The sa me applies to patients who follow the vaccination schedule but never start chemotherapy. Modified vaccination group : Patients will receive under the same rules as above, further booster injections 4 and 5 weeks after last chemotherapy injection and every 4 weeks from week 8 post-chemotherapy up to week 52, then every 12 weeks until 2 years or until withdrawal of consent or toxicity whichever is the earliest. Prophylactic treatment will not be required. From 26 January 2015 onward, • All groups: At any time during the vaccination schedule – if a patient exhibits signs of an allergic reaction (not just a local reaction) then they should be treated symptomatically and for all subsequent TG01 administrations they should be pre- medicated with intravenous antihistamine treatment (e.g. chlorpheniramine or dexchlorpheniramine ) 30 minutes before either the DTH injection (TG01 alone) when done before vaccination or before vaccination (i.e. before the GM- CSF injection which is followed by TG01 10- 15 minutes later or 15-20 minutes in the modified vac cinati on group) • Main group and concomitant group : For patients who have completed/finished chemotherapy – All TG01 administrations should be preceded by intravenous antihist amine treatment as above • All groups: Patients who have local reactions only – It is permi ssible to use topical therapies such as anti -histamine or steroid creams or EMLA cream for pain • All groups: Where a DTH injection is being performed the TG01 DTH dose should be a dministered 30 minutes before the GM -CSF/TG01 administration and patients shou ld be observed for at least 30 minutes after CT TG01 -01 Version v10.0 27 June 2018 Confidential 18 / 87 ALL GM -CSF/TG01 administrations Modified vaccination group: Prophylaxis will not be required at any stage of the study except if the patient continues vaccination after exp eriencing an event of hypersensitivity reaction. Endpoints Primary • Safety • Adverse events • Laboratory assessments • Immune response • DTH responses • Proliferative T- cell responses Secondary • Efficacy at 2 years • Disease free survival • Overall survival Exploratory • Relationship between KRAS status in res ected primary tumour and recurrence survival outcomes (including disease recurrence and overall survival) • Monitor CA19 -9 levels Schedule of Key Assessments: Screening / Baseline: The aim of this protocol is to inclu de patients that have undergone pancrea tic resection with curative intent and to subsequently treat the patients with the TG01 vaccine as soon as possible after the surgery . Patients must have signed the informed consent before starting baseline assessmen ts/treatment . Screening a ssessments to be done prior to GM-CSF/TG01 treatment • Surgical Resection (once resection is undertaken, TG01 treatment to start as soon as possible ) • Tumour sample from surgery stored for KRAS analysis • Informed consent Baseline assessments to be done within 7 days pri or to anticipated TG01 treatment • Demographic data and medical history • ECG • Pregnancy test (if appropriate) • Physical examination and performance status • Vital signs • Haematology / Biochemistry assessment • Urinalysis • Assessment of c oncurrent illness/therapy • CT-scan Treatment Period for patients starting TG01 vaccination first – main group CT TG01 -01 Version v10.0 27 June 2018 Confidential 19 / 87 (timings based on start of GM-CSF /TG01 treatment )- Table 1 : GM- CSF /TG01 +/- chemotherapy Initial Treatment Period (possibly up to week 11) +/ - chemotherapy cycles • GM-CSF/TG01 to start as soon as possible after surgical resection. Day 1 will be the first day of TG01 treatment. GM-CSF/TG01 1 will be administered on Days 1, 3, 5, 8, 15 and 22 and then 2- weekly until the end of chemotherap y treatment . Patients who do not start chemotherapy at all can move to a 4- weekly vaccination from vaccination week 1 0 to week 52 and will follow the “post -chemotherapy -52 weeks” schedule of Table 1 . • Chemotherapy will comme nce at least 3 weeks after start of GM- CSF/TG01 and preferable within 12 weeks from surger y (e.g. at day 22, day 36 or day 50 ). Patients can , however, start chemotherapy later or not start at all if needed. For patients receiving chemotherapy, 6 cycles of chemotherapy will be given and GM- CSF/TG01 will be administered on Days 1 and 15 of the 4- week cycles. • DTH skin test injections on days 1, 8, 15, 22 36, 50 and day 64. DTH reaction is assessed 48 h ± 4 h after each injection • Haematology and blood chemistry at days 1, 8, 22, 36, 50, and 64 taken prior to injection of GM -CSF/TG01 and Days 1, 8 and 15 of each gemcitabine cycle . Key laboratory values in