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 regard less of attribution. Note: Grade 1 events are not required to be reported. 7.2.3 NIH Intramural 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 NIH Intramural IRB. IND SPONSOR REPORTING CRITERIA From the time the subject receives the investiga tional agent/intervention to the time of the second follow-up evaluation, the investigator must immediately report to the sponsor, using the mandatory MedWatch Form FDA 3500A or equivale nt, any serious adverse event, whether or not considered drug-related, including those listed in the protocol or Investigator’s Brochure and must include an assessment of whether there is a reasonable possibility that the drug caused the event. For serious adverse events that occur after the second follow-up evaluation, only those events that have an attribution of at least possibly related to the agent/intervention will be reported. Required timing for reporting per the above guidelines: x Deaths (except death due to progressive dis ease) must be reported via email within 24 hours. A complete report must be s ubmitted within one business day. x Other serious adverse events as well as de aths due to progressive disease must be reported within one business day. Events will be submitted to the Center for Cancer Research (CCR) at CCRsafety@mail.nih.gov and to the CCR PI and study coordinator. Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 46All serious adverse events will be reported by the Sponsor (Center for Cancer Research) as per FDA 21 CFR 312.32. 7.3.1 Reporting Pregnancy Maternal Exposure If a patient becomes pregnant during study treatment, the treatment should be discontinued immediately. Pregnancies occurring during study treatment and for the first 120 days after the last vaccination should be reported to the Sponsor. The potential risk of exposure of the fetus to the investigational agent should be documen ted using the MedWatch Form FDA 3500A or equivalent. Pregnancy itself is not regarded as an SAE. Ho wever, as patients who become pregnant on study risk intrauterine exposure of the fetus to agents which may be teratogenic, the CCR is requesting that pregnancy should be reported in an expe dited manner as grade 3 “Pregnancy, puerperium and perinatal conditions - Other (pregnancy)” under the Pregnancy, puerperium and perinatal conditions SOC. Congenital abnormalities or birth defects and spontaneous miscarriages should be reported and handled as SAEs. Elective abortions without comp lications should not be handled as AEs. The outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, or congenital abnormality) should be followed up and documented. If any pregnancy occurs in the course of the study, then the investigator should inform the Sponsor within one day, i.e., immediately, but no later than 24 hours of when he or she becomes aware of it. The designated Sponsor representative will work with the investigator to en sure that all relevant information is provided to the Sponsor within 1- 5 calendar days for SAEs and within 30 days for all other pregnancies. The same timelines apply when outcome information is available. Paternal Exposure Male patients should refrain from fathering a ch ild or donating sperm during the study and for 120 days after the last vaccination. Pregnancy of the patient’s partner is not considered to be an AE. However, the outcome of all pregnancies (spontaneous miscarriage, elective ter mination, ectopic pregnancy, normal birth, or congenital abnormality) occurring fr om the date of the first dose until 120 days after the last dose should, if possible, be followed up and documented. SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL COLLABORATOR The Sponsor (Center for Cancer Research) will pr ovide Moderna with: (1) copies of all safety reports concurrently with their submission to the FDA; (2) a cumulative listing of adverse events (including suspected adverse reactions) on a quart erly basis; (3) notice within 48 hours of case completion with respect to a serious adverse event; and, (4) any other information affecting the safety of human subjects. This information will be submitted to Moderna at drugsafety@modernatx.com. Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 47Note: The quarterly cumulative listing of adverse events (including susp ected adverse reactions) will be submitted by the PI/research team to the Sponsor for reporting to Moderna. INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) REPORTING CRITERIA 7.5.1 Serious Adverse Event Reports to IBC The PI (or delegate) will notify IBC of any unexpected fatal or life-threatening experience associated with the use of the gene transfer produ ct as soon as possible but in no event later than 7 calendar days of initial receipt of the informa tion. Serious adverse events that are unexpected and associated with the use of the gene transfer product, but are not fatal or life-threatening, must be reported to the NIH IBC as soon as possible, but not later than 15 calendar days after the investigator’s initial receipt of the information. Adverse events may be reported by using the MedWatch Form FDA 3500A or equivalent. 