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Abbreviated Title: Vaccine and BCG for Bladder Ca CC Protocol \#: 14-C-0036 CTEP Protocol \#: 9539 **OSP\#:** 1310-1269 Version Date: February 13, 2018 NCT \#: NCT02015104 **IBC\#:** RD-13-X-04 Amendment: F  
| Title: A Randomized, Prospective, Phase II Study to Determine the Efficacy of Bacillus                                                                                                               |                                            |                                         |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------|-----------------------------------------|
| Calmette-Guerin (BCG) given in combination with PANVAC™ versus BCG given alone in  Adults with High Grade Non-Muscle Invasive Bladder Cancer (NMIBC) who failed at least 1  Induction Course of BCG. |                                            |                                         |
| Coordinating Center:                                                                                                                                                                                 | Center for Cancer Research, NCI            |                                         |
| NCI Principal Investigator:                                                                                                                                                                          | Piyush K. Agarwal, M.D.A-F                 |                                         |
|                                                                                                                                                                                                      | Urologic Oncology Branch (UOB), CCR, NCI   |                                         |
|                                                                                                                                                                                                      | 10 Center Dr., 2W-5940                     |                                         |
|                                                                                                                                                                                                      | Bethesda, MD 20892                         |                                         |
|                                                                                                                                                                                                      | (240) 760-6242                             |                                         |
|                                                                                                                                                                                                      | piyush.agarwal@nih.gov                     |                                         |
| Lead Associate Investigator:                                                                                                                                                                         | James Gulley, M.D., Ph.D.A-F               |                                         |
|                                                                                                                                                                                                      | Genitourinary Malignancies Branch (GMB),   |                                         |
|                                                                                                                                                                                                      | CCR, NCI                                   |                                         |
|                                                                                                                                                                                                      | 10 Center Dr., 12N226                      |                                         |
|                                                                                                                                                                                                      | Bethesda, MD 20892                         |                                         |
|                                                                                                                                                                                                      | (301) 480-7164  gulleyj@mail.nih.gov       |                                         |
| NIH Associate Investigators:                                                                                                                                                                         | Ravi Madan, M.D., GMB, CCR, NCIA-F         |                                         |
|                                                                                                                                                                                                      |                                            | *Andrea Apolo, M.D., GMB, CCR, NCIA,B,E |
|                                                                                                                                                                                                      | Martha Ninos, R.N., OCD, CCR, NCIA-C       |                                         |
|                                                                                                                                                                                                      | Sonia Bellfield, RN, OCD, CCR, NCIA-C      |                                         |
| Statistician:                                                                                                                                                                                        | *Joanna H. Shih, Ph.D.B,E,F                |                                         |
|                                                                                                                                                                                                      | Biometric Research Branch                  |                                         |
|                                                                                                                                                                                                      | Division of Cancer Treatment and Diagnosis |                                         |
|                                                                                                                                                                                                      | 9609 Medical Center Drive, Room 5W124      |                                         |
|                                                                                                                                                                                                      | Rockville, MD 20850                        |                                         |
|                                                                                                                                                                                                      | (240) 276-6035                             |                                         |
|                                                                                                                                                                                                      | jshih@mail.nih.gov1                        |                                         |  
Responsible Research Nurse: Sonia Bellfield, RN, OCD, CCR, NCIA-C  
| Referral Contact/  Study Coordinator:                      | Sonia Bellfield, RN, OCD, CCR, NCIA-C   |
|------------------------------------------------------------|-----------------------------------------|
|                                                            | Urologic Oncology Branch                |
|                                                            | 10 Center Drive, 6B04                   |
|                                                            | Bethesda, MD 20892                      |
|                                                            | (240) 760-6118                          |
|                                                            | sonia.bellfield@nih.gov                 |
| Non-NIH Associate Investigators: *Rebecca Dolan, CRNPA,B,E |                                         |  
* Indicates Associate Investigators who will not be making protocol related medical decisions or consenting or treating patients unless registered with CTEP. Investigator roles:
A. Obtain information by intervening or interacting with living individuals for research purposes B. Obtaining identifiable private information about living individuals C. Obtaining the voluntary informed consent of individuals to be subjects D. Makes decisions about subject eligibility E. Studying, interpreting, or analyzing identifiable private information or data/specimens for research purposes F. Studying, interpreting, or analyzing de-identified data or specimens for research purposes G. *Some/all research activities performed outside NIH*
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multi-institutional centers

Institution: Cancer Institute of New Jersey Institution FWA\#: 00001861  
| Principal Investigator:   | Eric Singer, M.D., M.A.  Cancer Institute of New Jersey                                                                                                          |
|---------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                           | Section of Urologic Oncology                                                                                                                                     |
|                           | The Cancer Institute of New Jersey                                                                                                                               |
|                           | 195 Little Albany Street  New Brunswick, NJ 08903                                                                                                                |
|                           | (732) 235-2043  eric.singer@rutgers.edu                                                                                                                          |
| IRB Contact:              | Kassie Muth  IRB of Record Name: Rutgers Cancer Institute of New Jersey  390 George Street, Suite 700, New Brunswick, NJ 08903  (732) 235-2135  muthka@umdnj.edu |
| Pharmacy Contact:         | Michael Kane, RPh, BCOP  95 Little Albany Street, New Brunswick, NJ 08903  (732) 235-8236  KaneMP@UMDNJ.EDU                                                      |
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ctep supplied investigational agents

| Agent name   | IND #     | IND Sponsor   | Manufacturer      |
|--------------|-----------|---------------|-------------------|
| PANVAC-V [Recombinant VacciniaCEA(D609)/MUC1(L93)/TRICOM] NSC 727026              | IND 11660 | CTEP          | Therion Biologics |
| PANVAC-F [Recombinant FowlpoxCEA(D609)/MUC1(L93)/TRICOM]  NSC 727027              | IND 11660 | CTEP          | Therion Biologics |  
Commercially available agents: TICE Bacillus Calmette-Guerin (BCG), NSC 614388 3
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precis background

x High grade (G3) non-muscle invasive urothelial carcinoma of the bladder (stages Ta, T1, and CIS) has a high rate of recurrence and progression x The standard of care therapeutic agent is a single induction course of bacillus CalmetteGuerin (BCG)
x Although a second induction course can be used in patients who fail a single induction course of BCG, only 35% of patients who failed an initial induction course will experience 12 month disease-free survival after receiving a second induction course x For those patients failing a second induction course, radical cystectomy with pelvic lymphadenectomy is the recommended treatment, although it has a high morbidity rate and a small but real mortality rate x Therefore, there is an unmet need for localized treatment for patients who fail an initial induction course of BCG that can potentially improve upon the poor results of a second induction course of BCG
x Recently, a unique pox viral vector-based vaccine, PANVAC™, has been shown to induce a CD4 and CD8 antigen-specific immune response against the tumor-associated antigens (TAAs), carcinoembryonic antigen (CEA) and mucin-1 (MUC-1). This vaccine also contains transgenes for three human T cell co-stimulatory molecules that can potentially augment an immune response x We hypothesize that the combined administration of BCG and PANVAC™ may augment the BCG-induced cytotoxic T lymphocyte response against bladder cancer cells expressing MUC-1 and/or CEA and potentially reverse BCG failure in patients that have failed one induction course of BCG
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objectives

x To determine if there is an improvement in disease-free survival (DFS*) with BCG +
PANVAC compared with BCG alone in a phase II study in non-muscle invasive high-grade urothelial carcinoma of the bladder who have failed to respond to intravesical BCG. *within 1 year post treatment
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eligibility

x Individuals who have failed at least one previous induction course of intravesical BCG,
defined as histologically confirmed persistent or relapsing tumor present on post-BCG endoscopic evaluation. All BCG failures will be considered for inclusion into the study, including BCG-refractory, -resistant, and -relapsing, as defined in the "Rationale and Background." For the purposes of the study, "BCG-refractory" and "BCG-resistant" subjects will be considered to have "BCG-persistent" disease.  
x Patients who are not currently candidates for radical cystectomy (e.g. patient refuses surgery, comorbidities preclude major surgery, etc.).  
x Normal organ function, ECOG 0-2.
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design

x This is a randomized, open label prospective, Phase II study in subjects with non-muscle invasive high grade urothelial carcinoma of the bladder who have failed at least one induction course of intravesical BCG, randomized to one of the following arms: TICE BCG +PANVAC™ or TICE BCG alone. Randomization is stratified by BCG treatment subgroup.  
x All subjects will receive intravesical TICE BCG (50mg) as per usual standard of care once weekly (+/- 2 days) starting in week 3 for a total of 6 weeks.  
x The combination arm will receive the pox viral vaccines that contain the transgenes for CEA
and MUC-1 (both with modified HLA-A2 agonist epitopes) as well as 3 human T-cell costimulatory molecules, B7-1, ICAM-1, and LFA-3 [rV-PANVAC™ (vaccinia) and rF-PANVAC™ (fowlpox)] as follows:
o rV-PANVAC™ 2 x 108 pfu SQ at week 0 (+/- 7 days) only.  
o rF-PANVAC™1 x 109 pfu SQ at weeks (+/- 7 days) 3, 7, 11, and 15.  
x For this Phase II study, we will test the hypothesis that subjects in the TICE BCG
+PANVAC™ arm have better disease-free survival than subjects in the TICE BCG alone arm.  
x Patient accrual is targeted at one patient per month during the first 6 months and 1-2 patients every 1-2 months afterwards, and follow-up period after completing accrual will be 12 months post treatment.  
x Based on a power of 84% and type 1 error (1-sided) of 0.15, a total of 49 subjects will need to be accrued.  
x Allowing for a proportion of the subjects not being evaluable, a maximum of 54 subjects will be accrued.  
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table of contents

| TABLE OF CONTENTS  PRÉCIS 4 SCHEMA 6 TABLE OF CONTENTS 7 1 OBJECTIVES 10 1.1 Primary Objective 10 1.2 Secondary Objectives 10 1.3 Exploratory Objectives 10 2 BACKGROUND 10 3 PATIENT SELECTION 13 3.1 Eligibility Criteria 13 3.2 Recruitment Strategies 16 3.3 Screening Evaluation 17 3.4 Baseline Evaluation 17 3.5 Gender And Minority Accrual Estimates 18 4 REGISTRATION PROCEDURES 19 4.1 General Guidelines 19 4.2 Registration Procedures 19 5 TREATMENT PLAN 20 5.1 Study Design 20 5.2 Trial Outline 21 5.3 Agent Administration 23 5.4 Dose Limiting Toxicity 24 5.5 General Concomitant Medication and Supportive Care Guidelines 26 5.6 Duration of Therapy 27 5.7 Duration of Follow Up 27 5.8 Criteria for Removal from Protocol Therapy and Off Study Criteria 27 6 DOSING DELAYS/DOSE MODIFICATIONS 29   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
| 6.1   | TICE BCG 29                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          |
|-------|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 6.2   | PANVAC™-V (vaccinia) and PANVAC™-F (fowlpox) 29                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      |
| 7     | ADVERSE EVENTS: LIST AND REPORTING REQUIREMENTS 30 7.1 Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs) 30 7.2 Definitions 36 7.3 Expedited Adverse Event Reporting to CTEP 38 7.4 Routine Adverse Event Reporting to CTEP 41 7.5 NCI-IRB and Clinical Director Reporting 41 7.6 Secondary Malignancy 42 7.7 Second Malignancy 43 7.8 NCI Guidance for Reporting Expedited Adverse Events for Multi-Center  Trials 43 7.9 NIH Office of Science Policy (OSP)/Institutional Biosafety Committee  (IBC) Reporting Criteria 43 7.10 Data and Safety Monitoring Plan 45 |
| 8     | PHARMACEUTICAL INFORMATION 45 8.1 CTEP IND Agents 45 8.2 Commercial agent 62                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         |
| 9     | BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 63 9.1 Laboratory Correlative Studies 63 9.2 Sample Storage, Tracking and Disposition 68                                                                                                                                                                                                                                                                                                                                                                                                                                                 |
| 10    | STUDY CALENDARS 71                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
| 11    | MEASUREMENT OF EFFECT 76 11.1 Response Criteria 76                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |
| 12    | DATA COLLECTION AND REPORTING/REGULATORY REQUIREMENTS 77 12.1 Data Collection 77 12.2 Toxicity Criteria 78 12.3 Data Reporting 78 12.4 CTEP Multicenter Guidelines 79 12.5 Collaborative Agreements Language 79                                                                                                                                                                                                                                                                                                                                                                      |  
| Version Date: February 13, 2018  13 STATISTICAL CONSIDERATIONS 81 13.1 Primary Endpoint, Stratification, and Sample Size Justification 81 13.2 Secondary Endpoints 83 13.3 Exploratory/Correlative Endpoints 83 13.4 Reporting and Exclusions 84 14 HUMAN SUBJECTS PROTECTIONS 85 14.1 Rationale For Subject Selection 85 14.2 Participation Of Children 85 14.3 Participation of Subjects Unable to Give Consent 85 14.4 Evaluation Of Benefits And Risks/Discomforts 86 14.5 Risks/Benefits Analysis 87 14.6 Consent Process And Documentation 87 15 REFERENCES 89 16 APPENDICES 92 16.1 Appendix A: Performance Status Criteria 92 16.2 Appendix B: CTEP Multicenter Guidelines 93 16.3 Appendix C: PANVAC [Recombinant VacciniaCEA(D609)/MUC1(L93)/TRICOM] Patient Instruction Sheet 95 16.4 Appendix D: NIH Problem Report Form 98 16.5 Appendix E: Specimen Collection 100 16.6 Appendix F: Sample Shipping Manifest 106   |
|---|
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1 objectives 1.1 primary objective

1.1.1 To determine if there is an improvement in disease-free survival (DFS*) with BCG +
PANVAC compared with BCG alone in a phase II study in non-muscle invasive highgrade urothelial carcinoma of the bladder who have failed to respond to intravesical BCG. *within 1 year post treatment
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1.2 secondary objectives

1.2.1 To estimate tumor upgrading and tumor upstaging rates for each study arm.  
1.2.2 To determine the safety of the combination therapy.
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1.3 exploratory objectives

1.3.1 To assess the expression of CEA and MUC-1 antigens in bladder tumor specimens preand post-treatment in both arms  
1.3.2 To assess the presence of CD4 and CD8 T cells in bladder tumor specimens pre- and post-treatment in both arms 1.3.3 To assess the presence of Tregs by double staining with FoxP3 and CD4 in bladder tumor specimens pre- and post-treatment in both arms 1.3.4 To assess the presence of myeloid derived suppressor cells (MDSC) in bladder tumor specimens pre- and post-treatment in both arms
1.3.5 To measure the CD4 antigen-specific response to CEA in peripheral blood mononuclear cells (PBMCs) obtained from blood 1.3.6 To measure the CD8 antigen-specific response to CEA, MUC-1, and Brachyury in all subjects who have the HLA-A2 allele in PBMCs obtained from blood  
1.3.7 To analyze all PBMC samples by flow cytometry for the following cell types: CD4, CD8, Tregs, MDSCs, and Natural Killer (NK) cells
1.3.8 To analyze sera samples obtained from blood at all time points for antibodies to CEA,
MUC-1, and Brachyury 1.3.9 To assess production of urinary cytokines and chemokines in collected samples
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2 background

