If the treatment is delayed due to concomitant surgery beyond 12 weeks, the subject may be discontinued from the study . 10.10 ADVERSE EVENTS AND SUPPORTIVE CARE: The most likely AEs associated with ADXS11 -001 are comprised primarily of individual flu- like symptoms (e.g., fever, chills, body ache, and fatigue) or cytokine release symptoms (e.g., headache, nausea, vomiting, tachycardia, shortness of breath, hypotension and rash) . The symptoms usually present within 2- 4 hours after the completion of infusions and are often mild to moderate and transient in nature or responds quickly to symptomatic treatment. In rare instances they may last up to 24 hours . No cumulative toxicity has been observed. Less likely AE’s include increase heart rate, low blood pressure, muscle aches, headaches, allergic reaction, changes in blood chemistry, changes in blood counts, and short term changes in liver function. Rare but serious AEs include high fever , difficulty breathing and hypotension. V11.2 (1/9/20 ) Page 24 of 50 Like all Listeria, ADXS11 -001 has a tropism for the liver. Transient asymptomatic elevations of ALT and alkaline phosphatase were observed after dosing in the Phase 1 trial without prophylactic medication administration. For that reason, patients with significant liver disease are excluded, and particular attention is to be paid to hepatic abnormalities. 10.10.1 Supportive Care Guidelines: The major safety findings with ADXS11- 001 occurring in >5% of subjects , as of J une 2016 (n=290) and being possibly, probably or definitely related include anemia ( 61.4%), chills ( 63.5%), fatigue ( 25.5%) , fever ( 57.6 %), nausea ( 36.9%), vomiting ( 30.3%), headaches ( 23.8%). Most are Grade 1 -2 in severity. Subjects should receive appropriate supportive care measures as deemed necessary by the treating Investigator with consideration given to the criteria the items outlined below. Nausea and vomiting - should be treated aggressively, and consideration should be given in subsequent cycles to the administration of prophylactic antiemetic therapy according to standard institutional practice. Subjects should be strongly encouraged to maintain liberal oral fluid intake. Cytokine Release Symptoms - are a constellation of inflammatory symptoms resulting from cytokine elevations associated with T cell engagement and proliferation. Symptoms related to cytokine release may include constitutional symptoms such as fever, chills, rigors, fatigue, headache, nausea, vomiting, rash, tachycardia, hypotension and shortness of breath which usually presents several hours after the infusion and lasts for up to 24 hours. These symptoms are caused by an increase in cytokines such as TNFα, IFNγ and IL- 6, all of which have been shown to occur after ADXS11- 001 administration, resulting from the body’s immune response to the therapy. Although, symptoms are often Grade 1- 2 and transient, resolving with symptomatic management within 30 minutes to 1 hour, in some instances (~ 6%) Grade 3- 4 hypotension has been seen. Therefore, close monitoring of blood pressure is strongly recommended at baseline, and during the post -infusion period. Increased levels of IL-6 have been strongly associated with capillary leak which manifests as hypotension due to the cytokines involved. We have observed elevated IL- 6 levels after infusion of ADXS11 -001, with peak levels occurring 2- 4 hours after infusion. Emerging evidence indicates that IL -6 antago nists, such as tocilizumab, have demonstrated good results in treating cytokine -induced hypotension [ 61, 62, 63, 64] and are therefore recommended for cases of severe hypotension refractory to supportive care (e.g., fluids and/or pressors). The management of cytokine release symptoms and guidelines for subsequent treatment for subjects who have experiences these AEs are shown in the table below. V11.2 (1/9/20 ) Page 25 of 50 Table B Recommended Management Guidelines for Adverse Events Associated with Cytokine Release Toxicity NCI CTCAE Grade or Severity Treatment Modification for Subsequent infusions Hypotension 1 Mild • Supportive care • Increase pretreatment IV fluids (e.g., 500 ml -1L normal saline) All other cytokine release symptoms (e.g. chills, rigors, fever, nausea, vomiting) 1 • Supportive care • No modification Hypotension 2 Moderate • Fluids and 1 dose of pressor (e.g. 0.3 mg epinephrine IM) • Increase monitoring of vital signs • If hypotension persist for more than one hour consider low dose corticosteroids (e.g. hydrocortisone 100 mg IV over 30 seconds • Extend infusion time to 2 hours. • Increase pretreatment IV fluids (e.g. 500 ml -1L normal saline) • Incorporate Glucocorticoid- Hydrocortisone or equivalent - 50 mg, IV, as premedication All other cytokine release symptoms (e.g. chills, rigors, fever, nausea, vomiting) 2 • Appropriate supportive care measure • Extend infusion time to 2 hours. • Consider increasing doses of prophylactic medications Hypotension 3 Severe • Fluids, high dose pressors (e.g. Dopamine 10 µg/kg/min) +1 dose tocilizumab*(4mg/kg over 1 hour) • If hypotension worsens or is unresponsive to above measures, administer corticosteroids • Discuss with Sponsor V11.2 (1/9/20 ) Page 26 of 50 Toxicity NCI CTCAE Grade or Severity Treatment Modification for Subsequent infusions • If