that tubes and media may be substituted based on availability with the permission of the PI or laboratory investigator.
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5.1.1 immune phenotyping

Exploratory immunologic studies will be conducted to evaluate the study drug's effect on the immune response before and after treatment, to gain insight into potential biomarkers, and help improve the administered therapy. Blood will be collected as per Study Calendar 3.5. The following immune assays may be performed at the Laboratory of Tumor Immunology and Biology (LTIB) at the NCI's Center for Cancer Research (CCR) in select participants where adequate samples are available:  
1. PBMCs may be analyzed for changes in standard immune cell types (CD4 and CD8 T cells, natural killer [NK] cells, regulatory T cells [Tregs], myeloid-derived suppressor cells [MDSCs], and dendritic cells) as well as 123 immune cell subsets, using multi-color flow cytometry.  
2. PBMCs from selected subjects may be analyzed for function of specific immune cell subsets, including CD4 and CD8 T cells, NK cells, Tregs, and MDSCs using flow-based assays.  
3. PBMCs may be analyzed for tumor antigen-specific immune responses using an intracellular cytokine staining assay. PBMCs will be stimulated in vitro with overlapping 15-mer peptide pools encoding the tumor-associated antigens such as CEA, MUC-1 and Brachyury; control peptide pools will involve the use of human leukocyte antigen peptide as a negative control and CEFT peptide mix as a positive control. CEFT is a mixture of peptides of CMV, Epstein-Barr virus, influenza, and tetanus toxin. Post-stimulation analyses of CD4 and CD8 T cells will involve the production of IFN-γ, IL-2, TNF, and the
degranulation marker CD107a. If sufficient PBMCs are available, assays may also be performed for the development of T cells to other tumor-associated antigens.  
5.1.2 Soluble Factors Samples for soluble factor analysis will be collected as per Study Calendar 3.5. -Sera and/or plasma may be analyzed pre- and post-therapy for the following soluble factors: sCD27, sCD40 ligand using commercial ELISA kits. -Sera and/or plasma may be analyzed for changes in cytokines (IFN-γ, IL-10, IL-12, IL-2, IL-4, etc.), chemokines, antibodies, tumor-associated antigens, and/or other markers using ELISA or multiplexed assays (e.g., Mesoscale, Luminex, cytokine bead array). 5.1.3 Analyses of Tumor Tissue for Immune Markers Study of immune infiltration as well as PD-L1 status within the tumor microenvironment pre vs. post treatment by IHC and/or multiplex immunofluorescence may be performed by the GMB TIME Lab. Where available, archival tumor samples will be requested. For participants with lesions amenable to biopsy, two optional biopsies may be performed at baseline and at first restaging. Tumor samples will be sent to the Laboratory of Pathology for disease evaluation; remaining samples will be used for research. Tissue samples for research may also be stored in CSP as described in Section **5.3.1**.
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5.2 samples for genetic/genomic analysis

