Do not make unauthorized copies. Table 6 . Grade 3 or greater Adverse Events reported, CL-PTL-121, Part 2. Event Term CTC Grade Relationship to VIGIL Relationship to Temozolomide Relationship to Irinotecan Number of Subjects Number of Events Platelet Count Decreased 3 Not Related Probably Related Probably Related 1 1 Anemia 3 Not Related Unlikely Related Unlikely Related 1 2 Chest Wall Pain 3 Not Related Not Related Not Related 1 1 Febrile Neutropenia 3 Not Related Probably Related Probably Related 1 1 Hypokalemia 3 Not Related Not Related Not Related 1 4 Neutrophil count decreased 3 Not Related Possibly Related Possibly Related 2 2 3 Not Related Probably Related Probably Related 1 2 4 Not Related Probably Related Probably Related 2 2 Platelet Count Decreased 3 Not Related Probably Related Probably Related 2 2 4 Not Related Not Related Not Related 1 1 4 Not Related Probably Related Probably Related 1 1 Pneumonitis 4 Not Related Not Related Not Related 1 1 Respiratory Failure 4 Not Related Not Related Not Related 1 1 Respiratory, thoracic and mediastinal disorders - Other, Empyema Lt. Thorax Infection 4 Not Related Not Related Not Related 1 1 Back Pain 5 Not Related Not Related Not Related 1 1 Musculoskeletal and connective tissue disorder - Other, Progressive Ewing’s Sarcoma 5 Not Related Not Related Not Related 1 1 An objective response by RECIST (partial response, 61% shrinkage of target lesions) was achieved in one patient (EW-167-3006), in addition CT scan abnormalities at baseline cancer sites which demonstrated prior PET avid uptake of FDG of this patient no longer demonstrated PET uptake after Vigil (see Figure 12 and Figure 13). This patient underwent biopsy of pulmonary and pelvic lesions which w ere still visible by CT scan but no longer PET avid. Results demonstrated no viable tumor presence. Furthermore, entirely necrotic, hyalinize tissue of the pulmonary sample indicates response to on-study therapy. Another patient EW-167-3003 similarly underwent PET scan evaluation and showed change from PET avid at baseline to PET negative 7 months after treatment initiation. This patient later after completion of Vigil developed an infection of the left lung cavity (s tatus p ost left pneumectomy) and passed away at Month 8 related to progressive infectious pneumonia. Autopsy was performed and the PET negative disease in the posterior chest wall seen on CT scan revealed no viable tumor cells at that site consistent with complete histologic disease response. Additionally , no other sites of microscopic cancer were found at autopsy. Patient EW-167-3010 had durable SD ≥6 months Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 37 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. and remains in good health. Consideration for second resection and assessment of detection of viable tumor at CT detectable disease sites is underway. Previously, we also reported complete histologic response in a prior Vigil monotherapy treatment patient ( F-062), who was not RECIST evaluable (Ghisoli, Rutledge et al. 2017) . This patient underwent a second harvest and second Vigil treatment with persistent detectable disease following first Vigil treatment and remains alive without recurrence 4 years/months following Vigil start. It was suggested that neoantigen patterns at different sites of cancer growth may have some variation and Vigil activity in part may relate to the neoantigen pattern contained on the autologous tissue harvested. As such, patients with delayed regression or mixed response could be considered for second Vigil harvest and treatment if other more optimal therapies are not available. Figure 12. EW -167-3006 Left Upper Lung posterior target lesion PET scan from baseline, Month 3, and Month 6 Figure 13. EW -167-3006 Left diaphragm soft tissue target lesion PET scan from baseline, Month 3, and Month 6. Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 38 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. Patient EW-167-3012 had all recurrent disease harvested for Vigil construction and remains without disease recurrence ≥ 6 months. Patients EW-167-3013, EW-167-3011 and EW-002- 3005 had progression in < 6 months despite treatment with Vigil, temozolomide and irinotecan. Summary of all participants responses are shown in Figure 14. Overall, historical disease progression would be expected within 2 months of ≥ third-line disease progression. Figure 14. Patient summary of PFS of all 10 intent to treat patients, Part 2 of CL-PTL-121. Fifty -seven percent (57%, 4/7) with a durable clinical response rate (for ≥ 6 months). 3.0 STUDY RATIONALE The results from the Phase I Vigil trial show product safety (both short-term and long-term through 3+ years), confirm effective transgene expression (GMCSF) and RNAi [furin] silencing, and support the rationale of the immunotherapeutic triad, i.e., autologous tumor cell therapy with Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 39 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. increased GMCSF expression and decreased TGFβ production shown to effectively modulate immunogenicity as evidenced by the correlation of IFNγ -ELISPOT responsiveness with overall survival and the elicitation of the CD4+ mediated circulating antibody responses against CT47 in two of the Phase 1 Ewing’s sarcoma patients. The preliminary evidence of safety, immune stimulation and clinical benefit from Vigil in patients with Ewing’s sarcoma treated in the Phase I setting supports evaluation of this therapy in