accord ance with the Prescribing Information for chemotherapy should be available prior to chemotherapy dosing . For patients who do not start chemotherapy at all, haematology and blood chemistry should be taken at days 1, 8, 22, 36, 50 and 64 and then every 12 weeks • Urinalysis as clinically indicated • Vital signs, concomitant medications and adverse events at each visit. • Physical examination and Performance Status before the start o f each gemcitabine cycle . For patients who do not start chemotherapy, these assessments should be done every 12 weeks. • Blood sampling for immunology – samples taken prior to GM - CSF/TG01 injection on day 1 and day 71 (or 78) • Blood sampling for CA19.9 on day 1 prior to GM -CSF/TG01 , prior chemotherapy 1st administration and monthly thereafter until end of chemotherapy. For patients who do not start chemotherapy, these assessments should be done on Day 1 and prior every 4-week ly vaccination cycle • A further 10 ml sample (5 ml serum; 5 ml plasma) will be taken and stored for potential analysis of additional biomarkers on day 1 prior to GM-CSF/TG01 , prior chemotherapy 1st administration and monthly thereafter until end of che motherapy. For patients who do not star t chemotherapy, these assessments should be done on Day 1 and prior every 4-weekly vaccination cycle • CT scan every 6 months from the start of vaccination and at any other time point if indicated Treatment Period for patients starting vaccination and chemo therapy at the same time – concomitant group (timings based on start of GM-CSF /TG01 CT TG01 -01 Version v10.0 27 June 2018 Confidential 20 / 87 treatment) – Table 2 : GM-CSF/TG01 +/- chemotherapy Initial Treatment Period (possibly up to week 13 ) +/- chemotherapy cycles • Day 1 will be the first day of TG01 treatment. GM -CSF/TG01 will be administered on Days 1, 3, 5, 8 and 15 and then 2- weekly until the end of chemotherapy treatment. • Chemotherapy will commence at the same time as GM-CSF/TG01 and 6 cycles of chemotherapy will be given. • DTH skin test injections on days 1, 8, 15, 29, 43, 57 and day 71. The DTH reaction is assessed 48 h ± 4 h after each injection • Haematology and blood chemistry at days 1, 8 and 15 of each gemcitabine cycle. Key laboratory values in accordance with t he Prescribing Information for chemotherapy should be available prior to chemotherapy dosing • Urinalysis as clinically indicated • Vital signs, concomitant medications and adverse events at each visit. • Physical examination and Performance Status before the s tart of each gemcitabine cycle • Blood sa mpling for immunology – samples taken prior to GM - CSF/TG01 injection on day 1 and week 13 • Blood sampling for CA19.9 on day 1 of each chemotherapy cycle, prior to GM -CSF/TG01 administration • A further 10 ml sample (5 ml serum; 5 ml plasma) will be taken an d stored for potential analysis of additional biomarkers on day 1 of each chemotherapy cycle , prior to GM -CSF/TG01 administration • CT scan every 6 months from the start of vaccination and at any other time point if ind icated Treatment Period for patients i n the modified vaccination group (timings based on start of GM -CSF/TG01 treatment) - Table 3: GM-CSF /TG01 +/- chemotherapy Initial Treatment Period (up to week 8) +/ - chemotherapy cycles • GM-CSF /TG01 to start as soon a s possible after surgical resection. Day 1 will be the first day of TG01 treatment. All patients will receive at least 5 vaccinations independent of the start of chemotherapy (Days 1, 8, 15, 22 and 36) then if chemotherapy hasn’t started, vaccination will be given 4- weekly until the start of c hemotherapy at which point vaccination will be put on hold until the end of chemotherapy treatment. Patients who do not start chemotherapy a t all will continue t o receive 4- weekly vaccinations until week 52 ( Table 3). • Chemotherapy will preferably commence at least 3 weeks after start of GM-CSF /TG01 . Patients can however start chemotherapy later or not start at all if more appropriate . For patients receiving chemotherapy, 6 cycles of chemotherapy will be given. Note t hat chemotherapy will not be delayed if it is considered important to start within 3 weeks of the start of vaccinations. • DTH skin test injections on da ys 36 and 50 . DTH reaction is assessed 48 h ± 4 h after each injection CT TG01 -01 Version v10.0 27 June 2018 Confidential 21 / 87 • Haematology and blood chemistry at days 1, 8, 22, 36, 50, and 64 taken prior to injection of GM -CSF/TG01 and Days 1, 8 and 15 of each gemcitabine cycle. Key laboratory values in accord ance with the Prescribing Information for chemotherapy should be available prior to chemotherapy dosing . For patients who do not start chemother apy at all, haematology and blood chemistry should be taken at days 1, 8, 22, 36, 50 and 64 and then every 12 weeks • Urinalysis as clinically indicated • Vital signs, concomitant medications and adverse events at each vi sit. • Physical examination and Performance Status before the start of each gemcitabine cycle. For patients who do not start chemotherapy, these assessments should be done every 12 weeks. • Blood sampling for immunology – samples taken prior to GM - CSF/TG01 injection on day 1 and at week 8 • Blood sa mpling for CA19.9 on day 1 prior to GM -CSF/TG01 , prior chemotherapy 1st administration and monthly thereafter until end of chemotherapy. For patients who do not start chemotherapy, these assessments should be done on Day 1 and prior every 4-weekly vaccinat ion cycle • A further 10 ml sample (5 ml serum; 5 ml plasma) will be taken and stored for potential analysis of additional biomarkers on day 1 prior to GM-CSF/TG01 , prior chemotherapy 1st administration and monthly thereafter until end of chemotherapy. For p atients who do not start chemotherapy, these assessments should be done on Day 1 and prior every 4-weekly vaccination cycle • CT scan every 6 months from the start of vaccination and at any other time point if indicated Post-Chemotherapy period or period from week 10 for patients who do not get chemotherapy Main group and concomitant group • GM-CSF/TG01 every 4 weeks until 52 weeks and then every 12 weeks for up to 2 years . For a ll these subsequent GM-CSF/TG01 administra tions the patients should be give n prophylactic treatment (30 minutes before treatment) to prevent possible occurrence of alle rgic reactions. • DTH skin test injections at the 2nd GM-CSF/TG01 injection after end of chemotherapy (8 weeks after last chemotherapy injection) and at week 52. The DTH reaction is to be assessed 48 h ± 4 h after TG01 injection. For patients not starting chemotherapy at all , DTH assessment is to be done at week 52 only. • Blood sampling for immunology– samples taken prior to GM - CSF/TG01 injection at 52 weeks • Blood sampling for CA19.9 and additional biomarkers – samples taken prior to GM-CSF/TG01 injection at 52 weeks. For patients not starting chemotherapy, samples should be taken prior every 4-week ly vaccination cycle and at week 52 • Physical examination and performance st atus at 52 weeks . For patients CT TG01 -01 Version v10.0 27 June 2018 Confidential 22 / 87 who do not start chemotherapy, these assessments should be done every 12 weeks and at week 52 • Vital signs, haematology and biochemistry at 12 weekly intervals • Concomitant medications and adverse events at each visit • CT scan e very 6 months from the start of vaccination and at any other time point if indicated Modified vaccination group: • GM-CSF/TG01 will be given 4 weeks and 5 weeks after end of chemotherapy and then every 4 weeks from wee k 8 post -chemotherapy until week 52. • DTH skin test at 3rd vaccination post -chemotherapy ( 8 weeks post- chemotherapy). The DTH reaction is to be assessed 48 h ± 4 h after TG01 injection. For patients not starting chemotherapy at all, the DTH test and assess ment are to be done at week 52 • Blood s ampling for immunology– sample to be collected 4 weeks after the last chemotherapy injection (1st vaccination injection) and at week 52 • Blood sampling for CA19.9 and additional biomarkers – samples to be taken prior to GM-CSF/TG01 injection at week 52. For patients not starting chemotherapy, samples should be taken prior every 4-week ly vaccination cycle and at week 52 • Physical examination and performance status to be taken at week 52. For patients who do not start che motherapy, these assessments should be done every 12 weeks and at week 52 • Vital signs, haematology and biochemistry at 12 weekly intervals • Concomitant medications and adverse events at each visit • CT scan every 6 months from the start of vaccination and at any other time point if indicated End of Study Visit ( 104 weeks or 4 week s after last GM -CSF /TG01 injection if patients is to be withdrawn) • Haematology and blood chemistry • Physical exam and Performance Status • Vital signs, concomitant medications and adve rse events • CT scan • Blood sampling for immunology, CA19.9 and additional biomarkers If patient is recurrence- free with or without an immune response, GM- CSF/TG01 will be given as per schedule until 52 weeks, then every 12 weeks until 2 years or until withd rawal of consent or toxicity whichever is the earliest . If patient has a positive immune response and recur s during the study treatment period, the patient should continue as per schedule until 