Mustafa Khasraw, M.D will now be the PI for the study. The PI change is reflect ed throughout the protocol . Clarified statements in Table 4. Schedule of Events footnote. Amended version 202002 12 Subject eligibility criteria upda ted to make it consistent across studies in the center. KPS ≥ 70%, Serum creatinine level was changed to ≤ 3 times institutional upper limit of normal for age, serum aspartate aminotransferase (AST) ≤ 3 times institutional upper limit of normal for age (Section 11). Amended version 20200 409 Updates to title page. Added description of the use of bevacizumab (reduced dose) to treat inflammatory reactions secondary to the immune response expected with DC vaccination (Section s 9.1, 9.1.3). Change in immune monitoring blood draws (amounts, tube types, timing) (Sections 12.2, 12.7.5). Table 4 in Section 12 has been completely revised. Change in how many weeks RT should be started after surgery and PI discretion language added (Section 9.1 ). Change in hemoglobin and bilirubin inclusion criteria (Section 11 ). Change in timing of MMSE at baseline (Section 12.1 ). Revised language regarding initial tissue testing (Section 12.1). Change in timing for early withdrawals being replaced (Sect ion 12.6.3). Curran Status removed (Section 12.7.2 ). Formatting changed and clarification made in Section 15.6.5 . Amended version 20220204 Updates made to staff on the face page. Removed 111In-labeled DCs and associated SPECT /CT scan at Vaccine #4 as objective already met in an earlier completed study (see Schema in Section 6, Table 4, and Sections 12.7.4 and 15.6.1 ). Slight revision to exclusion criteria related to current/recent participation in another study in Section 11 . Revise exclusion criteria in Section 11 to remove mention of SPECT I-ATTAC Version: 20220204 3 scan and to allow for patients with MRI -compatible devices. Schema in Section 6 re-done so no w an editable picture. I-ATTAC Version: 20220204 4 1 TABLE OF CONTENTS 1 TABLE OF CONTENTS ........................................................................................................ 4 2 LIST OF FIGURES ................................................................................................................ 7 3 LIST OF TABLES .................................................................................................................. 7 4 LIST OF ABBREVIATIONS ................................................................................................. 8 5 PROTOCOL SYNOPSIS AND RESEARCH SUMMARY ................................................ 11 6 STUDY SCHEMA................................................................................................................ 12 7 BACKGROUND AND SIGNIFICANCE ............................................................................ 13 7.1 Study Disease ............................................................................................................. 13 7.1 Study Agent ................................................................................................................ 13 7.1.1 Pre-Clinical Experience .......................................................................................... 19 7.1.2 Clinical Experience ................................................................................................. 20 7.2 Study Purpose/Rationale ............................................................................................. 23 8 OBJECTIVES AND ENDPOINTS ...................................................................................... 24 9 INVESTIGATIONAL PLAN ............................................................................................... 25 9.1 Study Design ............................................................................................................... 25 9.1.1 Definition of Unacceptable Toxicities .................................................................... 25 9.1.2 Dose Modification .................................................................................................. 26 9.1.3 Safety Considerations ............................................................................................. 26 9.1.4 Missed Doses .......................................................................................................... 27 9.1.5 Concomitant Medications ....................................................................................... 27 9.2 Rationale for Selection of Dose, Regimen, and Treatment Duration ......................... 28 9.3 Rationale for Correlative Studies ............................................................................... 28 9.4 Definition of Evaluable Subjects, On Study, and End of Study ................................. 28 9.5 Early Study Termination ............................................................................................ 28 10 STUDY DRUG ..................................................................................................................... 28 10.1 Names, Classification, and Mechanism of Action ..................................................... 28 10.2 Packaging and Labeling of Study Agents ................................................................... 30 10.3 Supply, Receipt, and Storage ...................................................................................... 30 10.4 Dispensing and Preparation ........................................................................................ 31 10.5 Compliance an d Accountability ................................................................................. 31 10.6 Disposal and Destruction ............................................................................................ 31 I-ATTAC Version: 20220204 5 11 SUBJECT ELIGIBILITY ..................................................................................................... 31 12 SCREENING AND ON -STUDY TESTS AND PROCEDURES ....................................... 33 12.1 Screening Examination ............................................................................................... 33 12.2 Treatment Period ........................................................................................................ 34 12.3 End of Treatment ........................................................................................................ 38 12.4 Follow -up Period ........................................................................................................ 38 12.5 End of Study ............................................................................................................... 38 12.6 Early Withdrawal of Subject(s) .................................................................................. 38 12.6.1 Criteria for Early Withdrawal ................................................................................. 38 12.6.2 Follow -up Re quirements for Early Withdrawal ..................................................... 38 12.6.3 Replacement of Early Withdrawal(s) ...................................................................... 39 12.7 Study Assessments ..................................................................................................... 39 12.7.1 Medical History ...................................................................................................... 39 12.7.2 Physical Exam ......................................................................................................... 39 12.7.3 Use of Antihistamines ............................................................................................. 