Bladder cancer accounts for the 4th most common cancer in men and the 12th most common cancer in women. An estimated 73,510 people living in the United States will be diagnosed with bladder cancer in 2012, with approximately 14,880 dying of bladder cancer in the same year.1 Most of these patients (>75%) will be diagnosed with non-muscle invasive bladder cancer and approximately 50% of these patients will present with high grade disease.2 High grade nonmuscle invasive bladder cancer (Ta, T1, and/or CIS) is difficult to treat because of high rates of recurrence and progression. The last major advance in bladder cancer therapy was the approval of bacillus Calmette-Guerin (BCG) in 1990 by the FDA.3 Currently, intravesical BCG given as an induction course (6 weeks of intravesical therapy) is the standard of care4,5 followed by maintenance therapy. BCG has an initial failure rate of ~35% in terms of disease recurrence or progression. In ~20-35% of cases that failed an initial induction course of BCG, a second course of induction BCG may be beneficial, but patients who fail two courses are often best served by radical cystectomy.6-8 Patients with CIS alone may respond at a higher rate to a second induction course, however, cystectomy may still be required in at least 1/3 of these patients. This surgery involves the en bloc removal of the bladder and adjacent organs (prostate in males and uterus in females) and concomitant creation of a urinary diversion, which can affect a patient's quality-oflife significantly. Moreover, Shabsigh et al. reported that 64% of patients who undergo cystectomy suffer at least one complication within the first 90 days after surgery9 and the operation has been reported to have at least a 2.5% perioperative mortality rate even at a highvolume center.10 This fact is reflected in a 2003 survey, which showed that 81% of urologists were reluctant to refer their patients to radical cystectomy despite failing 2 courses of intravescial therapy.11 In summary, radical cystectomy has the potential for significant morbidity and therefore, an unmet clinical need for intravesical therapy exists for these high grade non-muscle invasive bladder cancers that fail BCG. BCG failures can be subdivided into several groups based on the time to tumor response and/or recurrence.12 BCG-refractory disease is defined as the inability to be disease-free by 6 months after an induction course of BCG. In contrast, BCG-resistant disease is defined as the inability to be disease-free by 3 months after an induction course of BCG. Finally, BCG-relapsing disease is defined as recurrence of disease after being disease-free for at least 6 months after receiving BCG therapy. Unfortunately, disease-free survival rates at 12 months are not as well-defined based on these subclassifications. Thus, clinical endpoint trials involving this population should be randomized and stratified according to these subgroups to help better predict responders to therapy. BCG works by an unclear immunologic mechanism that promotes activation and infiltration of immune cells within the bladder wall. The immune system is critical as the administration of T
cells to athymic animals has been shown to restore their ability to respond to BCG therapy.**13,14**
A hypothesized mechanism for BCG is that it induces macrophage cytotoxicity and that Th1 immune system cytokines (e.g. TNF-α, IFN-γ, IL-12, and IL-18) play a positive role in the macrophage cytotoxicity while Th2 immune system cytokines (e.g. IL-4, IL-10) and T regulatory cells (Tregs) are potentially inhibitory to this BCG-induced macrophage cytotoxicity.15 T cell infiltration appears important as the degree of infiltration (CD3, CD4, and CD8) has been shown to be significantly greater in patients with a complete response to BCG in comparison to patients with a partial response or treatment failure.16 Modulation of the immune system is one strategy employed in cancer therapeutics. Tumor associated antigens (TAAs), which are unique molecules minimally expressed by normal tissues and over-expressed in cancer cells, can be used as immunologic targets. Recently, researchers at the NIH have developed a poxvirus cancer vaccine therapy called PANVAC™ that has demonstrated therapeutic efficacy against a variety of carcinomas. PANVAC™ consists of a primary vaccination with a replication competent recombinant vaccinia (rV-) viral vector followed by multiple booster vaccinations with a replication-incompetent recombinant fowlpox
(rF-) viral vector. These vectors contain transgenes for both TAAs and human T cell costimulatory molecules. Although TAAs are weakly immunogenic, a method of disrupting immune tolerance is to introduce TAAs to the immune system through poxviral vectors.17 Antigen-specific active immunotherapy is designed to generate immune responses, particularly cell-mediated responses, against specific TAAs using vaccines that express one or more of these antigens. The TAAs in PANVAC™ are epithelial mucin-1 (MUC-1) and carcinoembryonic antigen (CEA)
which are altered and overexpressed in many cancers.18 MUC-1 is a glycosylated transmembrane protein that is overexpressed in almost all human carcinomas. Furthermore, it has been demonstrated that the c-terminus of MUC-1 functions as an oncogene.**19,20** According to one study, MUC-1 is present in all cases of malignant urothelium, but increased expression is noted with higher grade and stage tumors.21 Another study demonstrated MUC-1 expression in 93% of bladder tumors studied.22 CEA is a glycosylated cell surface protein expressed in several tumors as well and in particularly in colorectal, ovarian, bladder, breast, and gastric tumors.23 CEA is expressed in 76% of high grade tumors and in 59% of pT1 bladder tumors.24 Co-stimulatory molecules are critical in the generation of T-cell responses especially against weak antigens such as TAAs. The initiation of an immune response requires at least two signals for activation of naïve T cells by antigen-presenting cells. The first signal is antigen specific, delivered through the T-cell receptor via the peptide/MHC, and causes the T cell to enter the cell cycle. The second, "co-stimulatory," signal is required for cytokine production and proliferation.  
At least three distinct molecules normally found on the surface of professional antigenpresenting cells have been reported to be capable of providing the second signal critical for Tcell activation: B7-1, ICAM-1, and LFA-3. Both antigen and co-stimulatory molecules must be expressed in the same cell to properly engage the TCR and co-stimulatory receptor. In order to achieve this, multigene constructs using poxviral vectors (avipox and vaccinia) have been generated. The co-stimulatory molecules are B7.1 (CD80), ICAM01 (CD54), and LFA-3
(CD58) and are referred to as TRICOM (triad of co-stimulatory molecules).25 Each of these costimulatory molecules binds to a different ligand, and the second messenger pathways of each ligand are unique, raising the potential for synergy of these molecules. The vaccines are therefore, summarized as rV-CEA-MUC-1-TRICOM (rV-PANVAC™) and rF-CEA-MUC-1-
TRICOM (rF-PANVAC™).  
PANVAC™ is injected subcutaneously, processed by antigen-presenting cells (APCs), and then induces CEA- and MUC-1-specific cytotoxic T lymphocyte responses that are then potentiated by the co-stimulatory molecules. The pox viral vectors have a high rate of cellular infection, can carry large amounts of transgenes, process genes in the cytoplasm of infected cells with a low risk of incorporation within the host genome, and have an established history of clinical safety in patients. In fact, several hundred patients have already been treated on clinical trials with pox viral vectors and there have been no dose limiting toxicities attributable to these vaccines.18 Initial studies with PANVAC showed that it was well tolerated and was associated with objective responses in some patients. One patient with metastatic ovarian cancer and symptomatic ascites had complete resolution of her ascites and normalization of her CA-125 (from 300 to <20) for 18 months.26 A patient with metastatic breast cancer has an ongoing complete response of her disease for over 3 years.27 The final results of a randomized phase II study were recently reported. This study enrolled 48 patients with metastatic breast cancer and randomized them to weekly docetaxel with PANVAC monthly vs. docetaxel alone. The primary endpoint was PFS. The median PFS for patients randomized to the combination arm was 6.6 months vs. 3.8 months in the chemotherapy alone arm.28 A phase II randomized controlled study involved 74 patients with completely resected metastases from colorectal cancer, who had received perioperative chemotherapy.29 Patients were randomized to receive 4 vaccinations with either PANVAC or dendritic cells modified with PANVAC. There was no significant difference in 2-year recurrence-free survival among the DC
arm (50%), the PANVAC arm (56%), and a contemporary control arm (55%). However, at a median follow-up of 40 months, the survival rate for vaccinated patients was 81%, which far exceeded that of the unvaccinated controls.  
Recently, a PSA specific vaccine, rV-PSA TRICOM and rF-PSA-TRICOM, was evaluated in a randomized, placebo-controlled, blinded Phase II study for minimally symptomatic metastatic castration-resistant prostate cancer. Although no difference in progression free survival was noted, patients receiving the vaccine had longer median survival by 8.5 months with hazard ratio of 0.56 (95% CI, 0.37 to 0.85), p=0.0061.30 Other studies have demonstrated safety of the vaccine in solid organ tumors when administered subcutaneously.**18,26,27** These initial studies suggest safety and activity in a broad range of tumor types. High grade non-muscle invasive bladder cancer tends to respond well to BCG and when it does not, there is evidence to suggest an incomplete or inefficient immune response. Given that CEA and MUC-1 are overexpressed in bladder cancer, we hypothesize that PANVAC™ will augment the BCG-induced cytotoxic T lymphocyte response against bladder cancer cells expressing MUC-1 and/or CEA, which will clinically result in a greater disease-free survival rate than BCG alone in patients who have failed at least one previous course of intravesical BCG. We also hypothesize that the PANVAC+BCG group will demonstrate decreased tumor upgrading and tumor upstaging, particularly with regards to invasion of the detrusor musculature, and predict that the combination treatment will not demonstrate greater treatment-related toxicities to intravesical BCG alone. Finally, we hypothesize that the immune response will be augmented in the PANVAC+BCG group compared to BCG alone as measured by secondary immunologic correlates described below.
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3 patient selection 3.1 eligibility

3.1.1.1 Patients must have histologically confirmed localized high grade (G3) transitional cell carcinoma (urothelial carcinoma) of the bladder that is stage Ta, T1, and/or CIS confirmed by the Laboratory of Pathology, NCI 90 days prior to study entry. This can be obtained at an outside hospital prior to entry into the study or at the NCI. However, all outside pathology specimens will require that the formalin-fixed paraffin embedded tissues be re-read by the Laboratory of Pathology, NCI. For patients enrolled at collaborating trial sites, diagnosis must be confirmed by the Department of Pathology at the institution where the patient is enrolled on the trial. Pathology can also be reviewed by the Laboratory of Pathology at the NCI if the participating trial site prefers another pathologic evaluation.  
3.1.1.2 Patients have failed at least one previous induction course of intravesical BCG, defined as histologically confirmed persistent or relapsing tumor present on post-BCG endoscopic evaluation. All BCG failures will be considered for inclusion into the study, including BCG-refractory, -resistant, and -relapsing, as defined in the "Rationale and Background." For the purposes of the study, "BCG-refractory" and "BCG-resistant" subjects will be considered to have "BCG-persistent" disease.  
3.1.1.3 Patients who are not currently candidates for radical cystectomy (e.g. patient refuses surgery, comorbidities preclude major surgery, etc.).  
3.1.1.4 Age >18 years.  
Because no dosing or adverse event data are currently available on the use of BCG in combination with PANVAC™ in patients <18 years of age, children are excluded from this study.  
3.1.1.5 ECOG performance status <2 (see Appendix A, Section **16.1**). 3.1.1.6 Patients must have normal organ and marrow function as defined below:
absolute neutrophil count >1,500/mcL  
platelets >50,000/mcL  
total bilirubin < 1.5 X institutional upper limit of normal AST(SGOT)/ALT(SGPT) ≤3 X institutional upper limit of normal estimated GFR (calculated using CKD-EPI equation) ≥ 30 mL/min/1.73 sq.m.  
3.1.1.7 Computerized Tomography (CT) urogram or Magnetic Resonance Imaging (MRI)
urogram. If urogram protocol not available or contrast allergy/poor renal function preclude such imaging, then noncontrast CT or MRI of the abdomen/pelvis within 45 days of study entry will suffice.  
3.1.1.8 Chest x-ray negative for metastatic disease. 3.1.1.9 Ability of patient to understand and the willingness to sign a written informed consent document.  
3.1.2 **Exclusion Criteria** 3.1.2.1 Previous pelvic radiation for bladder or prostate cancer if performed <12 months prior to enrollment into the study.  
3.1.2.2 Patients who are receiving any other concurrent investigational agents (patients are eligible to enroll 4 weeks after completion of prior agent).  
3.1.2.3 Patients who have had chemotherapy within 4 weeks (6 weeks for nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered from adverse events due to agents administered more than 4 weeks earlier. There will be at least a 3 week delay from the time of a previous bladder biopsy/TURBT to allow for adequate bladder healing prior to enrollment.  
3.1.2.4 Patients with a history of encephalitis, multiple sclerosis, or seizures within the last year
(from seizure disorder or brain metastasis) should be excluded from this clinical trial because of their poor prognosis and because they often develop progressive neurologic dysfunction that would confound the evaluation of neurologic and other adverse events.  
3.1.2.5 History of allergy or untoward reaction to prior vaccination with vaccinia virus 3.1.2.6 Patients should have no evidence of being immunocompromised as listed below:
x Human immunodeficiency virus positivity due to the potential for decreased tolerance and risk for severe side effects x Active autoimmune diseases requiring treatment or a history of autoimmune disease that might be stimulated by vaccine treatment. This requirement is due to the potential risks of exacerbating autoimmunity. Patients with endocrine disease that is controlled by replacement therapy including thyroid disease and adrenal disease and vitiligo may be enrolled.  
x History of splenectomy 3.1.2.7 Uncontrolled intercurrent illness which would interfere with the ability of the patient to carry out the treatment program, including, but not limited to, active second malignancy other than a cancer that has been successfully treated resulting in a high likelihood of long-term survival (e.g. completely resected basal cell or squamous cell carcinoma of the skin, stage 1 renal cell carcinoma treated with partial nephrectomy, treated low risk prostate cancer, etc.), inflammatory bowel disease (e.g. Crohn's disease or ulcerative colitis), active diverticulitis, ongoing or active infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would limit compliance with study requirements.  
3.1.2.8 Pregnant women are excluded from this study because the vaccines used in the study may have the 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 the vaccine, breastfeeding should be discontinued if the mother is treated with vaccines. These potential risks may also apply to other agents used in this study. Patients must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while her partner is participating in this study, she should inform her treating physician immediately 3.1.2.9 Concurrent use of systemic steroids, except for physiologic doses of systemic steroids for replacement or local (topical, nasal, or inhaled) steroid use. Limited doses of systemic steroids to prevent IV contrast, allergic reaction, or anaphylaxis (in patients who have known contrast allergies) are allowed. Although topical steroids are allowed, steroid eye-drops are contraindicated 3.1.2.10 Altered immune function, including immunodeficiency or history of immunodeficiency; eczema; history of eczema, or other eczematoid skin disorders; or those with acute, chronic or exfoliative skin conditions (e.g. atopic dermatitis, burns, impetigo, varicella zoster, severe acne, or other open rashes or wounds). There is an increased risk to patients or contacts with eczema, atopic dermatis, and other immune deficiencies who are at risk for eczema vaccination.  
3.1.2.11 Medical conditions which, in the opinion of the investigators, would jeopardize the patient or the integrity of the data obtained 3.1.2.12 Serious hypersensitivity reaction to egg products 3.1.2.13 Chronic hepatitis infection, including B and C, because of potential immune impairment 3.1.2.14 Clinically significant cardiomyopathy or cardiac complications, including recent myocardial infarction or cerebrovascular accident within one year, and/or unstable or uncontrolled angina 3.1.2.15 Previous intolerance to BCG intravesical therapy suggested by development of systemic BCG infection in the past and/or grade 4 or greater adverse effect by CTCAE v5.0.  
3.1.2.16 Patients unable to avoid close contact or household contact with the following high-risk individuals for three weeks after the Day 1 vaccination: (a) children ≤ 3 years of age, (b)
pregnant or nursing women, (c) individuals with prior or concurrent extensive eczema or other eczemoid skin disorders, or (d) immunocompromised individuals, such as those with HIV.
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3.1.3 inclusion of women and

Both men and women of all races and ethnic groups are eligible for this trial.
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3.2 recruitment strategies

This study will be listed on available websites (www.clinicaltrials.gov and others) and participants will be recruited from the current patient population at NIH.
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3.3 screening evaluation

3.3.1 Clinical Evaluation (within 28 days of before starting treatment). 3.3.1.1 History and physical examination 3.3.1.2 ECOG performance status 3.3.2 Viral Studies and Prior Vaccination Status 3.3.2.1 HIV test within 8 weeks of initial visit and repeat if clinically indicated 3.3.2.2 Hepatitis B and C titers within 8 weeks of initial visit and repeat if clinically indicated 3.3.2.3 Document known prior vaccinia vaccination (small pox vaccine)
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3.4 baseline evaluation

3.4.1 Laboratory studies (within 28 days before starting treatment) 3.4.1.1 Complete blood count plus differential and platelet count 3.4.1.2 Serum chemistries (Na+, K+, Cl-, CO2, glucose, BUN, creatinine, albumin, calcium, magnesium, phosphorus, alkaline phosphatase, ALT, AST, total bilirubin, LDH, prealbumin) with BUN and creatinine 3.4.1.3 PT, PTT 3.4.1.4 6 green top tubes of blood will be drawn for PBMCs, HLA Typing, and sera for correlative/exploratory research aims (e.g. ELISPOT, CD4+ Antigen-specific responses, etc.) on day 1 of study enrollment 3.4.1.5 Beta-HCG for women of child-bearing age (within 48 hours prior to day 1). In addition, patients, both male and female, should be willing to practice effective birth control during the study and four months following the last study treatment, unless they have had a prior hysterectomy, bilateral oophorectomy, or vasectomy 3.4.2 Urine studies 3.4.2.1 Urinalysis with urine culture (prior to operative procedures and within 2-21 days of operative procedures)
3.4.2.2 Urine cytology (prior to operative procedures and within 2-21 days of operative procedures or at time of operative procedure)
3.4.2.3 Urine collection for correlative/exploratory research aims (e.g. inflammatory cells, cytokines) at the time of operative procedure 3.4.3 Imaging (within past 45 days and of adequate quality) 3.4.3.1 Chest X-ray 3.4.3.2 Computerized Tomography (CT) urogram or Magnetic Resonance Imaging (MRI)
urogram. If urogram protocol not available or contrast allergy/poor renal function preclude such imaging, then CT or MRI of the abdomen/pelvis will suffice
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3.4.4 pathology

3.4.4.1 Formal review of available previous bladder tumor specimens by the Laboratory of Pathology, NCI, to confirm the bladder cancer diagnosis prior to enrollment into the study. For patients enrolled at collaborating trial sites, diagnosis must be confirmed by the Department of Pathology at the institution where the patent is enrolled on the trial. Pathology can also be reviewed by the Laboratory of Pathology at the NCI if the participating trial site prefers another pathologic evaluation.  
3.4.4.2 Tissues obtained at the NCI will be used to confirm diagnosis and for study of immunerelated markers. With preoperative patient permission, extra tissue not sent to Laboratory of Pathology, NCI, will be frozen for future analysis of immune-related markers and tumor infiltrates. This additional harvested tissue will be used for research purposes only and is not required for a candidate to participate in this protocol. Tissue will also be collected at collaborating trial sites as specified by Appendix E (Section 16.5).  
| Accrual Targets                                                           |            |       |    |    |    |
|---------------------------------------------------------------------------|------------|-------|----|----|----|
| Ethnic Category                                                           | Sex/Gender |       |    |    |    |
| Females                                                                   | Males      | Total |    |    |    |
| Hispanic or Latino                                                        | 4          | +     | 4  | =  | 8  |
| Not Hispanic or Latino                                                    | 23         | +     | 23 | =  | 46 |
| Ethnic Category: Total of all subjects                                    | 27         | +     | 27 | =  | 54 |
| Racial Category                                                           |            |       |    |    |    |
| American Indian or Alaskan Native                                         | 1          | +     | 1  | =  | 2  |
| Asian                                                                     | 1          | +     | 1  | =  | 2  |
| Black or African American                                                 | 4          | +     | 4  | =  | 8  |
| Native Hawaiian or other Pacific Islander                                 | 1          | +     | 1  | =  | 2  |
| White                                                                     | 20         | +     | 20 | =  | 40 |
| Racial Category: Total of all subjects                                    | 27         | +     | 27 | =  | 54 |
| Accrual Rate: 2-3 patients/month  Total Expected accrual: Min: 49 Max: 54 |            |       |    |    |    |
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3.5 gender and minority accrual

Projected Start Date of study: December 1, 2013 Anticipated Primary Completion Date: December 1, 2017
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4 registration procedures 4.1 general

Eligible patients will be entered on study centrally at the CCR by the Study Coordinator. Issues that would cause treatment delays should be discussed with the Principal Investigator. Except in very unusual circumstances, each participating institution will order DCTD-supplied agents directly from CTEP. Agents may be ordered by a participating site only after the initial IRB approval for the site has been forwarded by the Coordinating Center to the CTEP PIO (PIO@ctep.nci.nih.gov) except for Group studies.
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4.2 registration procedures 4.2.1 registration

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

Registration will be a two part process as patients are screened on this protocol. A protocol registration form will be supplied by the CCR study coordinator and updates will be provided as needed. Subject eligibility and demographic information is required for registration. To initially register a subject, after the participant has signed consent, complete the top portion of the form and send to CCR study coordinator. Once eligibility is confirmed, after completion of screening studies, complete the remainder of the form which is the eligibility checklist, indicating that the patient is being registered for treatment and send to CCR study coordinator. In addition, source documents supporting the eligibility criteria must be sent to the CCR study coordinator. The CCR study coordinator will notify you either by e-mail or fax that the protocol registration form has been received which will include the unique patient/subject ID number. Questions about eligibility should be directed to the CCR study coordinator or PI. Questions related to registration should be directed to the CCR study coordinator. Subjects that do not meet screening criteria should be removed from the study following the procedure in section **5.8.3**.
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4.3 randomization procedures