52 weeks, then every 12 weeks until 2 years or until withdrawal of consent or toxicity whichever is t he earliest. The same applies to patients who do not start chemotherapy. For all patients where possible, a survival follow -up will continue to be performed every 6 months after the initial 2 years of study period an d until the last remaining patient in the modified cohort reaches the 2 years study period or CT TG01 -01 Version v10.0 27 June 2018 Confidential 23 / 87 withdraws consent or experiences toxicity, whichever is the earliest . Thereafter, a survival follow -up will continue to be performed approximately every 12 months until end of life. Sample size Up to 32 patients will be enrolled in this study : 7 patients have been enrolled in the Phase I part 18-25 will be enrolled in the Phase II part with up to 1 3 patients enrolled in the modified vaccination group The modified vaccination group will consist of up to 13 patients. A review of data of the first 6 patients for DTH assessments after 8 weeks will determine whether the cohort should continue. At least 4/6 patients with a positive immune response are required to con tinue Statistical Methods and Planned Analyses: No formal statistics will be performed. All patients ( treated with chemotherapy or not ) will contribute to the interpretation of the whole trial. The proportion of patients with immune responses will be a ssessed. The safety and efficacy of the combination of GM -CSF/TG01 and chemotherapy will be descriptive. The incidence of pancreatic cancer recurrence and KRAS status during the Trial will be listed . CT TG01 -01 Version v10.0 27 June 2018 Confidential 24 / 87 2. INTRODUCTION Investigators should be familiar with the Investigator’s Brochure (IB). 2.1 Background 2.1.1 Pancreatic cancer Pancreatic cancer is one of the major causes of cancer death globally, with a 5 -year survival rate of less than 5%. The outlook for those patients who can undergo surgical resection is bette r, and in specialised centres, resection rates greater than 15% can be achieved. Although surgery cannot guarantee a cure, the 5- year survival does improve to around 10% following resection. There is a clear need to improve long- term survival in these patients. While the added survival benefit of adjuvant chemoradiotherapy with or without maintenance chemotherapy remains unclear, a more certain survival benefit has been demonstrated from adjuvant chemotherapy. 2.1.2 Rationale for the trial TG01 is an antigen -specific cancer immunotherapy (ASCI) containing a mixture of 7 different synthetic peptides designed to encompass all common RAS mutations at positions 12 and 13. The peptide sequences are identical to the amino acid sequence of wild-type RAS, except for one substitution of the amino acid at either position 12 or 13, which corresponds to amino acid substitutions found in the mutated p21 RAS protein expressed by pancreatic, colon and lung cancer cells. The occurrence of oncogenic mutations in p21 RAS in pa ncreatic cancer is very frequent (Capel la et al., 1991) and may be one of the reasons why every standard chemotherapy drug and new “targeted” drug tested in pancreatic adenocarcinomas have uniformly failed to significantly increase the survival of patients with pancreatic cancer. In Europe, chemotherapy alone is now recommended as adjuvant therapy based on the results of the ESPAC -1 and CONKO -001 trials (Neoptolemos et al., 2010; Oettle et al., 2007; Neuhaus et al., 2008). In particular, the CONKO -001 tri al indicates that the use of gemcitabin e in patients undergoing R0 or R1 resection for pancreatic cancer provides a regimen with minimal toxicity and a chance for a prolonged disease -free-survival compared to observation alone (13.4 months compared to 6 .9 months although there was no difference in overall survival) . Gemcitabine is therefore the most frequently used adjuvant in this setting. Combining gemcitabine with a n immunotherapy approach would, in theory, offer a regimen with minimal toxicity with th e aim to improve the recurrence rate an d potentially offer an improved overall survival. TG01 is administered to the patients by intradermal injection in combination with an adjuvant (GM -CSF/Molgramostim ). After administration , the peptides are taken up by antigen presenting cells like dendri tic cells (DCs) which thereafter travel to the draining CT TG01 -01 Version v10.0 27 June 2018 Confidential 25 / 87 lymph nodes and present the vaccine peptides, eventually after being trimmed by intracellular enzymatic antigen processing, in HLA molecules. This will enable the induction of T- cells with specificity for the various RAS mutations of TG01. Finally the induced T- cells will enter circulation and get activated upon recognition of cancer cells presenting relevant mutated RAS peptide epitopes in their HLA molecules. In addition to efficient killing of ca ncer cells by T- cells induced by TG01, also a broader immune response may be induced locally by enhanced stimulation of cross presentation and epitope spreading (local cytokine production by TG01 induced T- helper cell s stimulate DCs to take up debris from killed cancer cells and present all sorts of tumour associated peptide epitopes). 