7.5.2 Annual Reports to IBCWithin 60 days after the one-year anniversary of the date on which the IBC approved the initial protocol, and after each subsequent anniversary until the trial is completed, the PI (or delegate) shall submit the information described below. Alternatively, the NIH Intramural IRB continuing review report can be sent to the IBC in lieu of a separa te report. Please include the IBC protocol number on the report. Clinical Trial Information A brief summary of the status of the trial in progress or completed during the previous year. The summary is required to include the following information: x Title and purpose of the trial x Clinical site x Principal Investigator x Clinical protocol identifiers x Participant population (such as disease indi cation and general age group, e.g., adult or pediatric) x 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 br ief description of the reasons x 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. Progress Report and Data Analysis Information obtained during the previous year's clinical and non-clin ical investigations, including: x Narrative or tabular summary showing the most frequent and most serious adverse experiences by body system Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 48x Summary of all serious adverse events submitted during the past year x Summary of serious adverse events that were expected or considered to have causes not associated with the use of the gene transf er product such as disease progression or concurrent medications x If any deaths have occurred, the number of pa rticipants who died during participation in the investigation and causes of death x Brief description of any information obtained that is pertinent to an understanding of the gene transfer product’s actions, including, fo r example, informati on about dose-response, information from controlled trials, a nd information about bioavailability. DATA AND SAFETY MONITORING PLAN 7.6.1 Principal Investigator/Research Team The clinical research team will meet on a weekly basis when patients are being actively treated on the trial to discuss each patient. Decisions about enrollment and dose escalation, if applicable, will be made based on the toxicity data from prior patients. All data will be collected in a timely manner and reviewed by the PI or AI. Adverse events will be reported as required above. Any safety concerns , new information that might affect either the ethical and/or scientific conduct of the trial, or protocol devia tions will be reported to the NIH Intramural IRB using iRIS. The PI will review AE and response data on each pa tient to ensure safety and data accuracy. The PI will personally conduct or supervise the inve stigation and provide ap propriate delegation of responsibilities to other members of the research staff. 7.6.2 Sponsor Monitoring Plan As a Sponsor for clinical trials, FDA regulati ons require the CCR to maintain a monitoring program. The CCR’s program allows for confirmation of: study data, specifically data that could affect the interpretation of primary study endpoints; adherence to the protocol, regulations, and SOPs; and human subject’s protection. This is done through independent verification of study data with source documentation focusing on: x Informed consent process x Eligibility confirmation x Drug administration and accountability x Adverse events monitoring x Response assessment The monitoring program also extends to multi-site research when the CCR is the coordinating center. This trial will be monitored by personnel employed by a CCR contractor. Monitors are qualified by training and experience to monitor the progres s of clinical trials. Personnel monitoring this study will not be affiliated in any way with the trial conduct. Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 497.6.3 Safety Monitoring Committee (SMC) This protocol will require oversight from the SM C. Initial review will occur as soon as possible after the annual NIH Intramural IRB continuing re view 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 peri od. Written outcome letters will be generated in response to the monitoring activities and submitted to the PI and Clinical Director or Deputy Clinical Director, CCR, NCI. 8 STATISTICAL CONSIDERATIONS STATISTICAL HYPOTHESIS 8.1.1 Primary Efficacy Endpoints x Determine the clinical response rate in patients with meta static melanoma, gastrointestinal, or genitourinary cancers who receive NCI-4650. x Determine the safety of NCI-4650 in patients w ith metastatic melanoma, gastrointestinal, or genitourinary cancer. 