the subject’s condition does not improve or stabilize within 24 hours of the tocilizumab dose, administration of a second dose of tocilizumab +/ - corticosteroids should be considered. All other cytokine release symptoms (e.g. chills, rigors, fever, nausea, vomiting) 3 • Appropriate supportive care measures • Extend infusion time to 2 hours. • Consider increasing doses of prophylactic dose of NSAID, or antiemetic as appropriate Hypotension/ Organ toxicity, mechanical ventilation 4 Life threatening • Vigilant supportive care • Fluids • High dose pressors, • Tocilizumab (4mg/kg over 1 hour) +/ - corticosteroids (hydrocortisone 100 mg IV infused over 30 seconds administered every 2 hours until symptoms resolve to <Grade 1) • Permanently discontinue * Tocilizumab is a humanized, immunoglobulin G1k (IgG1k) anti- human IL -6R mAb approved for treatment of adult subjects with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response to Disease- Modifying Anti -Rheumatic Drug s (DMARDs), for the treatment of active polyarticular juvenile idiopathic arthritis (PJIA), and active systemic juvenile idiopathic arthritis (SJIA) in subjects 2 years of age and older. Tocilizumab works by preventing IL -6 binding to both cell - associated and soluble IL -6Rs. Although, it is not indicated for the treatment of cytokine release symptoms emerging clinical experience at several institutions has concluded that tocilizumab is an effective treatment for severe or life -threatening cytokine release symptoms . [61, 62, 63, 64] V11.2 (1/9/20 ) Page 27 of 50 Management of infusion reactions - While there is some overlap between the symptoms of cytokine release and infusion reactions, infusion reactions typically occur during the infusion, while symptoms associated with cytokine release typically occur after the infusion and are mediated by a different mechanism of action. Signs/symptoms of infusion reactions may include: allergic reaction/ hypersensitivity (including drug fever); arthralgia (joint pain); bronchospasm; cough; dizziness; dyspnea (shortness of breath); fatigue (asthenia, lethargy, malaise); headache; hypertension; hypotension; myalgia (muscle pain); nausea; pruritis/itching; rash/ desquamation; rigors/chills; sweating (diaphoresis); tachycardia; tumor pain (onset or exacerbation of tumor pain due to treatment); urticaria (hives, welts, wheals); vomiting. Table C below shows the management guidelines for subjects who experience an infusion reaction associated with administration of ADXS11 -001. V11.2 (1/9/20 ) Page 28 of 50 Table C: Management Guidelines for Infusion Reactions NCI CTCAE Grade Management Grade 1 Mild reaction; infusion interruption not indicated; intervention not indicated Increase monitoring of vital signs as medically indicated until the subject is deemed medically stable in the opinion of the Investigator. Grade 2 Requires infusion interruption but responds promptly to symptomatic treatment (e.g., antihistamines, NSAIDS, narcotics, IV fluids); prophylactic medications indicated for ≤24 hrs. 1. Stop Infusion and monitor symptoms. Additional appropriate medic al therapy may include but is not limited to: IV fluids Antihistamines NSAIDS Acetaminophen Narcotics 2. Increase monitoring of vital signs as medically indicated until the subject is deemed medi cally stable in the opinion of the Investigator. If symptoms resolve within one hour of stopping drug infusion, the infusion may be restarted at 50% of the original infusion rate. Otherwise dosing will be held until symptoms resolve and the subject should be premedicated for the next scheduled dose. Grades 3 or 4 Grade 3 : Prolonged (i.e., not rapidly responsive to symptomatic medication and/or brief interruption of infusion); recurrence of symptoms following initial improvement; hospitalization indicated for other clinical sequelae (e.g., renal impairment, pulmonary infiltrates) Grade 4: Life-threatening; pressor or ventilatory support indicated 3. Stop Infusion. Additional appropriate medical therapy may include but is not limited to: IV fluids Antihistamines NSAIDS Acetaminophen Narcotics Oxygen Pressors Corticosteroids Epinephrine 4. Increase monitoring of vital signs as medically indicated until the subject is deemed medically stable in the opinion of the Investigator. 5. Hospitalization may be indica ted. 6. Subjects who experience a Grade 4 reaction should be permanently discontinued from study. Subjects who experience a grade 3 reaction may be discontinued. Discussion with the Sponsor is recommended V11.2 (1/9/20 ) Page 29 of 50 10.10.2 Listeriosis and Listeria Infection- Identification and Management A person with wild type ( wt) listeriosis usually presents with fever and muscle aches, sometimes preceded by diarrhea or other gastrointestinal symptoms. Almost everyone who is diagnosed with listeriosis has an "invasive" infection, in which the bacteria spread beyond the gastrointestinal tract. The symptoms vary with the infected person. Pregnant women typically experience fever and other non -specific symptoms, such as fatigue and aches. However, infections during pregnancy can lead to miscarriage, stillbirth, premature delivery, or life- threatening infection of the newborn. In people other than pregnant women, symptoms can include headache, stiff