Where possible, RNA expression and T-cell receptor clonality analysis will be done on the peripheral blood as well as archived tumor tissue or optional biopsies to help further evaluate changes in immune response and RNA expression levels with treatment as well as to determine tumor and infiltrating lymphocyte characteristics which may be predictive of response to treatment. In addition, these analyses will also be used to gauge resistance mechanisms and additional targets for future therapy. Coded, linked samples may be analyzed for RNA expression levels using the Nanostring platform and T-cell receptor clonality using the ImmunoSeq platform (LTIB and NCI Frederick Genomic Core Facility). NCI Fredrick Genomic Core Facility: Leidos Biomedical Research, Inc: Dr. Xiaolin Wu ATRF, Rm C3016 8560 Progress Drive Frederick, MD 21701 Ph. 301-846-7677 5.2.2 Description of How Privacy and Confidentiality of Medical Information/Biological Specimens will be Maximized Confidentiality for genetic samples will be maintained as described (Section **5.3.1** and **5.3.2**).
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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 the National Institutes for Health (NIH) without appropriate approvals and/or agreements, if required. The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements of Section 7.2 5.3.1 Sample Management and Storage at Clinical Services Program - Leidos Biomedical Research, Inc. (CSP)
Clinical Services Program - Leidos Biomedical Research, Inc. Attn: Theresa Burks 1050 Boyles Street Bldg. 496/Room 121 Frederick, MD 21702 On days samples are drawn, Jen Bangh at CSP (part of NCI Frederick Central Repositories) should be notified (phone: [301] 846-5893; fax [301] 846-6222). She will arrange same-day courier delivery of the specimens. All data associated with the participant samples is protected by using a secure database. All samples drawn at the NIH Clinical Center will be transported to the Clinical Support Laboratory at the Frederick National Laboratory for Cancer Research by couriers. Samples will be tracked and managed by Central Repository database, where there is no link to personal identifiable information. All samples will be stored in either a -80ºC freezer or vapor phase liquid nitrogen. These freezers are located at NCI Frederick Central Repository in Frederick, Maryland. NCI Frederick Central Repositories (managed under a subcontract) store, among other things, biological specimens in support of NIH clinical studies. All specimens are stored in secure, limited-access facilities with sufficient security, backup, and emergency support capability and monitoring to ensure long-term integrity of the specimens for research. Specimens are stored in accordance with applicable HHS and FDA Protection of Human Subjects Regulations in accordance with the subcontractor's Federal-wide Assurance. The subcontractor's role limited to clinical research databases and repositories containing participant specimens. The subcontractor does not conduct or have any vested interest in research on human subjects but does provide services and support the efforts of its customers, many of which are involved in research on human subjects. It is the intent and purpose of the subcontractor to accept only coded, linked samples and sample information. To the limit of our ability, every effort will be made to ensure that protected information is not sent electronically or by hard copy or on vial labels. Sample data is stored in the BioSpecimen Inventory System II (BSI). This inventory tracking system is used to manage the storage and retrieval of specimens as well as to maintain specimen data. BSI is designed for controlled, concurrent access. It provides a real-time, multi-user environment for tracking millions of specimens. The system controls how and in what order database updates and searches are performed. This control prevents deadlocks and race conditions. For security, BSI has user password access, 3 types of user access levels, and 36 user permissions (levels of access) that can be set to control access to the system functions. BSI provides audit tracking for processes that are done to specimens including shipping, returning to inventory, aliquoting, thawing, additives, and other processes. BSI tracks the ancestry of specimens as they are aliquoted, as well as discrepancies and discrepancy resolution for specimens received by the repository. If a specimen goes out of the inventory, the system maintains data associated with the withdrawal request. Vials are labeled with a unique BSI ID which is printed in both eye-readable and bar-coded format. No participant-specific information is encoded in this ID. Investigators are granted view, input, and withdrawal authority only for their specimens. They may not view specimen data or access specimens for which they have not been authorized. Access to specimen storage is confined to repository staff. Visitors to the repositories are escorted by repository staff at all times. 5.3.2 Procedures for Storage of Tissue Specimens in the 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 tissues are stored 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 participant was enrolled.
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5.3.3 protocol completion/sample destruction

All specimens obtained in the protocol are used as defined in the protocol. Any specimens that are remaining at the completion of the protocol will be stored in the conditions described above. The study will remain open so long as sample or data analysis continues. Samples from consenting subjects will be stored until they are no longer of scientific value or if a subject withdraws consent for their continued use, at which time they will be destroyed. If the participant withdraws consent the participant's data will be excluded from future distributions, but data that have already been distributed for approved research use will not be able to be retrieved. The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will be per the requirements of Section 7.2.
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6 data collection and evaluation

The PI will be responsible for overseeing entry of data into a 21 CFR Part 11-compliant data capture system provided by the NCI CCR 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. 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. Document AEs from the time the study consent is signed through 28 days after removal from study treatment or until off-study, whichever comes first. Adverse events that are serious need to be recorded through 28 days after the last intervention. Beyond 28 days after the last intervention and through long term follow up (survival of subject), only adverse events which are serious and related to the study intervention need to be recorded. 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:
Results in discontinuation from the study  
Is associated with clinical signs or symptoms Requires treatment or any other therapeutic intervention Is associated with death or another serious adverse event, including hospitalization. Is judged by the Investigator to be of significant clinical impact If any abnormal laboratory result is considered clinically significant, the investigator will provide details about the action taken with respect to the test drug and about the participant's outcome.
End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH Intramural Records Retention Schedule as applicable. Loss or destruction of data: Should we become aware that a major breach in our plan to protect subject confidentiality and trial data has occurred, this will be reported expeditiously per requirements in Section **7.2.1**.
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what data will be shared?