2.1.3 Pre-clinical experience TG01 is an antigen specific cancer immunotherapy (ASCI) consisting of seven synthetic 17-mer ras -oncogene pepti des aimed to stimulate CD4 + Th-cells ag ainst tumour cell targets expressing mutated RAS peptides and, intended to be administered at a low dose 0.7 mg (0.1 mg each peptide) by intradermal injection. Due to the nature of TG 01 a number of non- clinical studies that would normally be undertaken as part of a formal development programme were not conducted in the case of TG 01 and the rat ionale for this is given below. The seven synthetic, naturally occurring, 17- mer ras -oncogene peptides that comprise TG01 have no intrinsic activity per se . Moreove r, the effects of TG 01 are not related to blood or plasma concentrations but are mediated through local peptide uptake into dendritic cells (DC’s) in the skin and immunological processing at the injection site. Subse quently DC’s in the skin migrate to the draining lymph node where they activate T-cells. The breakdown of proteins from dead cells takes place locally, in the tissue, where peptide fragments are rapidly degraded by tissue proteases/peptidases and do not reach the bloodstream. Indeed, even in an improbable ‘ worst case’ scenario, in which the peptides where to reach the systemic circulation, evidence indicates that they would be rapidly degraded in the blood, being undetectable 1 min after injection ( Yamada et al., 2006). Thus, taking into account the lack of intrinsic activity of the peptides, the lack of systemic exposure following intradermal injection and data from clinical studies, in which TG01 has been administered repeatedly to over 80 pancreatic ca ncer patients with only minor, transient adverse effects, a formal development programme, based on systemic exposure following administration, was not considered relevant. The non- clinical pharmacodynamics and rationale for developing TG01 was assessed in a number of published in vitro studies using T -cells from patients to demonstrate the ability of the peptides to elicit effector T -helper cells and cytotoxic T-lymphocytes (CTL) in humans . Initial studies, investigating whether specific immune responses could be generated against RAS, reporte d that immunization of a number of strains of mice with RAS peptides, bearing various point mutations at positions 12 or 61, elicited T -cells that specifically proliferated in response to RAS peptide stimulation ( Peac e et al., 1991). Moreover, several stu dies using synthetic RAS -oncogene peptide -loaded peripheral CT TG01 -01 Version v10.0 27 June 2018 Confidential 26 / 87 blood mononuclear cells (PBMC’s) from both healthy individuals and cancer patients have reported the induction of RAS -specific T -cell responses in vitro . Furthermore, both CD4+ and CD8+ T-cells h ave been identified and their ability to kill RAS -expressing target cells or inhibit the growth of cancer cell lines harbouring the corresponding RAS mutations has been demonstrated ( Gedde- Dahl et al., 1992 & 1994; Fossum et al., 1993 & 1994). Taken together, these reports, in addition to other published observations, indicated that targeting RAS by immunotherapy offered a feasible approach to potentially controlling pancreatic cancer cell growth in vivo . Single dose intravenous toxicology studies using either single, two or five KRAS peptide mixtures were undertaken in pigs, rabbits, rats and mice. Collectively, the 2 and 5 KRAS peptide single dose toxicity studies used all 7 of the KRAS peptides which comprise TG01 . Overall, these studies revealed no significant toxicological findings, presumably as a consequence of rapid degradation of the peptides in the blood following intravenous bolus injection and subsequent lack of systemic exposure. However, an exception to these observations was noted in a single dose, iv study following administration of the val 12 peptide in mice (study 927/002). In this study, administration of the highest dose of the val 12 peptide (50 mg/kg) led to subdued behaviour or convulsions in all 5 males and 5 females and two males and one female