8.1.2 Secondary Efficacy Endpoint x Determine whether administration of NCI-4650, a mRNA-based, PCV presenting immunogenic neoantigens, can increase the quantity and quality of circulating antigen-specific T-cells in patients with solid tumors. SAMPLE SIZE DETERMINATION The study will be conducted using a phase I dos e escalation followed by a phase II Simon minimax design in two cohorts: Cohort 2a, patients w ith melanoma and Cohor t 2b, patients with gastrointestinal or genitourinary cancer. Following dose escalation, the objective will be to determine if NCI-4650, given at the MTD, is associated with a clinical respons e rate that can rule out 5% ( p0=0.05) in favor of a modest 20% PR+CR rate (p1=0.20) in each of the two cohorts in Phase II. For each cohort in the Phase II portion of th is study, using a two-stage Simon minimax design, with alpha=0.10 (10% probability of accepting a p oor therapy) and beta =0.20 (20% probability of rejecting a good therapy), initially 12 evaluable patients will be enrolled. If 0 of the first 12 evaluable patients experience a clin ical response, then no further patients will be enrolled in that cohort. If 1 or more of the first 12 evaluable patients enrolled have a clinical response, then accrual will continue until a total of 21 evaluable patients have been enrolled in that cohort. As it may take several weeks to determine if a patient has experienced a clinical response, a temporary pause of up to 6 months in the accrual to the trial may be necessary to ensure that enrollment to the second stage is warranted. If 1-2 of the 21 ev aluable patients have a cl inical response, then this will be considered inadequa te for further investigation. If 3 or more of the 21 evaluable patients have a clinical response, then this w ill indicate that this strategy provides a new approach that may be worthy of further consid eration in that cohort. Under the null hypothesis (10% response rate), the probability of early termination per cohort is 54.0%. The dose escalation portion of the study may requ ire 6 patients per dose level. For purposes of sample size estimation, we will a ssume that as few as 12 and no more than 18 patients will be Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 50required to perform the initial safety evaluation. In order to complete th e dose escalation phase and Phase II, a total of up to 18+46 =64 patients may be required (allowing up to 2 inevaluable patients per Phase II cohort). Up to 6 patients enrolled at the MTD will count towards the accrual in the Phase II portion of the trial if they are evaluable for response and if they would be fully eligible for enrollment in the Phase II portion of the trial. Provided that about 2-3 patients per month will be able to be enrolled onto this trial, approximately 2-3 years may be needed to accrue the maximum number of requi red patients. However, as ade quate responses to proceed to the second stage of accrual may not occur, the trial may end up accruing many fewer patients. POPULATIONS FOR ANALYSES 8.3.1 Evaluable for Toxicity All patients will be evaluable for toxicity fro m the time of their first mRNA vaccine dose. 8.3.2 Evaluable for Objective ResponseOnly those patients who have measurable disease present at baseline, have received at least one course of therapy, and have had their disease re-evaluated will be considered evaluable for response. These patients will have their response classified accordin g to the definitions stated in Section 6.3.3. 8.3.3 Evaluable for Non-Target Disease Response Patients who have lesi ons present at baseline that are evalua ble but do not meet the definitions of measurable disease, have received at least one course of therapy, and have had their disease re- evaluated will be considered evaluable for non-tar get disease. The response assessment is based on the presence, absence, or unequivocal progression of the lesions. STATISTICAL ANALYSES 8.4.1 General Approach In the Phase I cohort, the toxicities experienced by patients at each dos e level will be reported per dose level. In the two Phase II cohorts, clinical responses will be determined and the fraction with a clinical response will be repor ted, along with confidence intervals. 8.4.2 Analysis of the Primary Efficacy Endpoints In the Phase I cohort, the toxicities experienced by patients at each dos e level will be reported per dose level. The grade of the toxicity as well as the type of toxicity will be tabulated per dose level. In the Phase II cohorts, the fraction of patients who experience a clinical response in each cohort will be reported along with 80% and 95% two-sided confidence intervals. 8.4.3 Analysis of the Secondary Efficacy Endpoint The study will aim to determine whether treatment administration can increase the quantity and quality of circulating antigen-specific T-cells, by measuring the reactivity of circulating cells against the immunizing peptides in Elispot and 41BB upregulation assays. The comparisons will be done using descriptive statistics, without formal statistical testing required. Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 518.4.4 Safety Analyses Safety will be monitored by identifying the type and severity of any adverse events. The fraction of patients who experience a DLT will be identified at a given dose level, with information reported about the number and grade of each type of DLT identified. 8.4.5 Intention-to-Treat Analysis An intention-to-treat (ITT) analysis will be condu cted of all patients enrolled to the study. A full CONSORT flow diagram will be included in all ITT analyses. 8.4.6 Planned Interim Analyses As noted in Section 8.2, results after the first stage of a Simon minimax two-stage design in each Phase II cohort will be examin ed to determine if the minimum number of responses has been obtained. 8.4.7 Sub-Group AnalysesThere are no planned analyses based on demographic characteristics since the power to do subgroup analyses would be limited a nd make interpretation difficult. 