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

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

Before publication.  
At the time of publication or shortly thereafter.  
6.2.2 Genomic Data Sharing Plan Unlinked genomic data will be deposited in public genomic databases such as dbGaP in compliance with the NIH Genomic Data Sharing Policy.
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6.3 response criteria 6.3.1 antitumor

Tumor assessments may include the following evaluations: physical examination (with photograph and measurement of skin lesions, as applicable); cross-sectional imaging using computed tomography (CT) or magnetic resonance imaging (MRI) scan of the chest, abdomen, and pelvis (pelvis scan is optional unless known pelvic disease is present at baseline); nuclear bone scan for subjects with known/suspected bone lesions; and CT or MRI scan of the brain (only as clinically warranted based on symptoms/findings). The preferred method of disease assessment is CT with contrast. If CT with contrast is contraindicated, CT of the chest without contrast and MRI scan of the abdomen/pelvis is preferred. At baseline, tumor lesions will be selected and categorized as target or non-target lesions. Target lesions include those lesions that can be accurately measured in at least 1 dimension as ≥ 20 mm with conventional techniques or ≥ 10 mm with CT scan. Malignant lymph nodes with a short axis diameter ≥ 15 mm can be considered target lesions. Up to a maximum of 2 target lesions per organ and 5 target lesions in total will be identified at baseline. These lesions should be representative of all involved organs and selected based on their size (those with the longest diameter) and their suitability for accurate repeated measurements. A sum of the longest lesion diameter (LLD) for all target lesions will be calculated and reported as the baseline sum LLD. For malignant lymph nodes identified as target lesions, the short axis diameter will be used in the sum of LLD calculation. All other lesions (or sites of disease) should be identified as non-target lesions (including bone lesions). All post-baseline response assessments should follow the same lesions identified at baseline. The same mode of assessment (e.g., CT) used to identify/evaluate lesions at baseline should be used throughout the course of the study unless subject safety necessitates a change (e.g., allergic reaction to contrast media). For the primary endpoint antitumor activity will be evaluated with target and/or non-target lesions according to RECIST Version 1.1.
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6.3.2 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:
By chest x-ray: > 20 mm; By CT scan:
o Scan slice thickness 5 mm or under: as > 10 mm o Scan slice thickness > 5 mm: double the slice thickness 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 participant, 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. 6.3.3 Methods for Evaluation of Measurable Disease All measurements should be taken and recorded in metric notation using a ruler or calipers. All baseline evaluations should be performed as closely as possible to the beginning of treatment and never more than 4 weeks before the beginning of the treatment. The same method of assessment and the same technique should be used to characterize each identified and reported lesion at baseline and during follow-up. Imaging-based evaluation is preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam.  
Clinical lesions: Clinical lesions will only be considered measurable when they are superficial
(e.g., skin nodules and palpable lymph nodes) and 10 mm diameter as assessed using calipers
(e.g., skin nodules). In the case of skin lesions, documentation by color photography, including a ruler to estimate the size of the lesion, is recommended. Chest x-ray: Lesions on chest x-ray are acceptable as measurable lesions when they are clearly defined and surrounded by aerated lung. However, CT is preferable. Conventional CT and MRI: This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. MRI is also acceptable in certain situations (e.g., for body scans). Use of MRI remains a complex issue. MRI has excellent contrast, spatial, and temporal resolution; however, there are many image acquisition variables involved in MRI, which greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable globally. As with CT, if an MRI is performed, the technical specifications of the scanning sequences used should be optimized for the evaluation of the type and site of disease. Furthermore, as with CT, the modality used at follow-up should be the same as was used at baseline and the lesions should be measured/assessed on the same pulse sequence. It is beyond the scope of the RECIST guidelines to prescribe specific MRI pulse sequence parameters for all scanners, body parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans should be performed with breath-hold scanning techniques, if possible.
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6.3.4 response criteria