died within 2 min of injection. All surviving animals recovered after 2 h. In contrast, no mortalities or clinical effects were noted following administration of the low (0.5 mg/kg) or intermediate ( 5 mg/kg) dose -levels. Moreover, no mor talities, clinical signs or macroscopic abnormalities were reported when the same doses of the val 12 peptide were administered to rats. Taken together, the most plausible mechanism to account for these observations, recorded specifically in the mouse, is related to the exceptionally small diameter of blood vessels in the murine brain, which may readily become clogged following injection of excessive amounts of peptides or macromolecules resulting in rapid death or cl inical symptoms such as lethargy, convulsions or subdued behaviour. Indeed, the val 12 peptide is considerably less soluble and more hydrophobic than the other 6 peptides in TG01, lending support to the idea that blocked microvessels in the murine brain resulted in the rapid deaths or clinical symptoms reported. Moreover, the dose of val 12 administered in this study was circa 5000 times the dose (of total peptides using the 7- peptide formulation) that has been routinely administered to humans in clinical studies. Hence, it is considered that a sufficient safety margin exists between the currently utilised clinical dose and the dose at which toxicity was specifically observed following administration of this single peptide in the mouse. The complete seven mutated RAS peptide mixture that compr ises TG01 has not been tested in animal toxicity studies to date. This was primarily due to the initial development plan for TG 01 which explored the safety of RAS immunotherapy based on the use of single peptides in pancreatic cancer patients. However, due to the high probability of a mismatch between the point mutation in the immunising peptide and the mutation expressed by the patients’ tumour, there was a requirement for each patient to be genotyped for RAS mutations in order to optimise therapy. Due to the tedious and costly nature of this approach, particularly with respect to the rapid deterioration of CT TG01 -01 Version v10.0 27 June 2018 Confidential 27 / 87 pancreatic cancer patients and the time required for RAS gene sequencing, it became obvious that such a strate gy was impractical. Consequently, it was decided to develop a product containing a mixture of seven peptides that encompassed all significant RAS mutations, thus negating the requirement for prior tumour typing. Although current regulatory guidelines indi cate that the range and type of genotox icity studies routinely conducted for pharmaceuticals are not applicable to biotechnology- derived pharmaceuticals such as synthetic peptides, prior to the issue of these guidelines, an Ames test was undertaken using a single KRAS peptide 12-V- p21 RAS(5-21). Concentrations of 31.2, 62.5, 125, 250, and 500μg/plate did not result in any mutagenic findings either in the presence or absence of liver S -9 mix. These naturally occurring peptides would not be expected to interact directly with DNA or other chromosomal material, and i n view of the current guideline, no further studies are planned. Additionally, these natural peptides have no potential to support or induce proliferation of transformed cells or clonal expansion leading to neoplasia and taken together with the rapid degradation, consequent lack of systemic exposure and the target patient population, no carcinogenicity have been undertaken. Moreover, whilst many biotechnology- derived products are immunogenic and have the potential to stimulate antibody production, the seven synthetic, 17- mer ras -oncogene peptides in TG01 are comprised entirely of naturally occurring amino acids and have no capacity to stimulate the formation of antibodies. Indeed, after processing by DC’s, the peptides elicit a highly specific immune respons e, stimulating CD4 + T-cells against specific tumour cell targets expressing mutated RAS peptides. This was evidenced in clinical data from Phase I/II studies indicating that a specific delayed -type hypersensitivity (DTH) reaction could be generated at skin sites in almost 50% of cancer patients. This body of clinical data also provides significant experience concerning local tolerance. In the case of TG01, repeated intradermal injections of the seven peptide mixture, co-administered with GM -CSF, have been given to more than 80 patients with pancreatic cancer using a 1, 2, 3, 4, 6 and 10 week dosing schedule. These clinical studies reported that injections were well tolerated, with only one patient reporting itching and one patient showing erythema at inje ction sites.