9 COLLABORATIVE AGREEMENTS MODERNA TX, INC. CTA #01051-17 Tumor specific antigens (TSAs) containing be tween 320 and 639 amino acids will be sent to Moderna (formerly Moderna Therapeutics, Inc.) for the manufacture of a single concatemeric mRNA construct to be formulated into a vaccin e for the same cancer patient. Sequencing data will be transferred electronically via the secu re, encrypted Globus file transfer system (Globus.org) under the current NCI license for this transfer software. The vaccine product and associated data will be returned to the NCI-SB. CDA #14358-18 The following data will be transferred to Moderna: (1) raw sequencing data, including tumor DNA whole exome, tumor RNA whole transc riptome, and normal DNA whole exome sequencing data in FASTQ and/or BAM format; (2) somatic variant calling results in VCF format; (3) gene expression quan tification results in plain text format; (4) patient HLA types (major alleles: HLA-A, -B, -C, -DRB1, and any ot her HLA class II alleles that are typed, in 4 digits resolution (e.g., HLA-A:02:01)) in plain text format; (5) a list of all neoantigens that had been tested; and, (6) a list of a ll neoantigens tested to be imm unogenic (i.e., true positives). Moderna will compare the neoantigen ranks predicted by Moderna’s algorithm with the true positive and negative data from the NCI-SB. Moderna will also perform an investigation on features that are important for ne oantigens to be immunogenic. Data will be transferred electronically via a secure encrypted Amazon Web Service S3 bucket or via the secure, encrypted Globus file transfer system (Globus.org) under the current NCI license for this transfer software. No physical specimens will be shipped under this agreement. Results from Moderna’s neoantigen prediction algorithm (a prioritized list of neoantigens for each patient), and a comparison with NCI-SB’s results, will be returned to the NCI-SB. Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 5210 HUMAN SUBJECTS PROTECTIONS RATIONALE FOR PATIENT SELECTION Subjects from both genders and all r acial/ethnic groups are eligible fo r this study if they meet the eligibility criteria. To date, there is no information that suggests that differences in drug metabolism or disease response would be expected in one group compared to another. Efforts will be made to extend accrual to a representative population, but in this preliminary study, a balance must be struck between patient safety considerations and limitations on the number of individuals exposed to potentially toxic and/or ineffective treatments on the one hand, and the need to explore gender and ethnic aspects of clinical research on the other hand. If differences in outcome that correlate to gender or to ethnic identity are noted, accrual may be expanded or a follow-up study may be written to investigate those differences more fully. PARTICIPATION OF CHILDREN Since the efficacy of this experimental pro cedure is unknown, it does not seem reasonable to expose children to this risk without further evidence of benefit. Should results of this study indicate efficacy in treating metast atic cancer, which is not responsiv e to other standard forms of therapy, future research can be conducted in th e pediatric population to evaluate potential benefit in that patient population. PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT Adults unable to give consent are excluded from enrolling in the protocol. However, re-consent may be necessary and there is a possibility, though unlikely, that subjects could become decisionally impaired. For this reason and because there is a prospect of direct benefit from research participation (see Section 10.5 DOOVXEMHFWV DJHZLOOEHRIIHUH GWKHRSSRUWXQLW\WR fill in their wishes for research and care, and assign a substitute decision maker on the “NIH Advance Directive for Health Care and Medical Research Participation” form so that another person can make decisions about their medical care in the event that they become incapacitated or cognitively impaired during the course of the study. The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for ev aluation as needed for the following: an independent assessment of whethe r an individual has the capacity to provide consent; assistance in identifying and assessing an appropriate surrogate when indicated; and/or an assessment of the capacity to appoint a surrogate. For those subjects that become incapacitated and do not have a pre-determined substitute decision maker, the procedures described in MAS Policy 87-4 and OHSRP SOP 14E for appointing a surrogate de cision maker for adult subjects who are (a) decisionally impaired, and (b) who do not have a le gal guardian or durable power of attorney, will be followed. EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS The experimental treatment has a chance to provi de clinical benefit though this is unknown. The NCI-SB has extensive experience with adoptive cell therapy (ACT) following treatment with high-dose aldesleukin, however this experimental treatment does not include the standard NCI-SB preparative regimen or high-dose aldesleuki n. Although we have seen responses to prior NCI-SB ACT treatments, we do not know if this change in our proces s will improve patient outcome. The risks associated with ACT are substa