There are two arms to this study and subjects will be randomized equally to either the TICE BCG arm or the combination arm of TICE BCG + PANVAC™. The study arms are described in detail below in Section 5.1. The arms will be stratified during randomization for TICE BCG subgroup based on number of previous induction courses and time of recurrence. This is described in more detail along with the statistical analysis in the statistical section (Section 13).
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5 treatment plan 5.1 study

This is a phase II study in subjects with non-muscle invasive (stages Ta, T1, and/or CIS) high grade urothelial carcinoma of the bladder who have failed at least one course of intravesical BCG. The study will be halted for 28 days after the first six patients with combination therapy are accrued and successfully treated. If any Grade 3 or greater toxicities are observed that do not resolve with conservative management, then they will be discussed with CTEP. With preliminary evidence of safety, the remaining subjects will be accrued to the trial. (See SCHEMA) 5.1.1 All subjects will receive BCG (TICE strain, 50 mg) intravesically as per usual standard of care once weekly (+/- 2 days) starting in week 3 for a total of 6 weeks (last dose in week 8).  
5.1.2 Subjects in the combination arm will receive the pox viral vaccines that contain the transgenes for CEA and MUC-1 (both with modified HLA-A2 agonist epitopes) as well as 3 human T-cell costimulatory molecules, B7-1, ICAM-1, and LFA-3 [rV-PANVAC™ (vaccinia) and rF-PANVAC™ (fowlpox)] as follows:
5.1.2.1 rV-PANVAC™ 2 x 108 pfu SQ at week 0 (+/- 7 days) only.  
5.1.2.2 rF-PANVAC™ 1 x 109 pfu SQ at weeks (+/- 7 days) 3, 7, 11, and 15.  
5.1.3 All subjects will provide blood, urine, and tissue (if available) at study entry and at the end of the study. Tissue at study entry can be obtained either from outside FFPE or from previous TURBT performed at NIH (see section **3.4.4.1**). This tissue is required for diagnosis. All subjects will also have blood drawn at weeks 3 and 8 to coincide with the start and end of BCG treatment. Urine samples will also be obtained before and after the 1st and 3rd instillation of BCG as defined in Section **9.1.2**.  
5.1.4 All subjects will undergo tuberculin skin testing using purified protein derivative (PPD)
at study entry (prior to receiving BCG instillation \#1) and around the time of the week 17-20 cystoscopy/EUA. The associated skin reaction will be evaluated by a health care provider within 48-72 hours after injection. Skin induration greater than 10mm in diameter will be considered a positive result. Initial PPD results do NOT preclude subsequent treatment with BCG - these results will only be used to assess the immunologic response to BCG (see section **9.1.1**).  
5.1.5 Between weeks 17-20 (+/- 7 days), a CT urogram and chest x-ray for re-staging purposes prior to biopsy, a planned cystoscopy, exam under anesthesia, and biopsy of the previous tumor area and/or any new areas of tumor to evaluate for the presence/recurrence of disease.  
5.1.6 After the initial 20 week study course, subjects will be followed for up to 1 year at the study center every 3 months per routine standard of care for high grade urothelial cancer of the bladder with cystoscopy and cytology. If recurrence is noted, it will be treated and if confirmed to be a recurrence on pathology, the patient will come off study. Surveillance and/or treatment for recurrences beyond the initial 12 months may be performed by outside urologists.
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5.2 trial outline

5.2.1 After meeting all entry criteria based on screening evaluation, subjects will be enrolled into the study. Of note, there will be at least a 3 week delay from the time a previous bladder biopsy/TURBT to allow for adequate bladder healing prior to enrollment.  
5.2.1.1 6 green top tubes of blood will be drawn for PBMCs, HLA Typing, and sera for correlative/exploratory research aims (e.g. ELISPOT, CD4+ Antigen-specific responses, etc.) on day 1 of study enrollment 5.2.1.2 Beta-HCG for women of child-bearing age (within 72 hours prior to day 1). In addition, patients, both male and female, should be willing to practice effective birth control during the study and four months following the last study treatment, unless they have had a prior hysterectomy, bilateral oophorectomy, or vasectomy.  
5.2.2 TICE BCG arm: 5.2.2.1 Weeks 3-8: Receive weekly (+/- 2 days) intravesical doses of BCG (TICE strain, 50 mg) as per usual standard of care for a total of 6 weeks. Urine will be tested weekly prior to each BCG administration and the presence of gross hematuria or evidence of a urinary tract infection will result in holding that week's BCG dose and postponing therapy until the following week. Also, at the beginning of each administration, patients will be queried about urinary symptoms.  
x Complaints of persistent dysuria, urgency, bladder spasms, and/or frequency from previous week's administration that is consistent with Grade 3 or greater toxicity will result in holding BCG administration for that week, supportive care (e.g. medications and hydration), and/or BCG dose reduction the following week at 1/3 normal dose as this can result in less toxicity with similar results for recurrence and progression.31 x Patients will be maintained at this reduced dose if they tolerate therapy. x Future inability to tolerate this reduced dose will result in holding BCG for that week and postponing the BCG until the following week and dropping to 1/6 of the normal dose as this dose may still be effective in prolonging progression-free and cancer-specific survival times.32 5.2.2.2 Blood and urine will be obtained for correlative studies as described in Section 9.1. 5.2.2.3 Between weeks 17-20 (+/- 7 days), a CT urogram and chest x-ray prior to biopsy, a planned cystoscopy, EUA, and TURBT will be done of previous tumor area and of any new areas of tumor. Tissue will be sent for pathology and be formalin-fixed paraffin embedded. If possible, some tissue will also be frozen.  
x If a suspicious lesion is identified, it will be biopsied. If recurrent tumor is not found, then the subject will return every 3 months for a surveillance cystoscopy as per standard-of-care. If recurrent tumor is found, the patient has met the primary endpoint of recurrence and will be taken off study.  
5.2.2.4 At every surveillance cystoscopy post-treatment up to 12 months, urine may be collected for cytology as well as for immune-related markers along with blood through 6 green top tubes for correlative immunologic aims.
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5.2.3 tice bcg + panvac™️

5.2.3.1 Enroll into study with baseline evaluation and studies as described in Section 3.4. Of note, there will be at least a 3 week delay from the time a previous bladder biopsy/TURBT to allow for adequate bladder healing prior to enrollment.  
5.2.3.2 Week 0 (+/- 7 days) - all subjects in this arm receive single vaccinia priming vaccine -
rV-PANVAC™ 2 x 108 pfu SQ after undergoing phlebotomy with 6 green top tubes for immunologic correlates.  
5.2.3.3 Weeks 3-8: Receive weekly (+/- 2 days) intravesical doses of BCG (TICE strain, 50 mg) as per usual standard of care for a total of 6 weeks. Urine will be tested weekly prior to each BCG administration and the presence of gross hematuria or evidence of a urinary tract infection will result in holding that week's BCG dose and postponing therapy until the following week. Also, at the beginning of each administration, patients will be queried about urinary symptoms.  
x Complaints of persistent dysuria, urgency, bladder spasms, and/or frequency from previous week's administration that is consistent with Grade 3 or greater toxicity will result in holding BCG administration for that week, supportive care (e.g.  
medications and hydration), and/or BCG dose reduction (BCG can be given 1/3rd of the normal dose on the following week as this can result in less toxicity with similar results for recurrence and progression31).  
x Subjects will be maintained at this reduced dose if they tolerate therapy. x Future inability to tolerate this reduced dose will result in holding BCG for that week and postponing the BCG until the following week and dropping to 1/6 of the normal dose as this dose may still be effective in prolonging progression-free and cancer-specific survival times.32 5.2.3.4 PANVAC administration will continue as planned regardless of any delays in BCG
administration. Research sample collection of urine will coincide with the first and third week of BCG instillation regardless of any delays with BCG administration. Research sample collection of blood will coincide with the first and sixth week of BCG instillation regardless of any delays with BCG administration. [For example, if BCG is first given on week 3 of the study, but held on week 4 and resumed on week 5, then urine collection would be collected on weeks 0, 3, 6 (previously week 5), 18-21 (previously 17-20), and optionally on follow-up visits. In this scenario, blood would be collected on weeks 0, 3, 9 (previously week 8), 18-21 (previously 17-20), and optionally on follow-up visits. The timing of PANVAC administration will NOT change in this scenario.] Week (+/- 7 days) 3, 7, 11, and 15 - all patients in this arm receive boost fowlpox vaccines - rF-PANVAC™ 1 x 109 pfu SQ
5.2.3.5 Blood and urine will be obtained for correlative studies as described in Section 9.1. 5.2.3.6 Between weeks 17-20 (+/- 7 days), a CT urogram and chest x-ray prior to biopsy, a planned cystoscopy, EUA, and TURBT will be done of previous tumor area and of any new areas of tumor. Tissue will be sent for pathology and be formalin-fixed paraffin embedded. If possible, some tissue will also be frozen.  
5.2.3.7 Also at the time of the end-of-study cystoscopy, urine will be collected for cytology and for immune-related markers along with blood for correlative aims.
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5.3 agent administration

Treatment will be administered on an outpatient basis. Reported adverse events and potential risks are described in Section 7. Appropriate dose modifications are described in Section 6. No investigational or commercial agents or therapies other than those described below may be administered with the intent to treat the patient's malignancy.
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other agents

Bacillus Calmette-Guerin (BCG) - TICE strain The administration of the agents is described below based on the treatment arms: 5.3.1 TICE BCG alone arm:
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weeks 3-8

Bacillus Calmette-Guerin (BCG) - TICE strain x Attenuated live strain of Mycobacterium bovis x Induction course of 6 weekly (+/- 2 days) instillations x Instillation volume (50 mg in 50 mL sterile saline).  
x Dose - 50 mg vial (TICE) is reconstituted in accompanying diluent and then further diluted in sterile, preservative-free saline according to manufacturer guidelines x Each week, RNs will sterilely insert a urethral catheter atraumatically into the subject's bladder and administer the reconstituted BCG. Following instillation of the 50 mL of BCG, the urethral catheter will be removed.  
x BCG will then be held in the bladder for 1-2 hours depending on patient ability to hold the medication in the bladder. The patient will then void in a toilet and rinse the toilet with bleach prior to flushing.  
x All equipment in contact with BCG will be treated as chemotherapeutic waste and disposed of as such in a MPW container.  
5.3.2 TICE BCG + PANVAC™ arm: Week 0 rV-PANVAC™ (vaccinia priming vaccine) 2 x 108 pfu subcutaneously (+/- 7 days).  
Week 3 BCG (+/- 2 days see details above).  
rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).  
Weeks 4-6 BCG (+/- 2 days see details above). Week 7 BCG (+/- 2 days see details above).  
rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).  
Week 8 BCG (+/- 2 days see details above). Week 11 rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).  
Week 15 rF-PANVAC™ (fowlpox boosting vaccine) 1 x 109 pfu subcutaneously (+/- 7 days).  
5.3.3 Precautions for the vaccines x Prior to administration of the drugs, safe-handling precautions should be thoroughly reviewed (see Section 8, precautions and special handling subsections of "Pharmaceutical Information").  
x The proper procedure for disposing the live vaccine is a critical part of drug administration (see Section 8, disposal sections of "Pharmaceutical Information").
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5.4 dose limiting toxicity

TICE BCG will be given in the standard dose and schedule as described above. All toxicities observed will be tabulated by maximum grade per subject. A dose limiting toxicity (DLT) will be any grade 3 or greater adverse effect (AE) by CTCAE v5.0 related to the investigational agent and persisting for more than one week and not improving by routine standard of care. In addition, any grade 3 or greater AE as per a previously published vaccinia toxicity grading scale33 related to the investigational agent will also be considered a DLT.  
Intravesical BCG therapy can lead to common side effects that are usually self-limited, particularly with dose reduction. These side effects include, but are not limited to, gross hematuria, dysuria, frequency, urgency, bladder spasms, and generalized cystitis. These side effects will not be considered a DLT if it is related to BCG and resolves with BCG dose reduction and/or postponing therapy by 1-2 weeks and treating symptoms with conservative management. In contrast, persistent side effects despite dose reduction/postponing of BCG therapy or the development of systemic BCG infection (aka "BCG-osis") will be considered a DLT. Severe adverse events due to local instillation of BCG are uncommon. In a retrospective analysis of 2602 patients reported in 1989, the overall rate of serious complications was less than five percent.34 The most common complication was fever >103ºF in 2.9 percent followed in decreasing frequency by:
x Significant hematuria (1 percent) x Granulomatous prostatitis (0.9 percent)  
x Pneumonitis and/or hepatitis (0.7 percent) x Arthralgia (0.5 percent) x Epididymitis (0.4 percent) x Sepsis (0.4 percent) x Rash (0.3 percent) x Ureteral obstruction (0.3 percent) x Contracted bladder (0.2 percent) x Renal abscess (0.1 percent) x Cytopenia (0.1 percent)
Systemic sepsis and even death can also develop early following local instillation of BCG. During the initial clinical experience with BCG as an intravesical agent, most cases of sepsis could be traced back to recognized errors in BCG administration such as traumatic catheterization, administration too early after transurethral surgery, or instillation during a concomitant UTI. All these conditions result in physical disruptions in the urothelial blood barrier. Sepsis has been estimated to occur in approximately one in every 15,000 patients treated with intravesical BCG.34 Prompt recognition and administration of multidrug, antibiotic therapy is necessary if true BCG sepsis occurs. 5.4.1 For the purpose of protecting subject safety, we implement the following stopping rule for safety monitoring of subjects who receive the combination therapy.  
5.4.2 If one subject experiences a grade 5 event, thought to be possibly or probably due to the combination therapy (PANVAC + BCG), the study will be stopped. For grade 3 or 4
events probably related to the investigational agent (PANVAC) and persisting for more than one week and not improving by routine standard of care, the study will be stopped according to the stopping rule described in Section 13.  
5.4.2.1 The exceptions to what constitute true adverse events/DLTs are previously noted.  
5.4.3 Formal dose escalation/Phase I study is not planned as the TICE BCG doses are consistent with standard of care and the TICE BCG is being administered in an intravesical fashion while the PANVAC™ is given subcutaneously and in doses that have been shown to be safe in multiple Phase I and Phase II studies in a variety of different cancers.
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5.5 general concomitant medication and

For the vaccine administration, anti-emetics and anti-diarrheal agents may be administered as required, but are not anticipated to be needed and should not be used prophylactically on the first cycle. The selection of the specific antiemetic regimen is at the discretion of the treating physician. Antiemetic regimens should not include dexamethasone or other steroids. Other supportive care with blood components, antibiotics, analgesics, general medical therapy, etc., will be delivered as required. Any subjects taking antibiotics for any reason must complete that course of therapy and be free of evidence of further infection before receiving any dose of vaccine. To avoid blunting of the immune response, we will avoid administering corticosteroids or other immunosuppressive agents unless medically indicated. Symptomatic anemia should be treated with appropriate red blood cell or erythropoietin support. Thrombocytopenia should be treated conservatively. In the absence of bleeding or a planned invasive procedure, platelet transfusions should be given for a platelet count below 10,000/mm3.  
If invasive procedures are planned or the subject develops bleeding, platelet transfusions should be administered in accordance with the standard of practice, usually maintaining a platelet count of >50,000/mm3.  
5.5.1 Treatment of Vaccinia Vaccination Complications
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5.5.1.1 vaccinia immune globulin (vig)

Vaccinia Immune Globulin (VIG): First-line treatment of some of the complications of vaccinia caused by dissemination of vaccinia virus (severe cases of inadvertent inoculation involving extensive lesions or if comorbid conditions exist, severe cases of generalized vaccinia in patients that are systemically ill and whose condition might be toxic or who have serious underlying immunosuppressive illnesses, eczema vaccinatum, and progressive vaccinia) is with VIG. VIG is contraindicated, however, for the treatment of isolated vaccinial keratitis. VIG is a sterile solution of the immunoglobulin fraction of pooled plasma from individuals inoculated with vaccinia vaccine. VIG is only available through the CDC's Strategic National Pharmaceutical Stockpile by contacting the CDC's Clinician Information Line at 1-877-5544625 or the Director's Emergency Operations Center (DEOC) at 770-488-7100. Upon receipt of a call from a patient or upon direct observation of a patient or contact who manifests signs and symptoms of any of the above conditions, the investigator should place a call to the CDC as soon as possible: 1) to initiate review of the clinical case, 2) to seek consultation on the appropriateness of VIG therapy, 3) to determine the appropriate VIG dose and dosing method for administration, if VIG therapy is required, and 4) to determine how to access and have the appropriate doses of VIG delivered. Early institution of VIG therapy is advised following recognition of clinical symptoms compatible with some vaccinia complications (eczema vaccinatum, severe generalized vaccinia, progressive vaccinia, and some cases of inadvertent inoculation). The effectiveness of VIG therapy appears to be time dependent. VIG has not proven to be of benefit in the treatment of post-vaccinial encephalitis, and is contraindicated for treatment of isolated vaccinial keratitis due to the increased risk of corneal scarring. A new IV formulation of VIG that has a lower level of aggregated protein allowing it to be used by either the IM or IV route is available through the CDC. This formulation will most likely be preferred for administration and the CDC will instruct investigators regarding appropriate dosing and method of administration based on the formulation and availability. There is no guarantee that VIG will successfully treat complications. At present, there are no other anti-viral therapies of proven benefit for the treatment of vaccinia-related complications. 5.5.1.2 Cidofovir (Vistide®, Gilead Sciences) Cidofovir (Vistide®, Gilead Sciences): Cidofovir is an FDA-approved antiviral drug for the treatment of CMV retinitis among patients with AIDS. Cell-based *in vitro* studies and animal model studies have demonstrated this agent's antiviral activity against certain orthopoxviruses. Currently, its efficacy in the treatment of vaccinia-related complications in humans is unknown. According to the CDC, VIG is recommended as first line of therapy. Cidofovir may be considered as a secondary treatment, and will only be used when VIG therapy is not effective [Medical Management of Smallpox (Vaccinia) Vaccine Adverse Reactions: Vaccinia Immune Globulin and Cidofovir. Last updated September 28, 2009. Available at: http://www.bt.cdc.gov/agent/smallpox/vaccination/mgmt-adv-reactions.asp]. The CDC has informed the NCI/CTEP that cidofovir will not be supplied through Strategic National Pharmaceutical Stockpile to investigators involved in CTEP-sponsored protocols utilizing recombinant vaccinia-based vaccines. Thus, investigators should obtain cidofovir for secondline therapy through commercial sources if necessary. Investigators should consult the CDC
Clinician Information Line at 1-877-554-4625 or the Director's Emergency Operations Center (DEOC) at 770-488-7100 regarding appropriateness of therapy and guidance.
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5.6 duration of therapy