39 12.7.4 Radiologic Evaluations ........................................................................................... 39 12.7.5 Immunologic Assessments ...................................................................................... 40 13 SAFETY MONITORING AND REPORTING .................................................................... 41 13.1 Adverse Events ........................................................................................................... 41 13.1.1 Reporting of AEs .................................................................................................... 42 13.2 Adver se Events of Special Interest ............................................................................. 42 13.3 Serious Adverse Events .............................................................................................. 42 13.3.1 Reporting of SAEs .................................................................................................. 43 13.4 External Data and Safety Monitoring Board .............................................................. 43 14 QUALITY CONTROL AND QUALITY ASSURANCE .................................................... 44 14.1 Monitoring .................................................................................................................. 44 14.2 Audits .......................................................................................................................... 44 14.3 Data Management and Processing .............................................................................. 45 14.3.1 Study Document ation .............................................................................................. 45 14.3.2 Data Management ................................................................................................... 45 14.3.3 Data Management Procedures and Data Verification ............................................. 46 14.3.4 Coding ..................................................................................................................... 46 14.3.5 Study Closure .......................................................................................................... 46 15 STATISTICAL METHODS AND DATA ANALYSIS ...................................................... 46 I-ATTAC Version: 20220204 6 15.1 Study Design Overview .............................................................................................. 46 15.2 Analysis Sets ............................................................................................................... 46 15.3 Patient Demographics and Other Baseline Char acteristics ........................................ 47 15.4 Treatments .................................................................................................................. 47 15.5 Primary Objective ....................................................................................................... 47 15.5.1 Variab le ................................................................................................................... 47 15.5.2 Statistical Hypothesis, Model, and Method of Analysis ......................................... 47 15.5.3 Handling of Missing Values, Censoring, and Discontinuation............................... 47 15.6 Secondary Objectives ................................................................................................. 48 15.6.1 Secondary Objective #1: Migration and Survival .................................................. 48 15.6.2 Secondary Objective #2: CCL3 and Survival ........................................................ 49 15.6.3 Secondary Objective #3: Polyfunctionality and Survival ...................................... 49 15.6.4 Secondary Objective #4: T Regs ............................................................................... 50 15.6.5 Secondary Objective #5: Toxicity ......................................................................... 51 15.7 Exploratory Objectives ............................................................................................... 52 15.7.1 Exploratory Objective #1: Migration and CCL3 ................................................... 52 15.7.2 Exploratory Objective #2: Polyfunctionality and Migration ................................. 53 15.7.3 Exploratory Objective #3: Polyfunctionality and CCL3 ....................................... 53 15.8 Interim Analysis ......................................................................................................... 53 15.9 Sample Size Calculation ............................................................................................. 53 16 ADMINISTRATIVE AND ETHICAL CONSIDERATIONS ............................................. 54 16.1 Regulatory and Ethical Compliance ........................................................................... 54 16.2 DUHS Institutional Review Board and DCI Cancer Protocol Committee ................. 54 16.3 Informed Consent ....................................................................................................... 54 16.4 Privacy, Confidentiality, and Data Storage ................................................................ 55 16.5 Data and Safety Monitoring ....................................................................................... 55 16.6 Protocol Amendments ................................................................................................ 55 16.7 Records Retention ....................................................................................................... 56 16.8 Conflict of Interest ...................................................................................................... 56 16.9 Registration Procedure ............................................................................................... 56 17 REFERENCES ..................................................................................................................... 57 18 APPENDICES ...................................................................................................................... 63 18.1 Standard Radiation Therapy ....................................................................................... 63 18.2 Temozolomide Therapy .............................................................................................. 63 I-ATTAC Version: 20220204 7 2 LIST OF FIGURES Figure 1. Study Schema ................................................................................................................ 12 Figure 2: Homeostatic Lymphodepletion Induced by Temozolomide Enhances Antigen- Specific Immune Responses. ...................................................................................................................... 17 Figure 3: Polyclonal Antibody Median Fluorescence Index (MFI) Against GM -CSF is Plotted Over Time Coinciding With Vaccine and Apheresis Administrations in One subject. Anti -GM- CSF Antibodies (IgG+IgM) Increases Over Time With Repeated Vaccinations Using Recombinant GM -CSF and Begin to Decrease After the Adjuvant Was R emoved. .................... 21 Figure 4: IgE Antibody Median Fluorescence Index (MFI) Against GM -CSF is Plotted Over Time Coinciding With Vaccine and Apheresis Administrations in One Subject. IgE Antibody Fluoresce nce Against GM -CSF Peaks at Vaccine#8, Consistent With the Subject’s Anaphylactic Episode at This Time Point Before Slowly Decreasing Back to Baseline After Adjuvant Removal. .......................................................................................................................................