If this test is positive at any time, the patient will be discontinued from the study. 4.4 STUDY ASSESSMENTS Signed, IRB-approved informed consent must be obtained from patients prior to any pretreatment assessments. All patients will undergo a cardiac assessment at baseline (MUGA preferred, ECHO allowed, consistency require) and at 3, 6, 12, and 24 months. Cardiac assessment will continue every six months if a patient experiences a greater than 10% reduction from baseline for the duration of the trial or until resolution. There will be an allowable window of +/- 2 weeks for each study interval assessment test, beginning from the baseline MUGA or ECHO. CONFIDENTIAL Page 30 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 All patients must have a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) (20 cc of blood) within two months of trial initiation (date of enrollment for full participation) and, for female patients, a urine pregnancy test (upon consent to study), for screening and immediately prior to any vaccine inoculations or DTH. Urine pregnancy tests will not be required for Herceptin infusions alone. If the pregnancy test is positive, the patient will be excluded from the study. Women who have had a hysterectomy, bilateral oopherectomy, tubal ligation, documented absence of menses for two years, or FSH hormonal laboratory results that verify menopause, will not be required to have pregnancy testing. For patients who have a complete metastatic evaluation (CBC, LFTs, CXR, chest and abdomen CT, bone scan, and PET scan) available, all studies will be screened, but these studies are not required for enrollment. Disease-free status will be assured by the patients’ primary treating/referring physician. Overall health screen will be assessed utilizing the ECOG performance status grading system (Appendix I). To ensure eligibility, each patient will be HLA-typed. They will be asked for 6-8 cc of blood for HLA-A2/A3/A24/A26 screening (FACS analysis performed in the CVDL at USUHS in Bethesda, MD or alternatively at UT M.D. Anderson as described in Section 4.4.5). All patients regardless of randomization may be assessed for baseline immunologic responses prior to receiving the first dose of Herceptin and prior to the first inoculation. This may occur at selected sites. Specimen handling, processing, and assays are described in Sections 4.4.3, 4.4.4, 4.4.6 and 4.4.7. All patients will be tested for pre-inoculation DTH reaction against the E75 vaccine peptide as described in Section 4.4.9. Reactions will be read 48-72 hours after placement of the peptide. 4.4.1 Assessments during Treatment All patients will undergo cardiac assessment as per Section 3.4 at 0, 3, 6, 12, and 24 months, +/- a 2 week window at each interval test, beginning from the baseline study. Cardiac assessment will continue every six months if a patient experiences a greater than 10% reduction from baseline for the duration of the trial. The safety assessments will be evaluated by the site-specific study investigators. They will be responsible for assessment of patients with any toxicity reported to, or identified by, the study coordinators. The coordinators will assess the patients prior to and after Herceptin infusion, prior to and after vaccine inoculation, and will assess the patient 48-72 hours after vaccine inoculation, and on an “as needed” basis. The investigators will review all ECHO or MUGA results done at protocol time points, as well as any abnormal laboratory or image findings. For both the regular inoculations and booster series of shots, the patients will be monitored for 30 minutes following inoculation and vital signs taken as needed. Patients will either return to their study site or be contacted by phone for questioning regarding any systemic and local toxicity during the initial 48-72 hours after inoculation. If they return to the study site, the local reaction at the inoculation sites will be examined and measured. For patients that do not return to the study site, a CONFIDENTIAL Page 31 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 tool will be given, and instructions provided to measure the local reaction. The NCI CTCAE version 4.03 graded toxicity scale (Appendix B) will be utilized to assess local and systemic toxicity. Blood samples will be obtained from all patients, regardless of randomization, to determine in vivo induction of peptide-specific immune responses as described in Sections 4.4.3, 4.4.4, 4.4.6 and 4.4.7. This may occur at selected sites. 4.4.2 Follow-Up Assessments The clinical endpoint of recurrence will be determined by patients’ own physicians in the medical and surgical and/or the hematology/oncology clinics at the individual study sites during routine follow-up screening of all enrolled patients, regardless of randomization, every three months for the first 24 months after completion of primary therapies and every six months thereafter with clinical exam, laboratory and radiographic surveillance, e.g., CT, bone, and mammographic scans as indicated. This follow-up strategy is standard of care for these patients. The determination of recurrence will be per standard of care by the treating/referring physicians and communicated to the study investigators on a routine basis. Documentation of the recurrence will be obtained. Whenever possible, pathologic confirmation of recurrence will be obtained. However, a patient will also be considered to have a recurrence if highly suggested on radiographic evaluation and treatment for the recurrence is initiated by the treating physician. Documentation of the latter will be obtained. Disease free survival (DFS) as described by the NCI is the length of time after treatment for a specific disease during which a patient survives with no sign of the disease. For the purposes of this trial, the DFS will be calculated from initiation of Herceptin therapy until date of last follow-up. If records are not available, patients, or their referring physicians, will be contacted to discern their disease status and every effort will be made to obtain documentation. All enrolled patients, regardless of randomization, will be followed for clinical recurrence for up to three years from the date of initiation of Herceptin therapy. This data will be added to the patient database. 4.4.3 Human Biological Specimens In order to determine in vitro induction of peptide-specific immune responses in the vaccinated patients and GM-CSF-specific responses in the immunoadjuvant only patients, 50 cc of blood will be drawn prior to the first Herceptin dose, prior to first DTH #1 inoculation in the series, and before the fourth inoculation for immunologic studies to be performed in the CVDL at USUHS or at MDACC (Appendix A). In addition, 50 cc of blood will be drawn at 3-4 weeks after completion of the primary inoculation series for immunologic studies. Thus, a total of 200 cc of blood will be drawn related to the primary inoculation series, at selected sites. De-identified patient blood samples showing only the unique study ID number are sent from study sites via overnight delivery to the CVDL/MDACC where immunologic response assays (see Sections 4.4.4, 4.4.6 and 4.4.7) are performed. At no point will CVDL/MDACC personnel have access to patient identifiers. All assays performed at CONFIDENTIAL Page 32 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 the CVDL/MDACC are for research purposes only. These functions are conducted under a separate protocol approved by the USUHS Research Office as constituting non-human patients research or similar protocol at MDACC. Fifty cc of blood will also be drawn before administration of each booster inoculation and as well as at 3-4 weeks post-inoculation to record the immunologic response to each of 4 booster inoculations for a total of 400 cc of blood. Therefore, a maximum of up to 600 cc of blood will be drawn from all patients regardless of randomization over 36 months for immunologic response assessment. This blood will be in addition to the clinical laboratory tests (CBC and CMP) needed for enrollment screening. The clinical tests will require a total of 20 cc. The HLA typing requires 6-8 cc. Therefore, a total of 628 cc of blood will be required for the entire study. As noted above, de-identified blood tubes for research purposes will be labeled only with the patients’ unique study number and sent via overnight delivery to the CVDL/MDACC. At no point will CVDL/MDACC personnel have access to patient identifiers. Excess blood not used in assays will be frozen and stored under the unique protocol number and identifier for up to five years from collection for additional immunologic studies as needed. No genetic testing will be performed on this material, and it will not be made available to any other unrelated investigator. Peripheral blood mononuclear cells (PBMC) can be isolated by ficoll gradient separation. A small number may be tested immediately for peptide recognition. Some can be utilized to expand peripheral blood lymphocytes (PBL) in culture in low dose IL-2 and stimulated as necessary under different conditions. Evidence of immunologic recognition of the vaccinated peptide may be assessed by clonal expansion (dimer or tetramer assays) and functional assays such as cytokine release/production (ELISPOT). Other immunologic assays may be selectively assessed as well (e.g., antibody production).