ntial, including, a delay in treatment due to the need to harvest and grow the cells, a surgical procedure (possible major) to obtain tumor for Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 53the cell product, the possibility that a cell produc t cannot be generated, infection due to the surgical procedure, and death. The risks in this treatment are detailed in Section 11. RISK/BENEFIT ANALYSIS Because all patients in this prot ocol have metastatic or recurr ent/refractory locally advanced cancer and limited life expectancies the potential benefit is thought to outweigh the potential risks. The risk/benefit analysis for adults with the capacity to consent, as well as for adults who may become unable to provide consent, is greater than minimal risk because the study treatment may be associated with severe side effects, with the prospect of direct benefit because the treatment may reduce the cancer burden. CONSENT PROCESS AND DOCUMENTATION Patients are initially consente d on protocols 99-C-0128 and 03-C- 0277. If the patient meets the thorough screening for eligibility, the patient, with family members or friends at the request of the patient, will be presented with the informed consent document for this protocol, who is requested to review it and to ask questions pr ior to agreeing to participate. The specific requirements, objectives, and potential advantages and disadvantages will be presented to the patient. The patient is reassured that participation on trial is entirely voluntary and that he/she can withdraw or decide against treatment at an y time without adverse consequences. The PI, AI, or clinical fellow is responsible for obtaining written consent from the patient. 10.6.1 Telephone Consent for Part One Registration Because many patients will have previously been treated on another NCI-SB protocol prior to beginning treatment on this protoc ol, these patients may not be onsite at the NIH Clinical Center in order to sign the informed consent document for this protocol. In these circumstances, in order to complete Part One of the re gistration procedure (see Section 2.3.2), the informed consent process and a detailed description of the protocol treatment will be discussed with the potential participant via phone. The informed consent document will be sent to the subject. An explanation of the study will be provided over the telephone after the subject has had the opportunity to read the consent form. The subject will sign and date the informed consent. A witness to the subject’s signature will sign and date the consent. The original informed consent document will be sent back to the consenting investigator who will sign and date the consent form with th e date the consent wa s obtained via telephone. A fully executed copy of the informed consent will be returned via mail to the subject. The informed consent process will be documented on a progress note by the consenting investigator. 10.6.2 Informed Consent of Non-English Speaking Subjects If there is an unexpected enrollment of a research participant for whom there is no translated extant NIH Intramural IRB-approved consent documen t, the PI and/or those authorized to obtain informed consent will use the Short Form Oral Consent Process as described in MAS Policy M77-2, OHSRP SOP 12, 45 CFR 46.117 (b) (2), and 21 CFR 50.27 (b) (2). The summary that will be used is the English version of the extant NIH Intramural IRB-approved consent document. Signed copies of both the English version of the consent and the translated short form Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 54will be given to the subject or their legally authorized representative and the signed original will be filed in the medical record. Unless the PI is fluent in the prospective subject’s language, an interpreter will be present to facilitate the conversation (using either the long-translated form or the short form). Preferably someone who is independent of th e subject (i.e., not a family member) will assist in presenting information and obtaining consent. Whenever possible, interpreters will be provided copies of the relevant consent documents well before the consent convers ation with the subject (24-48 hours if possible). We request prospective NIH Intramural IRB appr oval of the use of the short form process for non-English speaking subjects and will notify the NI H Intramural IRB at the time of continuing review of the frequency of the use of the Short Form. 11 PHARMACEUTICAL INFORMATION CELL PREPARATION The procedure for growing and expanding the autologous young TIL is similar to what is approved by the Food and Drug Administration and used in other NCI-SB TIL clinical studies. TIL will be grown and expanded fo r this trial according to SOPs which can be found in BB-IND 17858. INTRAMUSCULAR INJECTION PREPARATION 11.2.1 NCI-4650, mRNA-Based Persona lized Cancer Vaccine Description: The CoA for the NCI-4650 mRNA vaccine is in Appendix C , and the SOPs for the preparation of the mRNA vaccine are found in BB-IND 17858. This product will be provided for investigational use under BB-IND 17858, which is sponsored by the CCR. The vaccine is composed of cGMP grade mRNA. Neoantigens will be identified from a sequence comparison of a patient’s tumor and normal DNA