In the absence of treatment delays due to adverse event(s), therapy will continue as per the aforementioned schema. Off therapy criteria is listed in Section 0.
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5.7 duration of follow up

Subjects will be followed for 1 year after the initial 20 week study course is completed with surveillance cystoscopy or until death, whichever occurs first.
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5.8 criteria for removal from

Prior to removal from study, effort must be made to have all subjects complete a safety visit approximately 30 days following the last dose of study therapy. 5.8.1 Criteria for removal from protocol therapy x Intercurrent illness or medical circumstances: if at any time the constraints of this protocol are detrimental to the subject's health, the subject may be removed from protocol therapy. In this event, the reasons for withdrawal will be documented.  
x General or specific changes in the subject's condition render the subject unacceptable for further treatment in the judgment of the investigator (investigator discretion).  
x Participant requests to be withdrawn from active therapy x Enroll on another protocol or receives standard of care. x Unacceptable treatment-related toxicity (DLT) as defined in Section 5.4.  
x Grade 4 toxicity after vaccinia injection per table below35:  
| Vaccinia-Related Toxicity Grading  Grade 1   Cutaneous reaction extending to not more than 10 cm from vaccination site  Grade 2   Cutaneous reaction extending to more than 10 cm from the vaccination site or any  autoinoculation that resolves without sequelae Grade 3   Not applicable Grade 4  Autoinoculation syndrome with sequelae: postvaccinia encephalitis, vaccinia  gangrenosum, eczema gangrenosum, or Steven-Johnson syndrome   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
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5.8.2 off-study criteria

x Completed study follow-up period (1 year post treatment)
x Disease progression to muscle-invasive urothelial carcinoma of the bladder x Subject's request to be taken off study. In this event, the reasons for withdrawal will be documented.  
x If subjects are non-compliant with the protocol guidelines, they may be removed from the study at the discretion of the principal investigator.  
x Death
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5.8.3 off protocol therapy and

Authorized staff must notify Central Registration Office (CRO) when a subject is taken off protocol therapy and when a subject is taken off study. A Participant Status Updates Form from the web site (http://home.ccr.cancer.gov/intra/eligibility/welcome.htm) main page must be completed and sent via encrypted email to: NCI Central Registration Office ncicentralregistration-l@mail.nih.gov. For participating sites, the Participant Status Updates Form will be supplied by the CCR study coordinator. Send the completed form to the CCR study coordinator.
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6 dosing delays/dose modifications 6.1

The need for BCG dose modification may arise and has been described previously. To review, subjects will receive weekly (+/- 2 days) intravesical doses of BCG (TICE strain, 50 mg) as per usual standard of care for a total of 6 weeks. Urine will be tested weekly prior to each BCG administration and the presence of gross hematuria or a urinary tract infection by urinalysis will result in holding that week's BCG dose and postponing therapy until the following week. Also, at the beginning of each administration, subjects will be queried about urinary symptoms. Complaints of persistent dysuria, urgency, bladder spasms, and/or frequency from previous week's administration that is consistent with Grade 3 or greater toxicity will result in holding BCG administration for that week, supportive care (e.g. medications and hydration), and/or BCG dose reduction the following week at 1/3 normal dose as this can result in less toxicity with similar results for recurrence and progression.31 Complaints of non-infective cystitis or hematuria consistent with Grade 2 or higher will result in holding BCG administration for that week. Therapy will resume the following week at if these symptoms are at less than or equal to Grade 1. Subjects will be maintained at this reduced dose if they continue to fail to tolerate full dose therapy. Future inability to tolerate this reduced dose will result in holding BCG for that week and postponing the BCG until the following week and dropping to 1/6 of the normal dose (details in Section 5.2). Of note, weekly BCG postponement or dose reductions will not alter the vaccination schedule. For example, if the week 5 dose of BCG is withheld, the subject will still receive the next dose of PANVAC™-F on week 7, but the last dose of BCG would be given on week 9 instead of week 8 (assuming that no other BCG postponement is necessary).
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6.2 panvac™️-v (vaccinia) and panvac™️-f

x Subjects must have recovered to ≤ grade 1 toxicity related to vaccine for constitutional symptoms (that are not related to the BCG or medications related to BCG treatments) in order to receive a subsequent vaccination. These constitutional symptoms are listed in Section **7.1.1.1**.  
x Subjects with ≤ grade 2 toxicity not related to vaccine treatment (i.e. attributed to BCG) will remain eligible to receive vaccine.  
x Subjects that recover from grade 3 toxicity unrelated to vaccine treatment (i.e.  
related to BCG) will remain eligible for the vaccine. However, subjects that experience a grade 4 toxicity unrelated to vaccine treatment (i.e. attributed to BCG) will not remain eligible for further vaccine administration.  
x If BCG is permanently discontinued, the patient will remain eligible for further vaccine administration in the absence of a grade 4 toxicity.  
x Vaccination will be held for > grade 2 proteinuria measured initially by a urine dipstick but confirmed by a 24 hour urine collection.  
x If ≥grade 2 nonautoimmune toxicity attributable to the vaccine persists for > 42 days, the subject will not receive further vaccine inoculations and will be removed from the protocol treatment and followed for resolution of toxicity and immune endpoints.  
x Subjects who develop grade 3 injection site reactions will have their vaccine held until injection site reaction resolves to grade 2 or less.  
x Subjects who develop ≥ a grade 2 allergic or autoimmune disease that threatens vital organ function or any ≥ grade 3 autoimmunity, not related to a therapeutic response, will be removed from the protocol treatment and followed for resolution of toxicity and immune endpoints. Follow-up will be performed during each vaccination and blood draw interval for immunologic testing as described in Section 10 x Subjects who develop any grade 4 toxicity attributable to the study drug(s) will be removed from the protocol treatment and followed for resolution of toxicity and immune endpoints.  
x If a scheduled vaccine dose is missed due to scheduling or logistical issues, the vaccine may be given within 7 days of the appointed time (which resets the appointed date for further vaccinations) or be considered a missed dose. If the subject has a delay in vaccination not due to toxicity during the core phase, the vaccine may be delayed for up to 42 days without removal of the subject from study. BCG administration will not be affected by missed/delayed vaccine administrations.  
6.2.1.1 Dose modifications No dose modifications are allowed with this vaccine
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7 adverse events list and

Adverse event (AE) monitoring and reporting is a routine part of every clinical trial. The following list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will determine whether the event requires expedited reporting (via CTEP-AERS) **in addition** to routine reporting.
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7.1 comprehensive adverse events and

The Comprehensive Adverse Event and Potential Risks list (CAEPR) provides a single list of reported and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by body system. In addition to the comprehensive list, a subset of AEs, the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and is identified with *bold* and *italicized* text. The SPEER is a list of events that are protocolspecific exceptions to expedited reporting to NCI via CTEP-AERS (except as noted below).  
Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm for further clarification. NOTE: The highest grade currently reported is noted in parentheses next to the AE in the SPEER. Report **ONLY** AEs higher than this grade expeditiously via CTEP-AERS. If this CAEPR is part of a combination protocol using multiple investigational agents and has an AE listed on different SPEERs, use the lower of the grades to determine if expedited reporting is required.
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7.1.1 caeprs for ctep ind

For protocols with CAEPRs not including a "SPEER" category, protocol-specific exceptions to the CTEP-AERS reporting table can be found in the CAEPR's "ASAEL" category instead. This protocol-specific exception is limited to Grade 1 and Grade 2 ASAEL events, *i.e.* Grade 3 through Grade 5 ASAEL-listed events are NOT exceptions to CTEP-AERS reporting.  
7.1.1.1 PANVAC-V and PANVAC-F
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited reporting to NCI (except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for further clarification. Below is the CAEPR for PANVAC-VF/TRICOM.  
NOTE: Report AEs on the SPEER **ONLY IF** they exceed the grade noted in parentheses next to the AE in the SPEER. If this CAEPR is part of a combination protocol using multiple investigational agents and has an AE listed on different SPEERs, use the lower of the grades to determine if expedited reporting is required.  
| Version 1.3, May 30, 20141                                                                                                                                                     |                                                              |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------|
| Adverse Events with Possible Relationship                                                                                                                                      | Specific Protocol Exceptions to  Expedited Reporting (SPEER) |
| to PANVAC-VF/TRICOM  (CTCAE 4.0 Term)                                                                                                                                          |                                                              |
| BLOOD AND LYMPHATIC SYSTEM DISORDERS Anemia GASTROINTESTINAL DISORDERS Diarrhea Nausea Pancreatitis2  Vomiting GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS  Chills    | Chills (Gr 2)                                                |
| Fatigue                                                                                                                                                                        | Fatigue (Gr 2)                                               |
| Fever                                                                                                                                                                          | Fever (Gr 2)                                                 |
| Flu like symptoms                                                                                                                                                              | Flu like symptoms (Gr 2)                                     |
| Injection site reaction                                                                                                                                                        | Injection site reaction (Gr 2)                               |
| Pain INVESTIGATIONS Alanine aminotransferase increased  METABOLISM AND NUTRITION DISORDERS Anorexia Hypoalbuminemia MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS Arthralgia |                                                              |  
| Back pain Bone pain Generalized muscle weakness Myalgia                                                                                                                                                                                               | Myalgia (Gr 2)   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------|
| Pain in extremity NERVOUS SYSTEM DISORDERS  Headache                                                                                                                                                                                                  | Headache (Gr 2)  |
| Syncope RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS Cough SKIN AND SUBCUTANEOUS TISSUE DISORDERS Hyperhidrosis Pruritus Skin induration 1 This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed |                  |  
1This table will be updated as the toxicity profile of the agent is revised. Updates will be distributed to all Principal Investigators at the time of revision. The current version can be obtained by contacting PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and the agent should be included in the e-mail.  
2Transient pancreatitis was observed in at least one patient who received endoscopic ultrasound
(EUS)-guided intra-pancreatic tumor injection. Non-serious adverse events also reported on PANVAC-VF/TRICOM trials but with the relationship to PANVAC-VF/TRICOM still undetermined due to low frequency (i.e., <3%):
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eye disorders - eye pain

GASTROINTESTINAL DISORDERS - Abdominal pain; Colitis; Gastrointestinal disorders - Other (fluid around pancreas); Mucositis oral; Stomach pain GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; Edema limbs; Non-cardiac chest pain IMMUNE SYSTEM DISORDERS - Allergic reaction INVESTIGATIONS - Alkaline phosphatase increased; Aspartate aminotransferase increased; Blood bilirubin increased; Lipase increased; Lymphocyte count decreased; Serum amylase increased METABOLISM AND NUTRITION DISORDERS - Dehydration; Hypomagnesemia MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Neck pain NERVOUS SYSTEM DISORDERS - Dysgeusia PSYCHIATRIC DISORDERS - Agitation; Insomnia RENAL AND URINARY DISORDERS - Proteinuria RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Erythema multiforme; Rash maculopapular VASCULAR DISORDERS - Hot flashes; Hypotension
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notes

1. PANVAC-V [Recombinant Vaccinia-CEA(D609)/MUC1(L93)/TRICOM] and PANVAC-F [Recombinant Fowlpox-CEA(D609)/MUC1(L93)/TRICOM] when used in combination with other agents, either commercial or investigational, could be associated with changes in the frequency or severity of known events or the emergence of new patterns of events.  
2. Other potential risks or complications associated with the use of the vaccinia vaccine strain from which the attenuated recombinant vector is derived, include those observed during the smallpox vaccination programs:
x Inadvertent inoculation (autoinoculation and direct contact transmission) x Non-specific erythematous or urticarial rashes (generally self-limiting) and rarely, more serious bullous erythema multiforme (Stevens-Johnson syndrome)
x Generalized vaccinia (disseminated maculopapular or vesicular rash of varying extent on any part of the body)
x Eczema vaccinatum (vaccinial lesion development on areas of the skin that are, or had at one time been, eczematous)
x Progressive vaccinia (local vaccination lesion fails to heal and develops progressive necrosis, with destruction of large areas of skin, subcutaneous tissue, and underlying structures. Progressive lesions may spread to other skin surfaces and to bone and viscera)
x Post-vaccinial encephalitis/encephalomyelitis x Fetal vaccinia x Myocarditis/pericarditis 3. The inclusion of co-stimulatory molecules in these agents may theoretically stimulate autoimmunity or exacerbate existing disease in susceptible individuals.  
4. Thrombotic thrombocytopenic purpura (TTP) occurred with closely related agents, PROSTVAC-V/TRICOM [Recombinant Vaccinia-PSA(L155)/TRICOM] and PROSTVAC-F/TRICOM [Recombinant Fowlpox-PSA(L155)/TRICOM].  
7.1.2 Adverse Event List(s) for Commercial Agents 7.1.2.1 TICE Bacillus Calmette-Guerin (BCG) (See package insert for complete list of side effects) Symptoms of bladder irritability, related to the inflammatory response induced, are reported in approximately 60% of patients receiving TICE® BCG. The symptoms typically begin 4–6 hours after instillation and last 24–72 hours. The irritative side effects are usually seen following the third instillation, and tend to increase in severity after each administration. The irritative bladder adverse effects can usually be managed symptomatically with products such as pyridium, propantheline bromide, oxybutynin chloride and acetaminophen. The mechanism of action of the irritative side effects has not been firmly established, but is most consistent with an immunological mechanism. There is no evidence that dose reduction or antituberculous drug therapy can prevent or lessen the irritative toxicity of TICE® BCG. "Flu-like" symptoms (malaise, fever, and chills) which may accompany the localized, irritative toxicities often reflect hypersensitivity reactions which can be treated symptomatically. Antihistamines have also been used. Adverse reactions to TICE® BCG tend to be progressive in frequency and severity with subsequent instillation. Delay or postponement of subsequent treatment may or may not reduce the severity of a reaction during subsequent instillation. Although uncommon, serious infectious complications of intravesical BCG have been reported. The most serious infectious complication of BCG is disseminated sepsis with associated mortality. In addition, *M. bovis* infections have been reported in lung, liver, bone, bone marrow, kidney, regional lymph nodes, and prostate in patients who have received intravesical BCG. Some male genitourinary tract infections (orchitis/epididymitis) have been resistant to multiple drug antituberculous therapy and required orchiectomy. If a patient develops persistent fever or experiences an acute febrile illness consistent with BCG infection, BCG treatment should be discontinued and the patient immediately evaluated and treated for systemic infection. The local and systemic adverse reactions reported in a review of 674 patients with superficial bladder cancer, including 153 patients with carcinoma *in situ*, are summarized.  
| BLADDER CANCER, INCLUDING 153 WITH CARCINOMA IN SITU Adverse Event N Overall (Grade  Adverse Event                                                                                    | N                                                | Overall                                                                                               |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------|-------------------------------------------------------------------------------------------------------|
| ≥3)                                                                                                                                                                                   | (Grade ≥3)                                       |                                                                                                       |
| Dysuria Urinary  Frequency FluLike Syndrome  Hematuria Fever  Malaise/Fatigue  Cystitis Urgency  Nocturia  Cramps/Pain  Rigors  Nausea/Vomiting                                                                                                                                                                                       | 401  272  224  175  134  50 40  39 30  27 22  20 | 60% (11%)                                                                                             |
| 40% (7%) 33%  (9%) 26% (7%)  20% (8%) 7%  (0) 6% (2%) 6%  (1%) 5% (1%)  4% (1%) 3%  (1%) 3% (<1%)                                                                                     | Arthritis/Myalgia                                |                                                                                                       |
| Headache/Dizziness Urinary                                                                                                                                                            |                                                  |                                                                                                       |
| Incontinence Anorexia/Weight  Loss Urinary Debris Allergy  Cardiac (Unclassified) Genital  Inflammation/ Abscess  Respiratory (Unclassified)  Urinary Tract Infection  Abdominal Pain | 18  16  16  15  15  14  13  12  11  10  10       | 3% (<1%)  2% (0) 2%  (0) 2%  (<1%) 2%  (<1%) 2%  (<1%) 2%  (1%) 2%  (<1%) 2%  (<1%) 2%  (1%) 2%  (1%) |  
The following adverse events were reported in ≤1% of patients: anemia, BCG sepsis, coagulopathy, contracted bladder, diarrhea, epididymitis/prostatitis, hepatic granuloma, hepatitis, leukopenia, neurologic (unclassified), orchitis, pneumonitis, pyuria, rash, thrombocytopenia, urethritis, and urinary obstruction. In SWOG study 8795, toxicity evaluations were available on a total of 222 TICE® BCG-treated patients and 220 MMC-treated patients. Direct bladder toxicity (cramps, dysuria, frequency, urgency, hematuria, hemorrhagic cystitis, or incontinence) was seen more often with TICE® BCG, with 356 events compared to 234 events for MMC. Grade ≤2 toxicity was seen significantly more frequently following TICE® BCG treatment (p=0.003). No life-threatening toxicity was seen in either arm. Systemic toxicity with TICE® BCG was markedly increased compared to that of MMC, with 181 events for TICE® BCG compared to 80 for MMC. The frequency of toxicity was increased in all grades, particularly for grades 2 and 3. The most common complaints were malaise, fatigue and lethargy, fever, and abdominal pain. Thirty-two TICE® BCG patients were reported to have been treated with isoniazid. Five TICE® BCG patients had liver enzyme elevation, including two with grade 3 elevations. Eighteen of the 222 (8.1%) TICE® BCG patients failed to complete the prescribed protocol compared to 6.2% in the MMC group.
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7.2 definitions 7.2.1 adverse event

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

x **CTCAE term (AE description) and grade:** The descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized **death on study requires both** for AE reporting. CTCAE version 5.0 will be utilized for AE reporting beginning April 1, 2018. All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.
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x for expedited reporting purposes

- AEs for the agent that are *bold and italicized* in the CAEPR (*i.e.*, those listed in the SPEER column, Section **7.1.1**) should be reported through CTEP-AERS only if the grade is above the grade provided in the SPEER.  
- Other AEs for the protocol that do not require expedited reporting are outlined in Section 7.4.
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x attribution of the ae

