Do not make unauthorized copies. 6.5 Study Enrollme nt Exclusion Criteria In addition to the procurement exclusion criteria, subjects will NOT be eligible for study registration and randomization if meeting any of the following additional criteria: 1. Any anti -neoplastic therapy between tissue procurement for Vigil manufacture and start of study therapy. 2. Live vaccine used for the prevention of infectious disease administered < 30 days prior to the start of study therapy. 3. Post-surgery complication that in the opinion of the treating investigator would interfere with the patient’s study participation or make it not in the best interest of the patient to participate. 7.0 WITHDRAWAL 7.1 Discontinuation from Study Treatment Treatment will be continued until progressive disease by RECIST 1.1. However, insofar as some patients in our early vaccine trials had increased survival despite initial, short-term volume increase. There is accumulating evidence that some subjects treated with immune system stimulating agents may appear to demonstrate progression of disease by conventional response criteria before demonstrating clinical objective responses and/or stable disease and ultimately survival benefit. It may be that enhanced inflammation within tumors initially leads to an increase in tumor size or newly visible small lesions. Over time, both the malignant and inflammatory portions of the mass may then decrease leading to overt signs of clinical improvement. Therefore, selected subjects may be allowed to continue study therapy after investigator - assessed RECIST 1.1 progression and with agreement by the Gradalis medical monitor if the subject is determined to be deriving clinical benefit, tolerating study drug and meeting the following criteria: 1. Absence of symptoms and signs indicating clinically significant PD indicating disease progression. 2. No decline in ECOG performance status. 3. Absence of rapid progression of disease or of progressive tumor at critical anatomical sites (e.g., cord compression) requiring urgent alternative medical intervention. If subsequent imaging shows an objective response or stable disease relative to baseline, treatment with study agents will continue. If subsequent imaging again shows PD, patients will be discontinued from study therapy. Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 44 of 74 Confidential and proprietary information of Gradalis, Inc. Effective: 05-DEC-2018 It is the user’s responsibility to verify adequate training before executing a document. Do not make unauthorized copies. Subjects will discontinue study treatment if any of the following occur: 1. Disease progression by RECIST 1.1 criteria. 2. The patient experiences unacceptable (≥Grade 3) toxicity felt to be related to treatment with the Vigil immunotherapy that persists for >3 weeks. Subjects would be discontinued from both Vigil and chemotherapy. 3. The subject experiences unacceptable (≥Grade 3) toxicity felt to be related to treatment with irinotecan/temozolomide that persists for >3 weeks. Vigil therapy may be continued in monotherapy. 4. Persisting Grade 3 or 4 toxicity unrelated to treatment, defined as failing to normalize within 3 weeks. 5. Any Grade ≥ 3 allergic reactions related to Vigil. 6. Grade 2 autoimmune reactions unless there is evidence of clinical benefit. 7. An intercurrent illness, which would in the judgment of the investigator, affects assessments of clinical status to a significant degree or requires discontinuation of study treatment. 8. Cancer therapy other than protocol treatment. 9. Non-compliant with protocol or treatment. 10. Subject refuses to continue treatment. The date of and reason for discontinuation must be noted in the electronic Case Report Form (eCRF). Every effort should be made to complete the appropriate assessments. 7.2 Treatment Delay • Treatment may be delayed no more than 3 weeks to allow recovery from toxicity. • If ≥ one 2-week delay due to disease or infection occurs, subject status must be reviewed by sponsor. • If subjects miss doses, the doses will be made up the following week and continue on a revised every 3-week schedule thereafter. If Vigil administration is delayed, then irinotecan and temozolomide should concurrently be delayed. 8.0 INVESTIGATIONAL PLAN 8.1 Subject Screening and Registration Written documentation of full, non-contingent IRB approval of the protocol and consent document must be on file before a subject can be registered. Study participation begins once written informed consent is obtained. Subjects will be assigned a study identification number upon scheduling of tissue procurement for Vigil manufacture. Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 45 of 74 Confidential and proprietary information of Gradalis, Inc. Effective: 05-DEC-2018 It is the user’s responsibility to verify adequate training before executing a document. Do not make unauthorized copies. No later than the date of surgery, a pre-registration packet will be submitted by the site to Vigil@gradalisinc.com for medical monitor review. One to eight weeks after tissue procurement has occurred eligibility will be reconfirmed by the study site. The Site will register the subject by sending the registration packet to Vigil@gradalisinc.com for medical monitor review. Please allow 48 hours for subject registration as the medical monitor may review the subject’s source documents to ensure they meet the eligibility criteria. Once confirmed, the site will be notified of the eligibility and randomization result. 8.2 Tumor Procurement Refer to the Study Reference Manual for instructions. Surgery for tissue procurement for Vigil manufacture must be scheduled and approved in advance. The cumulative equivalent of a “grape” to “golf ball size” mass (~10-30 gm of prime tumor tissue / approximate 2 cm total diameter on imaging) is optimal for Vigil manufacturing. If surgeons have the option of collecting more tissue, more doses of Vigil may be prepared (up to 12 doses). Vigil manufacturing is rarely successful with small (<10 gm) tumor masses. Lesions extending into lumen (e.g., bowel) or tumor embedded in bone cannot be processed. Once the procured tissue is received at Gradalis, Inc. samples will be processed for autologous Vigil manufacture. 8.3 Vigil Immunotherapy Manufacturing Gradalis, Inc. will manufacture vaccine from the procured subject tumors. Gradalis, Inc. will release Vigil once all release criteria have been met and eligibility has been confirmed. No tissue or Vigil will be given to the participant or site apart from the outlined clinical protocol. Any excess tumor tissue, not used for Vigil manufacture will be used towards Vigil research and process development assays. 