sample. An al gorithm will predict muta ted sequences with a high probability of binding to a patient’s specific HLA repertoire. Neoantigens will be prepared as peptides, either as 25mers, with the mutate d amino acid residue situated at position 13, or as minimal epitopes. The patient’s TIL, cultured from a biopsy sample, will be screened for their ability to recognize these neoantigens pulsed onto dendritic cells. Neoantigens recognized by the patient’s TIL will be used to formulate the vaccine. The vaccine will be formulated for each administration as indicated below. The identif ied immunogenic neoantig en sequences will be sent electronically to Moderna for vaccine manufacturing. Upon receipt of the final NCI-4650 product, vaccine will be administered via intramuscular injection. Mode of Action: NCI-4650 is taken by antigen-p resenting cells that process and present the neoantigens on HLA molecules to tumor-specific cytotoxic T-lymphocytes, leading to a major histocompatibility complex-restricted cytotoxi c response against tumor cells bearing these neoantigens. Formulation: NCI-4650 is a novel mRNA-based, PCV directed against s ubject-specific tumor neoepitopes. The individual mRNA sequences are designed for each subject based on the pipeline for the identification of immunogenic T-cell epitopes derived from neoantigens recognized by TIL developed by the NCI-SB . Each NCI-4650 vaccine consists of mRNA encoding neoantigens designed specifically to each individual subject’s tumor mutanome, and HLA type. Each subject-specific NCI-4650 vaccine is formulated in LNPs comprised of four Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 55 lipid excipients: SM-102; 1,2-dimyristoyl- rac-glycero-3-methoxypolyethylene glycol-2000 (DMG-PEG 2000); 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC); and cholesterol. SM- 102 is a novel, ionizable lipid that complexes with the mRNA component of NCI-4650 (mRNA product intermediate [MPI]) to promote the formation of the LNPs. The commercially-available lipids, DMG-PEG 2000, DSPC, and cholesterol, al so contribute to the overall pharmaceutical properties of the LNPs. NCI-4650 is provided as a sterile liquid for injection in a 93 mM Tris, 7% propylene glycol, 1 mM DTPA buffer, at a concentration of 1.0 mg RNA/mL. Stability: Please refer to the NCI Pharmacy Manual. Storage: NCI-4650 must be stored in a restri cted access area under the storage conditions indicated on the product label and in the NCI Phar macy Manual. Vials should be stored frozen at -20°C (± 5°C) (-13°F to 5°F). How Supplied: NCI-4650 is supplied as solution for injection in 2-mL glass vials (with a septum stopper). Each vial contains 0.6 mL. Preparation: The dose volume for Dose Levels 1 and 2 will be held constant at approximately 0.3 mL per injection. The dose volume for Dose Level 3 (PN 85002) will be at least 0.39 mL. The NCI Pharmacy Manual contains specific instructions for the preparation and administration of each dose level of NCI-4650. The NCI Pharmacy Manual also contains details regarding sterility release of NCI-4650. Administration: For all subjects, NCI-4650 will be administered by IM injection into the deltoid muscle (alternating deltoid musc le sites should be used for each subsequent injection, and injection sites may also be rotated to thigh muscles). Toxicities: Risk to subjects receiving NCI-4650 is expected to be low and primarily involving mild to moderate injection site reactions, which have been observed in animal studies and generally observed and expected for other IM administered vaccines. These local reactions may consist of transient and dose-dependent pain, swelling, and erythema. Possible mild to moderate systemic reactions, which are also transient, may include fever, fatigue, chills, headache, myalgias, and arthralgias. Such AEs may, in part, be due to the poor biodegradability of LNP formulations used in other vaccine studies; the LNP that comprises NCI-4650 is designed to incorporate biodegradable properties that may have an improved safety pr ofile. In addition, other AEs that have been generally associated with approved IM administere d vaccines have included mild hematological and clinical chemistry abnormalities, which are usually reversible. Subjects receiving NCI-4650 could experience signs and symptoms compatible with a C activation- related pseudoallergy (CARPA) response, which has been obser ved in the administration of approved liposomal products, contrast agents, pegylated proteins, and antibodies, as well as for small interfering RNA products formulated in LNPs. The signs and symptoms of CARPA resemble those of an acute hypersensitivity reac tion. However, complement activation is far less likely to be associated with clinical sign s for LNP products such as NCI-4650, that are administered IM at a much lower dose on a mg/kg basis than other clinical entities that cause CARPA in humans and nonclinical species. Special Handling: Please refer to the NCI Pharmacy Manual. Abbreviated Title: mRNA-Based, Cancer Vaccine Version Date: January 23, 2019 56 12 REFERENCES 1. Klein L, Hinterberger M, Wirnsberger G, Kyewski B. Antigen presentation in the thymus for positive selection and central toleran ce induction. 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