- Definite - The AE *is clearly related* to the study treatment. - Probable - The AE *is likely related* to the study treatment. - Possible - The AE *may be related* to the study treatment. - Unlikely - The AE *is doubtfully related* to the study treatment.  
- Unrelated - The AE *is clearly NOT related* to the study treatment.
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7.2.2 suspected adverse reaction

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

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

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

An adverse event or suspected adverse reaction is considered serious if in the view of the investigator or the sponsor, it results in any of the following:
x Death x A life-threatening adverse drug experience x Inpatient hospitalization or prolongation of existing hospitalization x Persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
x A congenital anomaly/birth defect
x Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered a serious adverse drug experience when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition
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7.2.6 disability

A substantial disruption of a person's ability to conduct normal life functions.  
7.2.7 Life-threatening adverse drug experience Any adverse event or suspected adverse reaction that places the patient or subject, in the view of the investigator or sponsor, at immediate risk of death from the reaction as it occurred, i.e., it does not include a reaction that had it occurred in a more severe form, might have caused death.
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7.2.8 protocol deviation (nih definition)

Any change, divergence, or departure from the IRB-approved research protocol. 7.2.9 Non-compliance (NIH Definition) The failure to comply with applicable NIH Human Research Protections Program (HRPP) policies, IRB requirements, or regulatory requirements for the protection of human research subjects. 7.2.10 Unanticipated Problem Any incident, experience, or outcome that:
x Is unexpected in terms of nature, severity, or frequency in relation to
(a) the research risks that are described in the IRB-approved research protocol and informed consent document; Investigator's Brochure or other study documents, and (b) the characteristics of the subject population being studied; AND
x Is related or possibly related to participation in the research; AND  
x Suggests that the research places subjects or others at a g*reater risk of harm* (including physical, psychological, economic, or social harm) than was previously known or recognized.
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7.3 expedited adverse event reporting

7.3.1 Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event Reporting System), accessed via the CTEP Web site (http://ctep.cancer.gov). The reporting procedures to be followed are presented in the "NCI Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD (CTEP and CIP) and DCP INDs and IDEs" which can be downloaded from the CTEP Web site (http://ctep.cancer.gov). These requirements are briefly outlined in the tables below (Section **7.3.3**). In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be made to CTEP by telephone at 301-897-7497. Once Internet connectivity is restored, the 24-hour notification phoned in must be entered electronically into CTEP-AERS by the original submitter at the site. CTEP-AERS is programmed for automatic electronic distribution of reports to the following individuals: Study Coordinator of the Lead Organization, Principal Investigator, and the local treating physician. CTEP-AERS provides a copy feature for other e-mail recipients.  
7.3.2 Expedited Reporting Guidelines Use the NCI protocol number and the protocol-specific patient ID assigned during trial registration on all reports. Note: A death on study requires both routine and expedited reporting regardless of causality. Attribution to treatment or other cause must be provided. Death due to progressive disease should be reported as Grade 5 **"Disease progression"** in the system organ class (SOC) "General disorders and administration site conditions.". Evidence that the death was a manifestation of underlying disease (*e.g.*, radiological changes suggesting tumor growth or progression: clinical deterioration associated with a disease process) should be submitted.  
Pregnancy loss x Pregnancy loss is defined in CTCAE as "Death in utero." x Any Pregnancy loss should be reported expeditiously, as Grade 4 "Pregnancy loss" under the Pregnancy, puerperium and perinatal conditions SOC.  
x A Pregnancy loss should NOT be reported as a Grade 5 event under the Pregnancy, puerperium and perinatal conditions SOC, as currently CTEPAERS recognizes this event as a patient death.
A neonatal death should be reported expeditiously as Grade 4, "Death neonatal" under the General disorders and administration SOC.
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late phase 2 and phase

that Occur on Studies under an IND/IDE within 30 Days of the Last Administration of the Investigational Agent/Intervention1, 2 FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) NOTE: Investigators **MUST** immediately report to the sponsor (NCI) **ANY** Serious Adverse Events, whether or not they are considered related to the investigational agent(s)/intervention (21 CFR 312.64)
An adverse event is considered serious if it results in ANY of the following outcomes:
1) Death 2) A life-threatening adverse event 3) An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 hours 4) A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
5) A congenital anomaly/birth defect.  
6) Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization may be considered serious when, based upon medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. (FDA, 21 CFR 312.32; ICH
E2A and ICH E6).
ALL SERIOUS adverse events that meet the above criteria **MUST** be immediately reported to the NCI via CTEP-AERS within the timeframes detailed in the table below.  
| Hospitalization               | Grade 1          | Timeframes       | Grade 3 Timeframes   | Grade 4 & 5   |
|-------------------------------|------------------|------------------|----------------------|---------------|
| Grade 2                       |                  |                  |                      |               |
| Timeframes                    | Timeframes       |                  |                      |               |
| Resulting in  Hospitalization | 10 Calendar Days |                  |                      |               |
| ≥ 24 hrs                      | 24-Hour 5        |                  |                      |               |
| Not resulting in              | Calendar Days    |                  |                      |               |
| Hospitalization               | Not required     | 10 Calendar Days |                      |               |
| ≥ 24 hrs                      |                  |                  |                      |               |  
NOTE: Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR
Expedited AE reporting timelines are defined as:
o "24-Hour; 5 Calendar Days" - The AE must initially be reported via CTEP-AERS within 24 hours of learning of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report.  
o "10 Calendar Days" - A complete expedited report on the AE must be submitted within 10 calendar days of learning of the AE.  
1Serious adverse events that occur more than 30 days after the last administration of investigational agent/intervention and have an attribution of possible, probable, or definite require reporting as follows: Expedited 24-hour notification followed by complete report within 5 calendar days for:
x All Grade 4, and Grade 5 AEs Expedited 10 calendar day reports for:
x Grade 2 adverse events resulting in hospitalization or prolongation of hospitalization x Grade 3 adverse events 2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, rounded UP to the nearest whole day, after the agent/intervention was last administered. Footnote "1" above applies after this reporting period. Effective Date: May 5, 2011
7.3.3 Additional Protocol-Specific Expedited Adverse Event Reporting Exclusions For this protocol only, the AEs/grades listed below do not require expedited reporting via CTEP-AERS. However, they still must be reported through the routine reporting mechanism (Section 7.4):  
| CTCAE                         | Adverse                                                                                     | Grades                           | Hospitalization/                                                                                          |                                                                                             |                     |
|-------------------------------|---------------------------------------------------------------------------------------------|----------------------------------|-----------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------|---------------------|
| SOC                           | Event                                                                                       | Prolongation of  Hospitalization | Attribution                                                                                               | Comments                                                                                    |                     |
| Renal and  urinary  disorders | Gross                                                                                       | 1 & 2                            | This AE should not                                                                                        |                                                                                             |                     |
| hematuria                     | lead to hospitalization  except in the event of  continuous bladder  irrigation (CBI)       | Intravesical                     | Can be managed with                                                                                       |                                                                                             |                     |
| BCG                           | oral hydration and  possible BCG dose  reduction (per PI  discretion)                       |                                  |                                                                                                           |                                                                                             |                     |
| Renal and  urinary  disorders | Cystitis (noninfective)                                                                                             | 1 & 2                            | This AE should not  lead to hospitalization  except in the event of  continuous bladder  irrigation (CBI) | Intravesical                                                                                | Can be managed with |
| BCG                           | oral anti-cholinergics or  analgesics and possible  BCG dose reduction  (per PI discretion) |                                  |                                                                                                           |                                                                                             |                     |
| Renal and                     | Frequency/                                                                                  | 1 & 2                            | This AE should not                                                                                        | Intravesical                                                                                | Can be managed with |
| urinary                       | urgency                                                                                     | lead to hospitalization          | BCG                                                                                                       | oral anti-cholinergics or  analgesics and possible  BCG dose reduction  (per PI discretion) |                     |
| Renal and                     | Bladder                                                                                     | 1 & 2                            | This AE should not                                                                                        | Intravesical                                                                                | Can be managed with |
| urinary                       | pain/spasms                                                                                 | lead to hospitalization          | BCG                                                                                                       | oral anti-cholinergics or  analgesics and possible  BCG dose reduction  (per PI discretion) |                     |
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7.4 routine adverse event reporting

All Adverse Events **must** be reported in routine study data submissions. AEs reported through CTEP-AERS must also be reported in routine study data submissions.
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7.5 nci-irb and clinical director

7.5.1 NCI-IRB and NCI CD Expedited Reporting of Unanticipated Problems and Deaths The Protocol PI will report in the NIH Problem Form to the NCI-IRB and the NCI Clinical Director:
x All deaths, except deaths due to progressive disease x All Protocol Deviations x All Unanticipated Problems x All non-compliance Reports must be received within 7 days of PI awareness via iRIS. 7.5.2 NCI-IRB Requirements for PI Reporting at Continuing Review The protocol PI will report to the NCI-IRB:
1. A summary of all protocol deviations in a tabular format to include the date the deviation occurred, a brief description of the deviation and any corrective action.  
2. A summary of any instances of non-compliance 3. A tabular summary of the following adverse events:
x All Grade 2 **unexpected** events that are possibly, probably or definitely related to the research; x All Grade 3 and 4 events that are possibly, probably or definitely related to the research; x All Grade 5 events regardless of attribution; x All Serious Events regardless of attribution.  
NOTE: Grade 1 events are not required to be reported.  
7.5.3 NCI-IRB Reporting of IND Safety Reports Only IND Safety Reports that meet the definition of an unanticipated problem will need to be reported to the NCI IRB.
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7.6 secondary malignancy

A *secondary malignancy* is a cancer caused by treatment for a previous malignancy (*e.g.*,
treatment with investigational agent/intervention, radiation or chemotherapy). A secondary malignancy is not considered a metastasis of the initial neoplasm. CTEP requires all secondary malignancies that occur following treatment with an agent under an NCI IND/IDE be reported via CTEP-AERS. Three options are available to describe the event:
x Leukemia secondary to oncology chemotherapy (*e.g.*, acute myelocytic leukemia
[AML])
x Myelodysplastic syndrome (MDS)
x Treatment-related secondary malignancy Any malignancy possibly related to cancer treatment (including AML/MDS) should also be reported via the routine reporting mechanisms outlined in each protocol.
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7.7 second malignancy

A second malignancy is one unrelated to the treatment of a prior malignancy (and is **NOT** a metastasis from the initial malignancy). Second malignancies require **ONLY** routine reporting via CDUS unless otherwise specified.
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7.8 nci guidance for reporting

The site PI must immediately report to the coordinating center PI any serious adverse event, whether or not considered drug related, including those listed in the protocol or investigator brochure and must include an assessment of whether there is a reasonable possibility that the drug caused the event within 24 hours of PI awareness of the event. The Site PI must also report any protocol deviations to the coordinating center PI within 7 days of PI awareness as per the form provided in Appendix D (Section **16.4**). Participating centers must also submit the report to their IRB in accordance with their institutional policies. The appendices will be made available to other participating sites.
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7.9 nih office of science

The Principal Investigator (or delegate) will notify OBA via email (HGTprotocols@mail.nih.gov) and IBC of any unexpected fatal or life-threatening experience associated with the use of the vaccine as soon as possible but in no event later than 7 calendar days of initial receipt of the information. Serious adverse events that are unexpected and associated with the use of the vaccine, but are not fatal or life-threatening, much be reported to NIH OSP/IBC as soon as possible, but not later than 15 calendar days after the sponsor's initial receipt of the information. Adverse events may be reported by using the Adverse Event Reporting template available on the NIH OSP website at: http://osp.od.nih.gov/officebiotechnology-activities/biomedical-technology-assessment/hgt/gemcris or by using the FDA
Form 3500a.
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7.9.2 annual reports to osp/ibc

The study Principal Investigator will submit to OSP via email (HGTprotocols@mail.nih.gov) and IBC a brief report annually of the progress of the trial within 60 days of the anniversary date that the IND went into effect unless the IND sponsor has been authorized to submit this report. Within 60 days after the one-year anniversary of the date on which the investigational new drug (IND) application went into effect, and after each subsequent anniversary until the trial is completed, the Principal Investigator (or delegate) shall submit the information described below. Alternatively, the FDA annual report can be sent to OSP/IBC in lieu of a separate report. Please include the OSP/IBC protocol number on the annual report, and the updated clinical protocol.
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7.9.2.1 clinical trial information

A brief summary of the status of each trial in progress and each trial completed during the previous year. The summary is required to include the following information for each trial:
x the title and purpose of the trial x clinical site x the Principal Investigator x clinical protocol identifiers including the NIH OSP protocol number, NIH grant number(s) (if applicable), and the FDA IND application number;  
x participant population (such as disease indication and general age group, e.g., adult or pediatric);
x the total number of participants planned for inclusion in the trial; the number entered into the trial to date whose participation in the trial was completed; and the number who dropped out of the trial with a brief description of the reasons x the status of the trial, e.g., open to accrual of subjects, closed but data collection ongoing, or fully completed,
x if the trial has been completed, a brief description of any study results.  
7.9.2.2 Progress Report and Data Analysis Information obtained during the previous year's clinical and non-clinical investigations, including:  
x a narrative or tabular summary showing the most frequent and most serious adverse experiences by body system x a summary of all serious adverse events submitted during the past year x a summary of serious adverse events that were expected or considered to have causes not associated with the use of the gene transfer product such as disease progression or concurrent medications x if any deaths have occurred, the number of participants who died during participation in the investigation and causes of death x a brief description of any information obtained that is pertinent to an understanding of the gene transfer product's actions, including, for example, information about dose-response, information from controlled trials, and information about bioavailability.
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7.10 data and safety monitoring

7.10.1 Principal Investigator/Research Team All data will be abstracted in a timely manner and entered into C3D. Adverse events will be reported as required above. Any safety concerns, or new information that might affect either the ethical and or scientific conduct of the trial will be reported to the IRB using iRIS to the Sponsor. The principal investigator will review adverse event and response data on each patient to ensure safety and data accuracy. The principal investigator will personally conduct or supervise the investigation and provide appropriate delegation of responsibilities to other members of the research staff. 7.10.2 Sponsor Monitoring Plan The Sponsor will monitor the protocol as described in Section **12.3**. 7.10.3 Safety Monitoring Committee This protocol will require oversight from the Safety Monitoring Committee (SMC). Initial review will occur as soon as possible after the annual NCI-IRB continuing review date. Subsequently, each protocol will be reviewed as close to annually as the quarterly meeting schedule permits or more frequently as may be required by the SMC. For initial and subsequent reviews, protocols will not be reviewed if there is no accrual within the review period. Written outcome letters will be generated in response to the monitoring activities and submitted to the Principal investigator and Clinical Director or Deputy Clinical Director, CCR, NCI.
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8 pharmaceutical information

A list of the adverse events and potential risks associated with the investigational agents or commercial agents administered in this study can be found in Section 7.1.
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8.1 ctep ind agents 8.1.1

Classification: Recombinant vaccinia virus vector vaccine of the genus *Orthopoxvirus.* Description: PANVAC-V is a recombinant vaccinia virus vector vaccine containing genes for human CEA, MUC-1 and three co-stimulatory molecules (designated TRICOM): B7.1, ICAM-1
(intercellular adhesion molecule-1), and LFA-3 (leukocyte function-associated antigen-3). The CEA gene coding sequence is modified to code for a single amino acid substitution (aspartic acid, instead of asparagine at amino acid position 609) in one 9-mer, HLA-A2-restricted, immunodominant epitope designed to enhance immunogenicity. The MUC-1 gene coding sequence is also modified to code for a single amino substitution (leucine, instead of threonine at amino acid position 93) in one 10-mer, HLA-A2-restricted, immunodominant epitope designed to enhance immunogenicity. TBC-vTRICOM, is used as the parental virus for this recombinant vaccine, and is generated by insertion of the genes for the three co-stimulatory molecules into an attenuated, live, derivative of the Wyeth (New York City Board of Health) strain of vaccinia virus. A plasmid vector containing the modified CEA and MUC-1 genes is used to transfect primary chicken embryo dermal (CED) cells infected with the parental vaccinia virus to generate the recombinant vaccinia virus. The final PANVAC-V recombinant vaccine is generated by infection of primary CED cells with the recombinant vaccinia virus. Vaccinia virus can infect mammalian cells and express the inserted transgenes, and is a potent immune stimulator, eliciting both a strong humoral and cellular immune response. Vaccinia virus is replication competent in mammalian cells, making systemic infections possible.
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how supplied

Lot: 2-050103: PANVAC-V is supplied by the Pharmaceutical Management Branch, CTEP, NCI
in vials containing 0.3 mL of the vaccine at a final viral concentration titer of 2.1 x 109 pfu/mL formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 6.3 x 108 pfu's). All other lots: PANVAC-V is supplied by the Pharmaceutical Management Branch, CTEP, NCI in vials containing 0.75 mL of the vaccine at a final viral concentration titer of 4 x 108 pfu/mL formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 3 x 108 pfu's). Note: The PANVAC-V concentration varies between lots, requiring changes to dose preparation instructions. *Use extreme caution when preparing each dose.* Preparation: Thaw vials completely at room temperature. Ensure the thawed contents are at the bottom of the upright vial and vortex vigorously at high power for at least ten seconds prior to dose preparation. Perform all dilutions of the vaccine with 0.9% sodium chloride for injection, USP and vortex all dilutions vigorously again for at least ten seconds prior to withdrawing the final dose. **Note the concentration of the current supply of PANVAC-V on your institutional** preparation guidelines to avoid potentially serious dosing errors.
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panvac™️-v (vaccinia) lot 2-050103 (2.1

Allow the contents of one vial to thaw completely at room temperature. Ensure the thawed contents are at the bottom of the upright vial and vortex vigorously at high power for at least ten seconds. Add 0.7 mL of 0.9% sodium chloride, USP to the thawed vial to yield 1 mL of PANVAC™-V (vaccinia) at a concentration of 6.3 x 108 pfu/mL. Vortex vigorously at high power for at least ten seconds. Withdraw 0.32 mL (2 x 108 pfu) for subcutaneous administration.
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panvac™️-v (vaccinia) all other lots