a larger and randomized study and at earlier stage of recurrence (first recurrence). A lower tumor burden is typically associated with greater delay in progression with other immunotherapies. Mathematical modeling supports the concept of better control of disease progression with the combined use of effective chemotherapy (e.g., temozolomide/irinotecan as second line treatment in Ewing’s sarcoma) and immunotherapy (i.e., Vigil) in first relapse patient population (de Pillis, Gu et al. 2006). The utilization of the standard of care temozolomide/irinotecan regimen at investigator consensus defined dose and schedule appears to be minimally immunosuppressive and thus a reasonable option for combination with Vigil. Moreover, the temozolomide and irinotecan regimen at effective dose levels has low myelosuppressive toxicities (irinotecan 50mg/m 2/dose and temozolomide 100mg/m2/dose) and may increase the tumor antigen release and surface exposure of calreticulin (part of the specific danger -signaling system) as well as reduce the frequency of CD4+ CD25+ regulatory T-cells (Kim, Kim et al. 2010). In addition, given that Ewing’s sarcoma expression levels of type-1 associated chemokine ligands CXCL9, CXCL10, and CCL5 correlate with TIL expression chemokine receptors (CXCR3 and CCR5) (Berghuis, Santos et al. 2011) it is notable that temozolomide has been shown to enhance tumor matrix presentation of CXCL9 and CXCL10 in certain tumor models (Tan, Evrard et al. 2015). Temozolomide and irinotecan in combination have shown benign safety profiles without any Grade 3 treatment-related adverse events in seven combination treated Ewing’s Sarcoma patients of Part 2 of CL-PTL-121. Furthermore, clinical antitumor activity was demonstrated in 4 of the 7 combination treated patients, all of whom had previously failed temozolomide and irinotecan, as evidenced by 2 partial responses, one histological CR (autopsy) and one prolonged SD currently near 1 year in duration. Thus, the combination of low dose Vigil, irinotecan and temozolomide may not only increase anti -tumor responses but also prolong time to progression and improve the of quality of life in the treatment of Ewing’s sarcoma patients. 4.0 OBJECTIVES 4.1 Primary objective • To compare the progression free survival of subjects dosed with Vigil immunotherapy in combination with irinotecan and temozolomide vs. irinotecan and temozolomide. 4.2 Secondary objective(s) • To determine and compare the overall survival of subjects with relapsed or refractory Ewing’s sarcoma dosed with Vigil immunotherapy in combination with irinotecan and temozolomide. • To determine the objective response rate (RECIST 1.1) of patients with metastatic Ewing’s sarcoma refractory or intolerant to 1 prior line of systemic chemotherapy treated Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 40 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. with Vigil immunotherapy dosed with Vigil immunotherapy in combination with irinotecan and temozolomide • To determine the Vigil manufacturing success rate by gathering data from tumor tissue collection, Vigil construction, and test procedures. 5.0 STUDY DESIGN This is a multicenter, 1:1 randomized Phase III study of intradermal autologous Vigil immunotherapy (1.0 x 10 6 cells/injection; minimum of 4 to a maximum of 12 administrations) in combination with irinotecan and temozolomide in subjects with metastatic Ewing’s Sarcoma Family of Tumors (ESFT) refractory /intolerant or recurrent to 1 prior line of chemotherapy. Participants undergoing a standard surgical procedure (e.g., tumor biopsy or palliative resection) may have tumor tissue harvested for manufacture of investigational product Subjects meeting eligibility criteria including manufacture of a minimum of 4 immunotherapy doses of Vigil will be randomized to receive either: Group A (i) oral temozolomide 100 mg/m2 daily (Days 1 – 5, total dose 500 mg/m2/cycle), (ii) oral irinotecan 50 m g/m2 daily (Days 1 – 5, total dose 250mg/m2/cycle), and (iii) Vigil 1.0 x 106 cells/injection, intradermally on Day 15. OR Group B (i) oral temozolomide 100 mg/m2 daily (Days 1 – 5, total dose 500 mg/m2/cycle), and (ii) oral irinotecan 50 mg/m2 daily (Days 1 – 5, total dose 250mg/m2/cycle). If chemotherapy study drugs cannot be administered orally (i.e. size of capsule, nausea, etc.) it is the physician’s discretion to request intravenous administration of temozolomide at 100 mg/m2 daily and/or irinotecan 20 mg/m2 daily intravenously. One cycle = 21 days. Screening for the main portion of the study may occur as early as one week but no later than 8 weeks following tumor procurement. Vigil is typically released approximately 3 weeks after the completion of the two-day manufacturing process. At the time of data analysis the subjects will be stratified by initial response to frontline treatment (recurrent versus refractory (progressive)). Participants will be managed in an outpatient setting. Hematologic function, liver enzymes, renal function and electrolytes will be monitored. Blood for immune function analyses including IFNγ -ELISPOT analysis of cytotoxic T cell response to autologous tumor antigens will be collected at tissue procurement, post-procurement screening and Day 1 (prior to chemotherapy administration) at Cycles 2, 4, and 6, end of treatment (EOT), 3 months after EOT, and every 6 Ph III Ewing’s Sarcoma Vigil ± Irinotecan +Temozolomide IND 014205 CL-PTL-130 Version: 03 Page 41 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.