All the scans performed at Baseline and other imaging performed as clinically required (other supportive imaging) need to be repeated at subsequent visits. In general, lesions detected at Baseline need to be followed using the same imaging methodology and preferably the same imaging equipment at subsequent tumor evaluation visits. Brain CT / MRI scan should be performed, if clinically indicated by development of new specific symptoms or on the discretion of the Principal Investigator. For each subject, the Investigator will designate 1 or more of the following measures of tumor status to follow for determining response: CT or MRI images of primary and / or metastatic tumor masses, physical examination findings, and the results of other assessments. All available images collected during the trial period will be considered. The most appropriate measures to evaluate the tumor status of a subject should be used. The measure(s) to be chosen for sequential evaluation during the trial have to correspond to the measures used to document the progressive tumor status that qualifies the subject for enrollment. The tumor response assessment will be assessed and listed according to the Study Calendar 3.5. The foreseen treatment duration is until disease progression verified by a scan subsequent to the initial documentation of PD, unacceptable toxicity, or any criterion for withdrawal from the trial occurs (see Section 6.3). Before stopping the treatment, progressive disease should be confirmed by imaging 4 to 6 weeks (preferably 6 weeks, but not later) after progression has been diagnosed according to RECIST 1.1 [44, 45]. If progression is based on the occurrence of a new lesion in an area not scanned at Baseline, a further on-study scan 6 weeks later should be considered before performing the 28-Day Safety Follow-up visit. Treatment may be continued despite progression according to RECIST 1.1 at any time if: - There are no new or concerning symptoms. - There is no decrease in ECOG PS. - The Investigator does not consider it necessary to administer a salvage therapy. The treatment should be stopped immediately, if the subject does not tolerate M7824 or if therapeutic failure occurs, which requires urgent treatment with an additional drug or results in clinically significant progression / deterioration. Tumor responses to treatment will be assigned based on the evaluation of the response of target, non-target, and new lesions according to RECIST 1.1 (all measurements should be recorded in metric notation). - To assess objective response, the tumor burden at baseline will be estimated and used for comparison with subsequent measurements. At baseline, tumor lesions will be categorized in target and non-target lesions according to RECIST 1.1. Results for these evaluations will be recorded with as much specificity as possible so that pre and post-treatment results will provide the best opportunity for evaluating tumor response. Any CR or PR should be confirmed according to RECIST 1.1. In the case of a PR or CR, a confirmatory CT or MRI scan should be done no sooner than 4 weeks (preferably at the scheduled 6-week interval). The Investigator may perform scans in addition to a scheduled trial scan for medical reasons or if the Investigator suspects PD. As an exploratory endpoint antitumor activity will also be evaluated according to iRECIST Using iRECIST criteria the following will be incorporated into assessment:
1. An increase in the sum of target lesions of more than 20%, unequivocal increase in nontarget lesions or new lesions result in iUPD (unconfirmed progressive disease); iUPD can be assigned multiple times as long as iCPD (confirmed progressive disease) is not confirmed at the next assessment. 2. Progression is confirmed in the target lesion category if the next imaging assessment after iUPD (4–8 weeks later) confirms a further increase in sum of measures of target disease from iUPD, with an increase of at least 5 mm. Progression is confirmed in the non-target lesion category if subsequent imaging, done 4–8 weeks after iUPD, shows a further unequivocal increase in non-target lesions. Progression is confirmed in the new lesions category if at next assessment additional new lesions appear or an increase in size of previously seen new lesions is seen (≥5 mm for sum of new lesion target). 3. However, the criteria for iCPD (after iUPD) are not considered to have been met if complete response, partial response, or stable disease criteria (compared with baseline and as defined by RECIST 1.1) are met at the next assessment after iUPD. The status is reset
(unlike RECIST 1.1, in which any progression precludes later complete response, partial response, or stable disease). iCR, iPR, or iSD should then be assigned; and if no change is detected, then the timepoint response is iUPD.
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6.3.5 response criteria by recist

6.3.5.1 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. 6.3.5.2 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 participant 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). 6.3.5.3 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 participant's best response assignment will depend on the achievement of both measurement and confirmation criteria.