Allow the contents of one vial to thaw completely at room temperature. Ensure the thawed contents are at the bottom of the upright vial and vortex vigorously at high power for at least ten seconds. Withdraw 0.5 mL (2 x 108 pfu) for subcutaneous administration. Storage: Store intact vials of PANVAC-V at –70oC or colder.  
Stability: Shelf-life studies of the intact vials are ongoing. Once the intact vials are thawed, the vaccines maintain their potency for up to 4 days when stored at 2-8oC. Do not re-freeze thawed vials. Vials of PANVAC-V are for single-use only and do not contain a preservative. Administer prepared doses as soon as possible following preparation (i.e., within one hour). If necessary, store prepared doses at 2-8oC for up to 4 hours following preparation.  
Route of Administration: PANVAC-V is administered by subcutaneous injection.
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special handling and precautions

Vaccinia virus is classified as a Biosafety Level 2 agent. These agents are associated with human disease and are of moderate potential hazard to personnel and the environment. The recombinant vaccine is a preparation of a live virus affecting humans and contains DNA sequences derived from the human genome. Handle the recombinant vaccine as an infectious hazardous biological substance and dispose of waste materials as infectious hazardous biological waste, with incineration according to local institutional policies and according to local, state, and federal regulations.
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preparation handling and disposal recommendations

1. Prepare a biosafety manual which advises personnel of special hazards and specific instructions on practices and procedures.  
2. Post warning hazard signs on access doors, identifying the agents, the biosafety level, the name and phone number of the Principal Investigator or other responsible person, and any special requirements for entry.  
3. Establish policies and procedures allowing only personnel who are knowledgeable of the potential hazards and meet specific entry requirements (e.g., immunization) into agent preparation or storage areas.  
4. Strictly adhere to standard microbiological practices and techniques. 5. Limit/restrict access to preparation areas while dose preparation is in progress. 6. Use appropriate infection control measures (*e.g.*, thorough hand washing) after handling any materials.  
7. Institute and follow policies for safe handling of sharps. Use only needle-lock syringes and needles for dose preparation. Use extreme caution to prevent autoinoculation. Do not bend, shear, or replace the needle guard from the syringe following use. Promptly place used needles and syringes in puncture-resistant containers for disposal.  
8. Perform all dose preparations in a certified Class II biological safety cabinet, generally using procedures, guidelines and personal protective apparel used during preparation of antineoplastic agents [e.g., minimizing creation of aerosols; no eating, drinking, handling contact lenses or applying cosmetics in the work area; using appropriate personal protective apparel - gowns, sterile latex gloves (double-gloving is recommended), respirator masks, protective eye wear, hair cover].  
9. Perform all procedures carefully to minimize aerosol creation.  
10. Decontaminate the biological safety cabinet prior to dose preparation with sterile gauze soaked in 10% bleach solution (0.52% sodium hypochlorite solution), or other appropriate disinfectant suitable for decontamination, rinsing, then wiping down with sterile gauze soaked in 70% alcohol. Consult specific manufacturer's recommendations with respect to disinfectant concentration, contact time and method of application.  
11. Have all necessary supplies on-hand before beginning the preparation procedure. Develop a detailed worksheet outlining all supplies, dose calculations, and preparation procedures, and keep it available.  
12. Place an empty biohazard sharps container in the biosafety cabinet to dispose of all waste generated.  
13. Transport the agent from the –70oC freezer to the work area in leak proof bag.  
14. Wipe or spray items used for dose preparation with 70% alcohol before placing in the biological safety cabinet. Disinfectants should remain in contact with the surfaces for at least five minutes prior to dose preparation. Avoid exposing the virus to disinfectants.  
15. Wipe the syringe containing the prepared dose with 70% alcohol before removing it from the biological safety cabinet; transport it in a leak proof bag or container labeled with a biohazard symbol.  
16. Place all waste into a sharps container lined with the leak proof biohazard bag and decontaminate the biological safety cabinet again by wiping down all surfaces with sterile gauze soaked in 10% bleach solution, or other appropriate disinfectant, rinsing, then wiping down with sterile gauze soaked in 70% alcohol. Following decontamination, dispose of personal protective apparel in the biohazard safety bag.  
17. Place all waste and protective apparel in a leak proof biohazard bag, and place the bag inside a biohazard sharps container for incineration according to institutional policy and according to local, state, and federal regulations.  
18. Handle accidental spills similarly to antineoplastic spills and/or according to institutional policy:
x Prevent others from entering the area and allow aerosols time to settle (approximately 10 minutes).  
x Use protective apparel, eyewear, mask, and gloves.  
x Cover spills with disposable absorbent towels.  
x Decontaminate the area with 10% bleach solution, or other appropriate disinfectant suitable for decontamination, allowing approximately a 20-minute contact time.  
x Dispose of all waste and protective apparel as infectious biohazardous waste and incinerate according to institutional policy and according to local, state, and federal regulations.  
19. Immediately report spills and accidents resulting in overt exposure to recombinant DNA
molecules to the Institutional Biosafety Committee and NIH/OSP (Office of Science Policy). Send reports to the Office of Science Policy, National Institutes of Health, 6705 Rockledge Drive, Suite 750, MSC 7985, Bethesda, MD 20892-7985. Phone (301) 496-9838. Provide medical evaluation, surveillance, and treatment as appropriate and maintain written records of the event. For more information about biohazard risk group classification and biohazard safety levels:
x NIH Guidelines for Research Involving Recombinant DNA Molecules (NIH
Guidelines). See current version at: http://osp.od.nih.gov/sites/default/files/resources/NIH_Guidelines.pdf x Biosafety in Microbiological and Biomedical Laboratories; U. S. Department of Health and Human Services Centers for Disease Control and Prevention and National Institutes of Health. See current edition at: http://www.cdc.gov/biosafety/publications/index.htm
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precautions for healthcare workers

Recombinant vaccinia virus transmission risk to exposed healthcare workers is unknown. To date, no reports of transmission to healthcare personnel from vaccine recipients have been published. If appropriate infection control precautions are observed (such as covering the vaccination site and washing hands after contact with the vaccination site or bandages),
healthcare workers are probably at less risk of infection than laboratory workers because of the smaller volume and lower titers of virus in clinical specimens as compared with laboratory material. However, because of the potential risk for transmission, healthcare personnel who prepare or administer doses of recombinant vaccinia vaccine or have direct contact with contaminated dressings or other infectious material from participants in clinical studies must adhere to appropriate infection control measures and should be offered vaccination with the licensed vaccinia vaccine. Do not administer routine, non-emergency vaccination with the licensed vaccinia vaccine to healthcare workers, if they, or for at least three weeks after vaccination, their close household contacts (close household contacts are those who share housing or have close physical contact):
x have active eczema or a history of eczema or atopic dermatitis, or Darier's disease. x have other acute, chronic, or exfoliative skin conditions (e.g., burns, impetigo, varicella zoster, severe acne, or other open rashes or wounds), until the condition resolves.  
x are pregnant or intend to become pregnant within 4 weeks of vaccination or are breast-feeding. x are immunodeficient or immunocompromised (by disease or therapy), including HIV
infection.  
Additionally, do not administer routine, non-emergency vaccination with the licensed vaccinia vaccine to healthcare workers if the vaccinee:
x has a moderate or severe acute illness, until the illness resolves. x is less than 18 years of age, unless specifically indicated.  
x is undergoing topical steroid therapy for inflammatory eye diseases or undergoing therapy with systemic steroids; potential immune suppression increases risk for vaccinia-related complications.  
x has a history of allergy or serious reaction to prior vaccinia vaccination or any of the vaccine's components.  
x As a precaution, the CDC recommends that individuals with known cardiac disease (e.g.,
previous MI, angina, CHF, cardiomyopathy, stroke or TIA) or who have > 3 known risk factors for cardiac disease (e.g., hypertension, hypercholesterolemia, diabetes, first degree relative with onset of cardiac complications prior to age 50, smoker), not receive routine, non-emergency, prophylactic vaccination with the licensed vaccinia vaccine while a possible causal relationship between vaccination and cardiac events is being evaluated.  
Avoid exposure to the recombinant vaccinia vaccine, any contaminated dressings, or other infectious materials from patients, or the patient's inoculation site if you are pregnant or breastfeeding; have a history or presence of active eczema or atopic dermatitis; have acute, chronic or exfoliative skin conditions; or, are immunocompromised. More information on vaccinia precautions for healthcare workers can be obtained from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5010a1.htm\#tab2 and http://www.cdc.gov/mmwr/PDF/rr/rr5207.pdf. The CDC is the only source of the licensed vaccinia vaccine. The CDC will provide vaccinia vaccine to protect laboratory and other healthcare personnel, whose occupations place them at risk of exposure to vaccinia and other closely related orthopoxviruses, including vaccinia recombinants. The vaccine should be administered under the supervision of a physician selected by the study institution. Revaccination is recommended every 10 years. For instructions on obtaining the licensed vaccinia vaccine, contact Drug Services, National Center for Infectious Diseases, CDC at (404) 639-3670.
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recombinant vaccinia vaccine patient care

Cover vaccination sites with a sterile dry dressing (e.g., Telfa pad). Instruct patients on proper handhygiene, sterile dressing care, bathing, laundering of clothing, etc. Treat patient bandages or dressings removed from the vaccination site as infectious waste and dispose in appropriate biohazard containers. Do not administer the recombinant vaccinia vaccine if the recipient, or for at least three weeks after vaccination, their close household contacts (close household contacts are those who share housing or have close physical contact):
x have active eczema or a history of eczema or atopic dermatitis, or Darier's disease.  
x have other acute, chronic, or exfoliative skin conditions (e.g., burns, impetigo, varicella zoster, severe acne, contact dermatitis, psoriasis, herpes or other open rashes or wounds), until the condition resolves.  
x are pregnant or intend to become pregnant (due to the potential risk of fetal vaccinia); or are breast-feeding (due to the potential risk of contact transmission and inadvertent inoculation). It is currently unknown if vaccinia virus or antibodies are excreted in breast milk. Because there is no safety data available, patients (i.e., vaccinees) should avoid becoming pregnant, fathering a child, or breast-feeding for at least 4 months following completion of therapy with the recombinant vaccine.  
x are in close contact with children less than 3 years of age (due to the potential risk of contact transmission and inadvertent inoculation).  
x are immunodeficient or immunocompromised (by disease or therapy), including individuals with HIV infection.  
Additionally, do not administer the recombinant vaccinia vaccine if the vaccinee:  
x has a moderate or severe acute illness, until the illness resolves.  
x is undergoing topical steroid therapy for inflammatory eye diseases, or undergoing therapy with systemic steroids; potential immune suppression increases risk for vaccinia-related complications.  
x At this time, until a more definitive causal relationship is determined, it is recommended that patients with known CHF or clinically significant cardiomyopathy, not be vaccinated with recombinant vaccinia-based vaccines, due to the potential for development of myocarditis and/or pericarditis.
Although the CDC believes that there is no evidence to conclude that the licensed vaccinia vaccine used in the Smallpox Vaccination Program caused angina or heart attacks, it acknowledges a possible causal relationship between the vaccination and heart inflammation.  
The CDC continues to study the relationship, but in the meantime, recommends excluding individuals with underlying heart disease from participation in the current Smallpox Vaccination Program. Patients are being immunized with recombinant vaccinia vaccines with therapeutic intent and will be evaluated for cardiovascular risk factors and recent or symptomatic cardiac events per protocol eligibility criteria. Patients will be encouraged to minimize cardiovascular disease risks and encouraged to follow risk reduction according to standard medical practice.  
Due to the method of manufacturing (virus grown in primary chicken embryo dermal cells), do not administer the recombinant vaccinia vaccine to patients with a history of allergy to eggs or egg products. Do not administer the recombinant vaccinia vaccine to patients with a history of allergy or serious reaction to prior vaccinia vaccination (e.g., smallpox vaccination).
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potential complications associated with recombinant