8.4 Study Treatment Administration Treatment will be administered on an outpatient basis. Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 46 of 74 Confidential and proprietary information of Gradalis, Inc. Effective: 05-DEC-2018 It is the user’s responsibility to verify adequate training before executing a document. Do not make unauthorized copies. 8.4.1 Schedule, Dose and Administration Group A Drug Dose Schedule Temozolomide 100 mg/m2 daily, oral Days 1 – 5, every 21 days Irinotecan 50 mg/m2 daily, oral Days 1 – 5, every 21 days Vigil 1.0 x 106 cells/injection, intradermal Day 15, every 21 days Cross -Over Subjects Drug Dose Schedule Vigil 1.0 x 106 cells/injection, intradermal every 21 days Subjects will receive Vigil at 1.0 x 106 cells via intradermal injection every 3 weeks for a minimum of 4 administrations to a maximum of 12 administrations depending on quantity of Vigil manufactured from surgical specimens and so long as the patient is clinically stable and without disease progression. The sites of injection for Vigil will be rotated between the right and left upper arms. If the ipsilateral axillary lymph nodes were radiated or surgically removed during prior therapy, alternative sites may be used. Group B Drug Dose Schedule Temozolomide 100 mg/m2 daily, oral Days 1 – 5, every 21 days Irinotecan 50 mg/m2 daily, oral Days 1 – 5, every 21 days Please contact the sponsor with any dose adjustment considerations. Irinotecan Preparation Order the injectable formulation of irinotecan from central supplier, Clinigen . Draw up 1 cycle of (five doses) into provided oral syringes and dispense to the subject with instructions to refrigerate until administration. Irinotecan may be mixed with cranberry -grape juice before administration to mask the bitter flavor and administered once daily on Days 1 through 5 of each 3-week cycle. Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 47 of 74 Confidential and proprietary information of Gradalis, Inc. Effective: 05-DEC-2018 It is the user’s responsibility to verify adequate training before executing a document. Do not make unauthorized copies. Temozolomide Preparation Temozolomide capsules for 1 cycle will be obtained by the patient with administration instructions. Temozolomide may be opened and mixed in apple sauce or juice if unable to swallow whole capsules. Temozolomide is administered on Days 1 through 5 of each 3-week course and given at least 1 hour before irinotecan. Subjects should be instructed to complete a dosing diary for the administration of oral irinotecan and oral temozolomide. Premedications and post medications Vigil: EMLA® may be utilized at the injection site prior to Vigil administration. Analgesics may be employed as necessary. As noted above, systemic steroids or other immunosuppressants should be avoided due to immune inhibition activity. Temozolomide / irinotecan: Per package inserts and institutional standards. A home supply of anti-emetic (e.g. ondansetron) is highly recommended to take before temozolomide and as needed. Also, a patient supply of an anti -diarrheal medication (e.g. loperamide) should be available after irinotecan for use as needed. The patient should be educated with a study calendar indicating days to get chemotherapy and/or Vigil as well as supportive care medications and when Vigil is given. Vigil Immunotherapy Transfer All manufactured Vigil will be stored in the vapor phase of liquid nitrogen until ready for use. The site will contact Gradalis, Inc. when the study agent is needed for subject administration. Gradalis will complete a Drug Transfer and Administration Form to release the subject vaccine. The clinic will sign off on the form upon receipt of the administration. Please reference the Study Reference Manual for preparation and handling information. Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 48 of 74 Confidential and proprietary information of Gradalis, Inc. Effective: 05-DEC-2018 It is the user’s responsibility to verify adequate training before executing a document. Do not make unauthorized copies. Dose Modification for Vigil Toxicity If > Grade 2 toxicity by NCI Common Toxicity Criteria (excluding Grade 3 injection site reactions) develops related to study treatment the Vigil dose will be reduced by 50% and continued. Dose Modifications for temozolomide and irinotecan Dose modifications for temozolomide, and irinotecan may be necessary for subject safety and should be carried out in accordance with the Investigator’s standard of practice, the package inserts, and institutional standards. Please contact the sponsor regarding any dose modifications. If irinotecan + temozolomide is administered beyond 12 cycles, it will be administered off study and no longer provided by Gradalis . If irinotecan + temozolomide is discontinued, Vigil may be administered every 3 weeks until all manufactured product is exhausted or when disease progression is noted. Study Regimen Delay 8.5 Concomitant Medications and Supportive Care The following medications and interventions, unless otherwise specified, are prohibited from the time of study screening until the End of Treatment visit: • Anti -cancer therapy, including chemotherapy, radiotherapy, or endocrine therapy other than those required per protocol. • Any investigational drug or device other than Vigil. • Systemic —oral, IV, injectable—corticosteroids (e.g., dexamethasone) should be avoided in subjects who are administered Vigil. If deemed by the investigator to be necessary, short term (<30 days) systemic steroids ≤ 0.25 mg/kg (max 10mg) prednisone-equivalent per day and inhaled steroids are permitted while on protocol. Other steroid regimens and/or immunosuppressives are generally prohibited. Contact the Gradalis medical monitor if other steroidal regimens are clinically needed. • Localized radiotherapy is permitted for palliation of painful lesions at the investigator’s discretion. However, medical management in place of radiation therapy should be used, if clinically appropriate.Inactivated vaccines are allowed on study, if deemed appropriate by the investigator. Live vaccines are prohibited while on study. • Valproic Acid (due to temozolomide) • Strong CYP34A inducers and inhibitors (due to irinotecan) Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 49 of 74 Confidential and proprietary information of Gradalis, Inc. Effective: 05-DEC-2018 It is the user’s responsibility to verify adequate training before executing a document.