When vaccinia vaccine is administered by scarification for vaccination against smallpox, expected local reactions in individuals that have not previously been vaccinated with vaccinia include the appearance of a red papule in 3-4 days, followed by vesiculation in 5-6 days, and then the formation of a pustule on days 8-9. A large area of erythema may surround the vesicle and pustule. A crusted scab usually forms by the second week and sloughs by the third week, leaving a well-formed scar. Maximal viral shedding occurs from days 4-14, but can continue until the scab is shed from the skin. Other normal local reactions can include development of local satellite lesions, regional lymphadenopathy that can persist for weeks following healing of the skin lesion, considerable local edema, and intense inflammation from the vaccination (i.e., viral cellulites), which may be confused with bacterial cellulites. Systemic symptoms typically occur between 8-10 days post-vaccination and include fever, malaise, headache, chills, nausea, myalgia, local lymphadenopathy, soreness and intense erythema surrounding the vaccination site. When administered by scarification in individuals that have previously been vaccinated with vaccinia, expected local reactions include the appearance of a clear cut pustule 6-8 days following vaccination or the development of an area of definite induration around a central lesion that may be an ulcer or scab 6-8 days following vaccination. The response to re-vaccination depends on the degree of residual immunity following previous vaccination. Similar systemic symptoms may occur, but typically at a lower frequency. When recombinant vaccinia vaccines are administered by intradermal, intralesional, subcutaneous or intramuscular routes of injection, milder local reactions are expected, but similar systemic symptoms may occur. There have been a number of complications reported in the literature associated with vaccinia vaccination for smallpox. Reported complications from vaccinia vaccine when given by scarification include: a) auto-inoculation of other sites with vaccinia, b) generalized vaccinia, c) eczema vaccinatum, d) progressive vaccinia (vaccinia necrosum), or e) post-vaccinial encephalitis. In a 1968 ten-state survey, cases of these complications per million vaccinations in adult recipients (> 20 years of age) of vaccinia primary vaccination and revaccination were:  
| Primary Vaccination        | Revaccination   |     |
|----------------------------|-----------------|-----|
| auto-inoculation           | 606.1           | 25  |
| generalized vaccinia       | 212.1           | 9.1 |
| eczema vaccinatum          | 30.3            | 4.5 |
| progressive vaccinia       | none reported   | 6.8 |
| postvaccinial encephalitis | none reported   | 4.5 |  
Based on a 1968 national survey, the number of deaths in primary vaccinees was approximately 1 per million and the number of deaths in recipients of revaccination was approximately 0.25 per million. Deaths were most often the result of postvaccinial encephalitis or progressive vaccinia.  
Information has been reported by the US Department of Defense (DoD) during the postvaccination surveillance assessment of adverse events in military personnel following implementation of a smallpox vaccination program from the period of December 13, 2002 through May 28, 2003. Although not directly comparable to historical numbers, due to differences in multiple population variables, estimated cases (number of cases per million vaccinations based on vaccination of 450,293 personnel, with a median age of 26 years and 70.5% as primary vaccinees) of these same complications per million vaccinations were:  
| auto-inoculation           | 107           |
|----------------------------|---------------|
| generalized vaccinia       | 80            |
| eczema vaccinatum          | none reported |
| progressive vaccinia       | none reported |
| postvaccinial encephalitis | 2.2           |  
Generally, self-limited adverse reactions that can be serious, but not life-threatening include autoinoculation, erythematous and urticarial rashes, and generalized vaccinia. More serious lifethreatening complications include progressive vaccinia, eczema vaccinatum, and post-vaccinial encephalitis/encephalomyelitis. The complications of vaccinia vaccination may involve a number of different reactions:
1. **Non-specific erythematous or urticarial rashes:** These rashes can appear approximately 10 days after vaccination and may sometimes be confused with generalized vaccinia, but are generally self-limiting. Patients are usually afebrile and these benign rashes usually resolve spontaneously within 2-4 days. Erythema multiforme can present as different types of lesions, including macules, papules, urticaria, and bull's eye lesions (dark papule or vesicle surrounded by a pale zone and an area of erythema). These lesions may be extremely pruritic, lasting up to four weeks. Rarely, more serious bullous erythema multiforme (Stevens-Johnson syndrome) may occur, requiring hospitalization. Vaccinia Immune Globulin (VIG) therapy is not indicated to treat these rashes. Supportive care measures are warranted since these rashes are likely manifestations of an immune response or hypersensitivity reaction to the vaccine and are not likely to contain vaccinia virus.  
2. **Bacterial Infection:** Vaccination site infection, most likely due to staphylococcus and streptococcus normal skin flora, is rare. Onset is approximately 5 days post-vaccination and is more common in children. Appropriate antibiotic therapy is required.  
3. **Inadvertent Inoculation**: This can occur in the vaccinee (autoinoculation) as well as in close contacts (contact transmission). Accidental infection is the most common complication of vaccinia vaccination, accounting for approximately 50% of all complications associated with vaccination and revaccination. This usually results from autoinoculation of vaccinia virus transferred from the site of the vaccination. Sites typically involved include the face, eyelids, nose, mouth, genitalia, or rectum, but can also involve the arms, legs, and trunk. Contact transmission of vaccinia, with accompanying toxicities, may occur when a recently vaccinated individual has contact with a susceptible individual. In a 1968 ten-state survey, contact transmissions were reported to occur at a rate of 27 infections per million vaccinations. The age group in which contact transmission occurred most commonly was in children d 5 years. Eczema vaccinatum as a result of contact transmission may result in a more severe syndrome than that seen in vaccinees, perhaps because of multiple simultaneous inoculations. About 30% of eczema vaccinatum cases reported in the 1968 ten-state survey were a result of contact transmission. It is possible that the number of cases of contact transmission would be greater in today's population, due to a largely unvaccinated patient population against smallpox. Contact transmission rarely results in postvaccinial encephalitis or progressive vaccinia. Most cases of inadvertent inoculation usually resolve without specific therapy and resolution of lesions follow the same course as the vaccination site in immunocompetent individuals. VIG can be used for severe cases involving extensive lesions or if comorbid conditions exist. VIG is contraindicated in the presence of isolated keratitis due to the risk of increased corneal scarring. VIG use can be considered in cases of ocular implantation, with keratitis, if vision-threatening or if other life-threatening vaccinia-related complications exist that require VIG therapy.  
4. **Generalized vaccinia:** Generalized vaccinia is characterized by a disseminated maculopapular or vesicular rash of varying extent on any part of the body and typically develops 6-9 days after vaccination. The lesions follow the same course as the vaccination site lesion. The lesions are hematogenously spread and may contain vaccinia virus. In immunocompetent individuals, the rash is generally self-limiting and requires supportive care therapy. VIG treatment can be used in severe cases for patients who are systemically ill and whose condition might be toxic or who have serious underlying immunosuppressive illnesses. The differential diagnosis of GV includes eczema vaccinatum, erthyema multiforme, inadvertent inoculation at multiple sites, and uncommonly, early stages of progressive vaccinia or other vesicular diseases (*e.g.*, severe chickenpox or disseminated herpes). Several publications have investigated the reporting of GV among those individuals who received smallpox vaccinations during 2003. Out of 38,440 vaccine recipients, 29 reports of possible GV during January 2003–December 2003 were identified but only 2 reports met the case definition. More than 75% of the reports received a final diagnosis of hypersensitivity reaction or nonspecific rash after review by dermatologists or because laboratory results were negative for vaccinia and other orthopox viruses. Of 74 cases investigated in 753,226 smallpox vaccinations administered in December 2002 to December 2004, 50 (67.6%) met the case definition of possible GV. Cases occurred more frequently in primary vaccinees (rate, 81 per 1 million vaccinees) than in those revaccinated (rate, 32 per 1 million vaccinees). However, none met the case definition of probable or confirmed GV, including 15 with virologically negative laboratory evaluations (*e.g.*, culture, polymerase chain reaction, or skin biopsy). Twenty-one reports of postscab lesions were made between January and August 2003 among 37,542 smallpox vaccinees. The lesions (scab and/or fluid) of seven patients were tested for vaccinia virus by use of polymerase chain reaction and/or immunohistochemistry; all were found to be negative. In addition, the postscab lesions of four of the patients were biopsied. The results from two of the biopsies suggested an allergic contact dermatitis, and results of one each demonstrated chronic dermatitis and squamous cell carcinoma. None of the four biopsied lesions had histologic evidence of viropathic changes and no evidence supported smallpox vaccination as a cause for any of the lesions.  
5. **Eczema vaccinatum:** Eczema vaccinatum is a serious complication in persons with eczema and other types of chronic or exfoliative skin conditions. It can also occur among eczematous contacts of recently vaccinated persons. Vaccinial lesions (generalized papular, vesicular or pustular lesions) develop on areas of the skin that are, or had at one time been, eczematous. These areas become highly inflamed and lesions may spread to healthy skin. The rash is often accompanied by fever and individuals are systemically ill. The fatality rate for untreated cases (prior to availability of VIG) has been reported from 30-40%. Following availability of VIG, mortality was reduced to approximately 7%. Early diagnosis and prompt treatment with VIG is necessary to reduce mortality.  
6. **Progressive vaccinia:** Progressive vaccinia is the most serious cutaneous complication, occurring when the local vaccination lesion fails to heal and develops progressive necrosis, with destruction of large areas of skin, subcutaneous tissue, and underlying structures. Progressive lesions may spread to other skin surfaces and to bone and viscera. Progressive vaccinia is associated with a high mortality rate. This complication has been seen in patients with a compromised immune system due to a congenital deficiency, lymphoproliferative disease, immunosuppressive treatment, or HIV infection. Management should include aggressive VIG therapy.  
7. **Post-Vaccinial Encephalitis/Encephalomyelitis**: Vaccinial complications affecting the CNS are unpredictable. Post-vaccinial encephalitis typically affects children < 2 years of age and is characterized by an onset of symptoms 6-10 days following vaccination, which include seizures, hemiplegia, aphasia, and transient amnesia. Histopathological changes include generalized cerebral edema, mild lymphocytic meningeal infiltration, ganglion degenerative changes and perivascular hemorrhages. Older children and adults can develop encephalitis or encephalomyelitis characterized by an onset of symptoms 11-15 days following vaccination, which include fever, vomiting, headache, malaise, and anorexia, progressing to loss of consciousness, amnesia, confusion, disorientation, restlessness, delirium, drowsiness, seizures and coma. Histopathological changes include demyelination with lymphocytic infiltration, but limited cerebral edema. Mortality rates have ranged from 15-25%, with 25% of patients who recover being left with varying degrees and types of neurological deficits. VIG has not been shown to be effective in treating CNS disease and is not recommended. Post-vaccinial encephalitis/encephalomyelitis are diagnoses of exclusion and are not believed to be a result of replicating vaccinia virus. Although no specific therapy exists, supportive care, anticonvulsants, and intensive care might be required. A review of vaccinia-related deaths (68) during a 9-year period (1959–1966 and 1968) revealed that among first-time vaccines, 36 (52%) patients died as a result of post-vaccinial encephalitis.  
8. **Fetal Vaccinia**: Fetal vaccinia is a rare, but serious complication following vaccinia vaccination during pregnancy or shortly before conception (e.g., within four weeks). To date, fewer than 50 cases have been reported and often result in fetal or neonatal death. Efficacy of VIG therapy in a viable infant or used prophylactically in women during pregnancy is unknown. The CDC has established a National Smallpox Vaccine in Pregnancy Registry. This registry will follow women during their pregnancies and their babies, after they are born, to determine the outcome of such pregnancies. The CDC can be contacted at (404) 639-8253.  
9. **Myocarditis/Pericarditis:** The CDC has recommended a temporary medical deferral to the voluntary Smallpox Vaccination Program for persons with heart disease or cardiovascular risk factors (March 25, 2003) and issued "interim supplementary information" regarding evidence that smallpox vaccination may cause myocarditis and/or pericarditis (March 31, 2003) in people recently vaccinated with the smallpox vaccine. The cardiac events reported include myocardial infarction, angina, myocarditis, pericarditis, and myopericarditis. Although the CDC believes that there is no evidence to conclude that the licensed vaccinia vaccine causes angina or heart attacks, it acknowledges a possible causal relationship between the vaccination and heart inflammation. The CDC continues to study the relationship, but in the meantime, recommends that individuals with underlying heart disease be excluded from participation in the current Smallpox Vaccination Program. While it is currently not possible to fully evaluate the risk of cardiac events or the risk of myocarditis, pericarditis, or myopericarditis associated with vaccinia vaccination, it is reasonable to inform patients participating in studies using recombinant vaccinia virus of these reports and provide relevant guidance for evaluating these events. Further investigation from the ongoing vaccine program may provide additional data regarding an association or lack of association with cardiovascular disease. Patients are being immunized with recombinant vaccinia vaccines with therapeutic intent and will be evaluated for cardiovascular risk factors and recent or symptomatic cardiac events per protocol eligibility criteria. Patients will be encouraged to minimize cardiovascular disease risks and encouraged to follow risk reduction according to standard medical practice. At this time the evidence for an association with myocarditis, pericarditis, or myopericarditis seems plausible, but a rare event. If not otherwise excluded, patients with known CHF or clinically significant cardiomyopathy requiring treatment should be excluded from protocol eligibility. Out of a total of 540,824 military personnel vaccinated with a New York City Board of Health strain of vaccinia from December 2002 through December 2003, 67 developed symptomatic myopericarditis. In the 61 ECGs that were reviewed, an identifiable abnormality was evident in 46 (75.4%). The most common abnormalities included STsegment changes observed evident in 40 patients (65.6%); 5 patients (8.2%) had normal variant early repolarization, and T-wave abnormalities were noted in 11 patients (18.0%). In addition, cardiac enzymes were elevated in 60 of 61 (98.4%) patients evaluated with this assay. On follow-up of 64 patients, all patients had objective normalization of electrocardiography, echocardiography, graded exercise testing, laboratory testing, and functional status; 8 (13%) reported atypical, non-limiting persistent chest discomfort. Among 37,901 health care workers vaccinated with the identical strain, 21 myo/pericarditis cases were identified; 18 (86%) were revacinees. Twelve met criteria for either myocarditis or myopericarditis, and 9 met criteria for pericarditis only (6 suspected and 3 probable). The severity of myo/pericarditis was mild, with no fatalities, although 9 patients (43%) were hospitalized.
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treatment of vaccinia vaccination complications

Vaccinia Immune Globulin (VIG): First-line treatment of some of the complications of vaccinia caused by dissemination of vaccinia virus (severe cases of inadvertent inoculation involving extensive lesions or if comorbid conditions exist, severe cases of generalized vaccinia in patients that are systemically ill and whose condition might be toxic or who have serious underlying immunosuppressive illnesses, eczema vaccinatum, and progressive vaccinia) is with VIG. VIG is contraindicated, however, for the treatment of isolated vaccinial keratitis. VIG is a sterile solution of the immunoglobulin fraction of pooled plasma from individuals inoculated with vaccinia vaccine. VIG is only available through the CDC's Strategic National Pharmaceutical Stockpile by contacting the CDC's Clinician Information Line at 1-877-5544625 or the Director's Emergency Operations Center (DEOC) at 770-488-7100. Upon receipt of a call from a patient or upon direct observation of a patient or contact who manifests signs and symptoms of any of the above conditions, the investigator should place a call to the CDC as soon as possible: 1) to initiate review of the clinical case, 2) to seek consultation on the appropriateness of VIG therapy, 3) to determine the appropriate VIG dose and dosing method for administration, if VIG therapy is required, and 4) to determine how to access and have the appropriate doses of VIG delivered. Early institution of VIG therapy is advised following recognition of clinical symptoms compatible with some vaccinia complications (eczema vaccinatum, severe generalized vaccinia, progressive vaccinia, and some cases of inadvertent inoculation). The effectiveness of VIG therapy appears to be time dependent. VIG has not proven to be of benefit in the treatment of post-vaccinial encephalitis, and is contraindicated for treatment of isolated vaccinial keratitis due to the increased risk of corneal scarring. A new IV formulation of VIG that has a lower level of aggregated protein allowing it to be used by either the IM or IV route is available through the CDC. This formulation will most likely be preferred for administration and the CDC will instruct investigators regarding appropriate dosing and method of administration based on the formulation and availability. There is no guarantee that VIG will successfully treat complications. At present, there are no other anti-viral therapies of proven benefit for the treatment of vaccinia-related complications. Cidofovir (Vistide®, Gilead Sciences): Cidofovir is an FDA-approved antiviral drug for the treatment of CMV retinitis among patients with AIDS. Cell-based *in vitro* studies and animal model studies have demonstrated this agent's antiviral activity against certain orthopoxviruses. Currently, its efficacy in the treatment of vaccinia-related complications in humans is unknown. According to the CDC, VIG is recommended as first line of therapy. Cidofovir may be considered as a secondary treatment, and will only be used when VIG therapy is not effective [Medical Management of Smallpox (Vaccinia) Vaccine Adverse Reactions: Vaccinia Immune Globulin and Cidofovir. Last updated February 21, 2003. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5204a1.htm ]. The CDC has informed the NCI/CTEP that cidofovir will not be supplied through Strategic National Pharmaceutical Stockpile to investigators involved in CTEP-sponsored protocols utilizing recombinant vacciniabased vaccines. Thus, investigators should obtain cidofovir for second-line therapy through commercial sources if necessary. Investigators should consult the CDC Clinician Information Line at 1-877-554-4625 or the Director's Emergency Operations Center (DEOC) at 770-4887100 regarding appropriateness of therapy and guidance.
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8.1.2 panvac-f (nsc 727027)

Other Names: Recombinant-Fowlpox-CEA(D609)/MUC-1(L93)/TRICOM
Classification: Recombinant fowlpox virus vector vaccine of the genus *Avipoxvirus.* Product Description: PANVAC-F is a recombinant fowlpox virus vector vaccine containing genes for human CEA, MUC-1 and three co-stimulatory molecules (designated TRICOM):
B7.1, ICAM-1 (intercellular adhesion molecule-1), and LFA-3 (leukocyte function-associated antigen-3). The CEA gene coding sequence is modified to code for a single amino acid substitution (aspartic acid, instead of asparagine at amino acid position 609) in one 9-mer, HLAA2-restricted, immunodominant epitope designed to enhance immunogenicity. The MUC-1 gene coding sequence is also modified to code for a single amino substitution (leucine, instead of threonine at amino acid position 93) in one 10-mer, HLA-A2-restricted, immunodominant epitope designed to enhance immunogenicity. An attenuated, live, plaque-purified isolate from the POXVAC-TC strain of fowlpox virus was used as the parental virus for this recombinant vaccine. A plasmid vector containing the modified CEA and MUC-1 genes and a plasmid vector containing the genes for the three co-stimulatory molecules were used to transfect primary chicken embryo dermal (CED) cells infected with the parental virus to generate the recombinant fowlpox virus. The final PANVAC-F recombinant vaccine is manufactured by infection of primary CED cells with the recombinant fowlpox virus. Fowlpox virus can infect mammalian cells and express the inserted transgenes to stimulate both humoral and cellular immunity, but cannot replicate in non-avian species, making systemic infections unlikely.
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how supplied

Lot: 3-052203: PANVAC-F is supplied by the Pharmaceutical Management Branch, CTEP, NCI in vials containing 0.3 mL of the vaccine at a final viral concentration titer of 5.8 x 109 pfu/mL formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 1.74 x 109 pfu's). All other lots: PANVAC-F is supplied by the Pharmaceutical Management Branch, CTEP, NCI in vials containing 0.75 mL of the vaccine at a final viral concentration titer of 2 x 109 pfu/mL formulated in phosphate-buffered saline containing 10% glycerol (total vial contents = 1.5 x 109 pfu's).
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note the panvac-f concentration may

Preparation: Thaw vials completely at room temperature. Ensure the thawed contents are at the bottom of the upright vial and vortex vigorously at high power for at least ten seconds prior to dose preparation. Perform all dilutions of the vaccine with 0.9% sodium chloride for injection, USP and vortex all dilutions vigorously again for at least ten seconds prior to withdrawing the final dose. **Note the concentration of the current supply of PANVAC-F on your institutional** preparation guidelines to avoid potentially serious dosing errors.
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panvac-f (fowlpox) lot 3-052203 (5.8

Thaw one vial completely at room temperature. Ensure the thawed contents are at the bottom of the upright vial and vortex vigorously at high power for at least 10 seconds. Withdraw 0.18mL (1 x 109 pfu) from the thawed vial for subcutaneous injection.
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panvac-f (fowlpox) all other lots

Thaw one vial completely at room temperature. Ensure the thawed contents are at the bottom of the upright vial and vortex vigorously at high power for at least 10 seconds. Withdraw 0.5mL (1 x 109 pfu) from the thawed vial for subcutaneous injection.  
Storage: Store intact vials of PANVAC-F at –70oC or colder.  
Stability: Shelf-life stability studies of the intact vials are ongoing. Once the intact vials are thawed, the vaccines maintain their potency for up to 4 days when stored at 2-8oC. Do not re-freeze thawed vials. Vials of PANVAC-F are for single-use only and do not contain a preservative. Administer prepared doses as soon as possible following preparation (i.e., within one hour). If necessary, store prepared doses at 2-8oC for up to 4 hours following preparation.  
Route of Administration: PANVAC-F is administered by subcutaneous injection. Other routes of administration have been studied. Refer to protocol for specific information.
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special handling

Fowlpox virus is classified as a Biosafety Level 1 agent. These agents are not known to cause disease in healthy human adults and are of minimal potential hazard to personnel and the environment under ordinary conditions of use. Clinicians can use techniques generally acceptable for nonpathogenic material. The recombinant vaccine is a preparation of a live virus (infectious for birds) containing DNA sequences derived from the human genome. Handle the recombinant vaccine as a hazardous biological substance and dispose of waste materials as hazardous biological waste, with incineration according to local institutional policy and according to local, state, and federal regulations. Healthcare workers handling the recombinant fowlpox vaccine should avoid direct contact with pet birds for at least 72 hours after working with the agent.
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preparation handling and disposal recommendations

1. Strictly adhere to standard microbiological practices and techniques. 2. Limit/restrict access to preparation areas while dose preparation is in progress. 3. Use appropriate infection control measures (e.g., thorough hand washing) after handling any materials.  
4. Institute and follow policies for safe handling of sharps. 5. Perform all dose preparations in a certified Class II biological safety cabinet, generally using procedures, guidelines and personal protective apparel used during preparation of antineoplastic agents [e.g., minimizing creation of aerosols; no eating, drinking, handling contact lenses or applying cosmetics in the work area; using appropriate personal protective apparel - gowns, sterile latex gloves (double-gloving is recommended), respirator masks, protective eye wear, hair cover].  
6. Decontaminate the biological safety cabinet prior to dose preparation with sterile gauze soaked in 10% bleach solution (0.52% sodium hypochlorite solution), or other appropriate disinfectant suitable for decontamination, rinsing, then wiping down with sterile gauze soaked in 70% alcohol. Consult specific manufacturer's recommendations with respect to disinfectant concentration, contact time and method of application.  
7. Have all necessary supplies on-hand before beginning the preparation procedure. Develop a detailed worksheet outlining all supplies, dose calculations, and preparation procedures, and keep it available.  
8. Place an empty biohazard sharps container lined with a leak-proof biohazard bag in or near the biosafety cabinet to dispose of all waste generated.  
9. Transport the agent from the –70oC freezer to the work area in leak proof bag.  
10. Wipe or spray items used for dose preparation with 70% alcohol before placing in the biological safety cabinet. Disinfectants should remain in contact with the surfaces for at least five minutes prior to dose preparation. Avoid exposing the virus to disinfectants.  
11. Wipe the syringe containing the prepared dose with 70% alcohol before removing it from the biological safety cabinet; transport it in a leak proof bag or container labeled with a biohazard symbol.  
12. Place all waste into the sharps container lined with the leak proof biohazard bag and decontaminate the biological safety cabinet again by wiping down all surfaces with sterile gauze soaked in 10% bleach solution, or other appropriate disinfectant, rinsing, then wiping down with sterile gauze soaked in 70% alcohol. Following decontamination, dispose of personal protective apparel in the biohazard safety bag.  
13. Incinerate waste according to institutional policy and according to local, state, and federal regulations.  
14. Handle accidental spills similarly to antineoplastic spills and/or according to institutional policy:
x Prevent others from entering the area and allow aerosols time to settle (approximately 10 minutes).  
x Use protective apparel, eyewear, mask, and gloves.  
x Cover spills with disposable absorbent towels. x Decontaminate the area with 10% bleach solution, or other appropriate disinfectant suitable for decontamination, allowing approximately a 20-minute contact time.  
x Dispose of all waste as biohazardous waste and incinerate according to institutional policy and according to local, state, and federal regulations.  
15. Immediately report spills and accidents resulting in overt exposure to recombinant DNA
molecules to the Institutional Biosafety Committee and NIH/OSP (Office of Science Policy). Send reports to the Office of Science Policy, National Institutes of Health, 6705 Rockledge Drive, Suite 750, MSC 7985, Bethesda, MD 20892-7985. Phone (301) 496-9838. Provide medical evaluation, surveillance, and treatment as appropriate and maintain written records of the event.  
For more information about biohazard risk group classification and biohazard safety levels:
x NIH Guidelines for Research Involving Recombinant DNA Molecules (NIH
Guidelines). See current version at:
http://osp.od.nih.gov/sites/default/files/resources/NIH_Guidelines.pdf x Biosafety in Microbiological and Biomedical Laboratories; U. S. Department of Health and Human Services Centers for Disease Control and Prevention and National Institutes of Health. See current edition at: http://www.cdc.gov/biosafety/publications/index.htm
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patient care implications

Cover vaccination sites with a sterile dry dressing (e.g., Telfa pad). Once the injection site is healed, no further barrier is necessary. As a precaution, protect injection sites that are exhibiting evidence of weeping, oozing or ulceration with a sterile dry dressing. In these circumstances, instruct patients to avoid direct contact of the injection site with susceptible individuals (e.g.; those who may be immunocompromised by disease or therapy). Instruct patients to avoid becoming pregnant, breast feeding or fathering a child for at least 4 months following therapy completion with the recombinant vaccine. Instruct patients receiving fowlpox vaccines to avoid direct contact with pet birds for at least 72 hours after vaccination or while there are any visible lesions at the injection site. Due to the method of manufacturing (virus grown in primary chicken embryo dermal cells), patients with a history of allergy to eggs or egg products should not receive the vaccine.
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8.1.3 agent procurement 8.1.3.1 agent

NCI-supplied PANVAC-V (NSC 727026) and PANVAC-F (NSC 727027) may be requested by the Principal Investigator (or their authorized designee) at each participating institution. Pharmaceutical Management Branch (PMB) policy requires that agent be shipped directly to the institution where the patient is to be treated. PMB does not permit the transfer of agents between institutions (unless prior approval from PMB is obtained.) The CTEP assigned protocol number must be used for ordering all CTEP supplied investigational agents. The responsible investigator at each participating institution must be registered with CTEP, DCTD through an annual submission of FDA form 1572 (Statement of Investigator), Curriculum Vitae, Supplemental Investigator Data Form, and Financial Disclosure Form. If there are several participating investigators at one institution, CTEP supplied investigational agents for the study should be ordered under the name of one lead investigator at that institution. Active CTEP-registered investigators and investigator-designated shipping designees and ordering designees can submit agent requests through the PMB Online Agent Order Processing (OAOP) application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx). Access to OAOP requires the establishment of a CTEP Identity and Access Management (IAM) account (https://eapps-ctep.nci.nih.gov/iam/) and the maintenance of an "active" account status and a "current" password. For questions about drug orders, transfers, returns, or accountability, call 240-276-6575 Monday through Friday between 8:30 am and 4:30 pm (ET) or email PMBAfterHours@mail.nih.gov anytime. 8.1.3.2 Agent Inventory Records The investigator, or a responsible party designated by the investigator, must maintain a careful record of the inventory and disposition of all agents received from DCTD using the NCI Drug Accountability Record Form (DARF). (See the NCI Investigator's Handbook for Procedures for Drug Accountability and Storage.)
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8.2 commercial agent 8.2.1 tice

(Please see package insert for complete drug information)
8.2.1.1 Indications and Usage TICE® BCG is indicated for the treatment and prophylaxis of carcinoma *in situ* (CIS) of the urinary bladder, and for the prophylaxis of primary or recurrent stage Ta and/or T1 papillary tumors following transurethral resection (TUR). TICE® BCG is not recommended for stage TaG1 papillary tumors, unless they are judged to be at high risk of tumor recurrence.
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tice bcg is not indicated

The dose for the intravesical treatment of carcinoma *in situ* and for the prophylaxis of recurrent papillary tumors consists of one vial of TICE® BCG suspended in 50 ml preservative-free saline.
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do not inject subcutaneously or

TICE® BCG should not be used in immunosuppressed patients or persons with congenital or acquired immune deficiencies, whether due to concurrent disease (e.g., AIDS, leukemia, lymphoma) cancer therapy (e.g., cytotoxic drugs, radiation) or immunosuppressive therapy (e.g., corticosteroids). Treatment should be postponed until resolution of a concurrent febrile illness, urinary tract infection, or gross hematuria. Seven to 14 days should elapse before BCG is administered following biopsy, TUR, or traumatic catheterization. TICE® BCG should not be administered to persons with active tuberculosis. Active tuberculosis should be ruled out in individuals who are PPD positive before starting treatment with TICE® BCG.
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9 biomarker correlative and special

Please refer to Appendix E (Section 16.5) for more information. 9.1.1 Tuberculin Skin Testing PPD results will be used to assess the immunologic response to BCG therapy. This premise is based on a previous report that correlates PPD positivity with improved tumor recurrence-free intervals after BCG treatment (Luftenegger et al, J Urol, Feb 1996, Vol 155, 1483-7).
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9.1.2 urine

For the BCG alone arm, urine may be collected at weeks 3, 5, and at the end of the study. For the BCG + PANVAC vaccine arm, urine may be collected at weeks 0, 3, 5, and at the end of the study. Collection volume will range from 30 to 100 mL with each collection. An attempt will be made to collect urine prior to BCG instillation and 2 hours after BCG drainage, based on previous study demonstrating urinary cytokine changes during these time points (Bisiaux et al, J Urol, Vol 181, April 2009, 1571-80). The aliquot will be stored in the Agarwal laboratory at -80ºC for future proteomic and/or biomarker discovery studies depending on availability. Studies have shown minimal degradation of urinary peptides upon thawing and analysis of specimens 36. Urinary levels of certain cytokines can be prognostic for response to bladder immunotherapy. For example, large amounts of TRAIL are noted in the urine of patients who have responded to BCG therapy 37.  
Therefore, we will potentially check urinary levels of the following cytokines and chemokines by ELISA: TRAIL, IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-18, IFN-γ, and TNF-α at week 0, week 3, week 5 (2-8 hours after last BCG dose has best yield) 38 and at the end of the study.
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9.1.3 blood

For the BCG alone arm, blood samples for research analysis will be obtained  
x at week 0 or at randomization by 1 10cc purple top tube x prior to treatment at weeks 3 and 8 by 2 10cc red top tubes and 6 10cc green top tubes x at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes and 6 10cc green top tubes.
For the BCG + PANVAC vaccine arm, blood samples for research analysis will be obtained  
x at week 0 by 1 10cc purple top tube x prior to treatment at weeks 0, 3, 8, 11, and 15 by 2 10cc red top tubes and 6 10cc green top tubes
x at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes and 6 10cc green top tubes.  
Blood may also be collected on follow-up visits for up to 12 months following end of study cystoscopy. No more than 10.5 mL/kg or 550 mL, whichever is smaller, will be obtained from adult subjects over an 8-week period. The studies and method of storage for these specimens are described in Sections **9.1.5** and 9.2.
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9.1.4 tissue (if clinically available)

For subjects at the NIH: If tissue is clinically available, the Urologic Oncology Branch procedures for tissue collection will be followed. A procurement form will be completed. The tissue procurement nurse or a UOB-designated procurement staff member will work with an NCI pathologist following resection of the specimen to obtain tumor tissue from the resected specimen. This will then be delivered by the procurement nurse or UOB Procurement staff member to the Urologic Oncology Branch Research Laboratory for individual processing. Specimens will be placed in cryovials and also be snap frozen in OCT for frozen tissue sections. Additional tissue will be placed into antibiotic-enriched culture media in order to establish an urothelial cancer cell line. Patients will have the opportunity to opt out of cell line creation from their tissues. Tissue that is used solely for research purposes will be obtained only if it can be obtained with minimal risk of complications from the procedure and only after the procedure has been explained to the patient and informed consent obtained. In that event, the patient will be invited to participate in a tissue procurement protocol such as 97-C-0147. cDNA arrays may be performed on tumor tissues to compare gene expression profiles in tumor cells before and after treatment with BCG or BCG and PANVAC. Immunohistochemical and or cytogenetic analyses may be performed, depending on the tumor of origin. Cell lines may be characterized by karyotyping, interphase fluorescence in situ hybridization (FISH) mapping, immunohistochemistry, and/or flow cytometry. Differences between cell lines will be manipulated to study the various molecular pathways active in nutrient sensing, cell cycle, cell signaling, proliferation, apoptosis, angiogenesis, and metastatic potential in urothelial cancer. Tumor-produced factors may be evaluated in serum or urine or a search for new tumor markers may be performed. We may evaluate proteomic profiles of tissues or serum or urine and correlate these with disease and stage. This may potentially allow for the detection of noninvasive predictive and/or prognostic biomarkers from urine specimens.  
Pathologic material, such as fixed tissue blocks from surgery performed at the NIH Clinical Center, outside surgeries or autopsy materials, may be obtained at the request of, and with written permission from the subject, or appropriate relatives. These samples may undergo pathologic analysis by individuals in the NCI Laboratory of Pathology to confirm diagnosis and may undergo histo-immunologic or other analysis. In particular to the current study, we would like to study the T-cell infiltration pattern within bladder tumors pre- and post-treatment. Specifically, we will look at:
x The expression of CEA and MUC-1 antigens in bladder tumor specimens pre- and posttreatment in both arms x The presence of CD4 and CD8 T cells in bladder tumor specimens pre- and post-treatment in both arms x The presence of regulatory T cells (Tregs) by double staining with FoxP3 and CD4 in bladder tumor specimens pre- and post-treatment in both arms x The presence of myeloid derived suppressor cells (MDSC) in bladder tumor specimens preand post-treatment in both arms
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9.1.5 collection of immunologic blood

x at week 0 or at randomization by 1 10cc purple top tube x prior to treatment at weeks 3 and 8 by 2 10cc red top tubes and 6 10cc green top tubes x at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes and 6 10cc green top tubes.
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for the bcg + panvac

x at week 0 by 1 10cc purple top tube x prior to treatment at weeks 0, 3, 8, 11, and 15 by 2 10cc red top tubes and 6 10cc green top tubes x at the end of study (between weeks 17-20) by 1 10cc purple top tube, 2 10cc red top tubes and 6 10cc green top tubes.  
Additionally, blood may be collected on follow-up visits for up to 12 months following end of study cystoscopy/ bladder biopsy. From this blood, PBMCs and sera will be isolated, when appropriate samples are available, for the following immune correlates: Immunologic testing will include:
1. Circulating Tumor Cytokines (CTC) analysis 2. IFN-gamma ELISPOT assays for CD8 T-cell responses specific for CEA, MUC-1, and Brachyury (Limited to patients with HLA-A2 allele)
3. Measure CD4 antigen-specific response to CEA 4. Sera samples will be analyzed for the development of antibodies to CEA, MUC-1 and Brachyury. (Samples from baseline and at end of study)
5. Flow cytometry analysis using 10 markers of all PBMC samples for each of the following cell types: CD4, CD8, Tregs, MDSCs, and NK.  
6. Serum for NCA (CEA-CAM) titers will be drawn anytime that a patient exhibits new onset neutropenia (ANC <1000)
7. Immunologic studies will be repeated more frequently if clinically indicated, and any abnormalities potentially related to treatment will be followed until they have resolved, or have been determined to not be treatment-related or until the participant's primary medical care is transferred from the principal investigator.  
9.1.6 The immunologic testing samples for CTC analysis will be processed at:
Dr. Piyush Agarwal's Lab 10 Center Drive, 1W-5888 Bethesda, MD 20892 For patients at CINJ, research samples consisting of 2 purple top tubes (week 0 and week 17-20) will be drawn. These tubes will be further processed as per Appendix E, Section **16.5** and then shipped via Fed-Ex to Dr. Agarwal's lab:
Piyush K. Agarwal, MD c/o Julian Custer or Quentin Li Urologic Oncology Branch 10 Center Drive, 1W-5888 Bethesda, MD 20892 9.1.7 The other immunologic testing samples will be processed at:
Clinical Services Program NCI Frederick Cancer Research and Development Center PO Box B Frederick MD 21702 301-846-1000 On days samples are drawn, Jen Bangh at CSP should be notified (phone: [301] 846-5893; fax [301] 846-6222). She will arrange same day courier delivery of the specimens drawn at NIH. For patients at CINJ, research samples consisting of 6 green top tubes and 2 red top tubes will be drawn at multiple time points (see Study Calendar, Section 10). The green top tubes will be sent via overnight Fed-Ex to the NCI Frederick Repository at the address below (see Appendix E, Section **16.5)**:
Leidos Biomedical Research Attn: Bill Kopp/Theresa Burks 1050 Boyles Street Bldg. 469/Room 121 Frederick, MD 21702 Phone 301-846-5125 or 301-846-1707 The red top tubes will be spun down and stored in a -80˚C freezer at CINJ. These serum samples will be batched and then shipped to the NCI Frederick Repository (address above) at intervals. Once a patient's treatment schedule has been determined, Caroline Jochems at the Laboratory of Tumor Immunology and Biology/NIH should be notified at jochemscm@mail.nih.gov for planning purposes.
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9.1.7.1 biopsies

Biopsies will be obtained at the end of therapy solely for diagnostic purposes as per standard of care to ensure that cancer is no longer present. After pathologic diagnosis, each biopsy specimen will be further analyzed by immunohistochemistry for the following: (a) expression of CEA and MUC-1 antigens on tumor cells, (b) the presence of CD4 and CD8 T cells, (c) the presence of regulatory T cells (Tregs) by double staining with FoxP3 and CD4, and (d) the presence of myeloid derived suppressor cells (MDSC). Satisfactory analytical performance characteristics (specificity, sensitivity and reproducibility at the minimum) of individual antibodies or affinity ligands for use in immunohistochemistry will be demonstrated prior to analyses of glycosylated CEA and MUC-1 on tumor cells, CD4 and CD8 T cells, Tregs by double staining with FoxP3 and CD4, and MDSC.
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9.1.7.2 pbmcs sera and urine

The following time points will be analyzed: baseline (prior to vaccination in vaccination arm), week 3 (prior to BCG for both arms), week 8 (prior to last BCG for both arms), and at end of study (between weeks 17-20).
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pbmcs

All patients who have the HLA-A2 allele will be analyzed by ELISPOT for CD8 T-cell responses specific for CEA, MUC-1, and a cascade antigen Brachyury. All samples will be evaluated for CD4 responses specific for CEA protein. All immune assays will have appropriate antigen controls. All PBMC samples will be analyzed by flow cytometry using 10 markers for each of the following cell types: CD4, CD8, Tregs, MDSCs, and NK.  
x Satisfactory analytical performance characteristics of individual antibodies or affinity ligands for use in ELISPOT, flow cytometry, or ELISA will be demonstrated prior to analyses of the proposed protein markers, cytokines and chemokines.  
x Analyses of sera samples for quantitation of antibodies to CEA, MUC-1 and a cascade antigen Brachyury will be described in detail to show clinically recapitulated tumor-associated antigens, including glycosylated proteins, are used in measuring autoantibodies in sera.
Background: Our studies in the LTIB have demonstrated the ELISPOT assay for IFN-γ production to be quantitative and reproducible as a measure of human T-cell responses to vaccination (26). The continued use of one reproducible assay has been instrumental in our ability to evaluate and compare patients' immune responses using different vaccines and vaccine strategies in the same institution, and among different cancer centers. ELISPOT assays employing the CEA agonist peptide and the MUC-1 agonist peptide have already been developed.
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sera

Sera samples at all time points will be analyzed for the development of antibodies to CEA, MUC-1, and a cascade antigen Brachyury.
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urine

Urine samples may be collected at baseline and at the end of therapy (week 17-20) for the presence of cytokines and chemokines. In addition, an effort will be made to collect urine at the time of BCG instillation \#1 and \#3 to assess for cytokine production in response to BCG therapy (as described earlier in section **9.1.2** and in Section **16.5** (Appendix E). For patients at CINJ, research samples consisting of urine (week 0, week 3, week 5, and week 17-20) will be drawn. These tubes will be further processed as per Appendix E, Section **16.5** and then shipped via Fed-Ex to Dr. Agarwal's lab:
Piyush K. Agarwal, MD c/o Julian Custer or Quentin Li Urologic Oncology Branch 10 Center Drive, 1W-5888 Bethesda, MD 20892 Bladder cancer is believed to be an immune-modulated malignancy and therefore the immune correlatives will be used to establish whether or not there is an immune basis for bladder cancer. If tumors are found to have a certain proportion of immune subsets, then the correlatives may be used as potential markers of disease in the future.
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9.2 sample storage tracking and

All specimens obtained for research purposes will be coded upon arrival in the UOB research laboratory to maintain patient confidentiality. All samples will be accessioned and entered into a database (such as LabMatrix) with access limited to the PI and UOB research data managers. The location of all samples will be carefully tracked in the database. All stored samples will be coded and identifying patient information will not be placed on sample containers. Stored samples will be kept in freezers/refrigerators or secure containers located in the Urologic Oncology Branch research laboratories or in approved storage facilities. The research samples collected will be used for the correlative/biomarker studies mentioned above in Section 9.1.  
Tissue slides/blocks may be obtained in order to determine protocol eligibility. Tissues are submitted to the NCI Laboratory of Pathology at the NIH Clinical Center for clinical determination of histologic features. Specialized stains/assays may be used to clarify tissue phenotype. After completion of analysis, tissue slides/blocks are either returned to the originating pathology department or archived in the Laboratory of Pathology or Urologic Oncology Branch and tracked in the UOB database (LabMatrix). Archived material will be retained for the duration of the study unless the originating pathology department requests return. Coded/anonymous samples with minimal clinical information may be shared with qualified NIH and non-NIH researchers who have IRB-approved protocols with similar research objectives. No personal identifying information such as name, address, or date of birth will be provided to the non-UOB investigator. In the event a subject is eligible to participate in a clinical trial based on tumor characteristics, coded tissue samples may be sent to an outside laboratory. Samples will be ordered and tracked through CRIS Screens. Should a CRIS screen not be available, the NIH form 2803-1 will be completed and will accompany the specimen and be filed in the medical records. Samples will not be sent outside the NIH without IRB notification and an executed MTA. Subjects will be given the option of consenting to current and future use of their research samples per the informed consent process with their option declared in the consent document. Samples will be destroyed at the completion of the study on those subjects who decline future use of their samples. Otherwise, any specimens that are remaining at the completion of the protocol will be stored for an indefinite amount of time. These specimens may be banked and used in the future to investigate new scientific questions related to this study. However, this research may only be done if the risks of any new questions were covered in the consent document and protocol. Any new uses of the samples other than those defined in this protocol will be submitted prospectively for IRB review and approval. The IRB will be notified in the event research samples are inadvertently lost or destroyed