neck, confusion, loss of balance, and convulsions in addition to fever and muscle aches. Listeriosis can present in different ways. In older adults and people with immunocompromising conditions, septicemia and meningitis are the most common clinical presentations. [58] Subjects may need immediate evaluation with a brain CT scan or MRI and a lumbar puncture with the analysis of spinal fluid to rule out meningitis. For symptomatic subjects, diagnosis is confirmed only after isolation of Lm from a normally sterile site, s uch as blood or spinal fluid (in the setting of nervous system involvement), or amniotic fluid/placenta (in the setting of pregnancy). Stool samples are of limited use and are not recommended. Lm can be isolated readily on routine media, but care must be taken to distinguish this organism from other Gram -positive rods, particularly diphtheroids. Selective enrichment media improve rates of isolation from contaminated specimens. You can expect that the cultures will take approximately 1- 2 days for growth. Importantly, a negative culture does not rule out infection in the presence of strong clinical suspicion. Serological tests are unreliable, and not recommended at the present time [ 58]. Listeriosis is treated with a wide range of antibiotics. In preclinical studies, wt -Lm and ADXS11- 001 are susceptible to the lowest tested concentration of the following antimicrobial agents: ampicillin, amoxicillin/K clavulanate, ciprofloxacin, erythromycin, gentamicin, penicillin, tetracycline, trimethoprim/sulfamethoxazole and vancomycin (IV). ADXS11- 001 is resistant to both streptomycin and chloramphenicol . 10.10.3 Management and Surveillance of Listeria during Study Participation In the event a subject experiences a persistent fever lasting 72 hours after receiving study treatment then the oral antibiotic regimen will be replaced by broad spectrum IV antibiotic treatment. If symptoms consistent with sepsis occur close to ADXS11 -001 administration or at any time after ADXS11 -001 administration, immediate medical attention must be sought. A microbial culture will be taken to identify the agent of sepsis and antibiotic sensitivity testing should be performed to confirm susceptibility. An infectious disease consult should be obtained for further management of these subjects . All subjects will receive a 6- month course of an oral antibiotic regimen as a prophylactic measure approximately 72 hours following the completion of the last dose of ADXS11- 001 treatment or at the time of study discontinuation. This additional safety measure is intended to eradicate Lm from the body. V11.2 (1/9/20 ) Page 30 of 50 Lm surveillance monitoring will also be initiated following the completion of the last dose of ADXS11 -001 treatment or at the time of study discontinuation. This monitoring will include obtaining a blood sample for CBC, comprehensive metabolic panel (CMP), including CRP and ESR, and blood cultures for the detection of Listeria . Testing will be performed on all subjects who have received at least 1 dose of ADXS11- 001 and occur 3 months(+/ - 2 weeks), 6 mont hs(+/ - 3 weeks), 9 months(+/ - 1 Month), 12 months(+/ - 1 Month), and every 4 months(+/ - 1 Month) for year 2 and year 3 postoperatively. Should a diagnosis of listeriosis be made at any point after treatment with ADXS11- 001 is completed, immediate and intensive IV antibiotic treatment (ampicillin +/ - gentamycin or other IV antibiotic regimen as indicated) is required . An infectious disease consult should be obtained. Based on each individual subject’s case and at the discretion of the treating physician, the removal of any foreign medical object that has been present since treatment with ADXS11 -001 was initiated may be warranted. It is extremely important that the Investigator, his/her research staff, other healthcare providers involved in the care of the subject as well as each subject participating in this study are educated and made aware of the signs and symptoms of listeriosis and the potential for delayed listeremia/listeriosis. Educational materials for the Investigator, research staff, health care providers and subjects will be prepared and educational training performed. 10.10.4 Potential for delayed/late L isteria infection: ADXS11 -001 has been attenuated by ≥4 logs in comparison to the wild- type (wt) -Lm. ADXS11 - 001 is cleared by SCID mice lacking a functioning cellular immune system, as well as by gamma interferon knockout mice lacking adaptive immunity. ADXS11- 001 has been shown to be nonpathogenic in mouse models. In a Phase 1 clinical study, in the absence of antibiotics, Lm was rapidly cleared from the blood. No Lm was detected in the blood, urine or feces of any subject beyond 48 hours post -dosing and at the highest dose of ADXS11 -001 tested (1 x 10 10 CFU)52. wt-Lm is known to form and persist within biofilms especially on medical devices despite antibiotic treatment.53 Although rare, medical device– related infections such as ventriculo- peritoneal shunt infection, peritoneovenous shunt infection, and prosthetic joint infection have been reported. 54-57 ADXS11 -001 is highly sensitive to antibiotics such as ampicillin and trimethoprim/sulfamethoxazole which can be an e ffective treatment regimen for L isteria infection. However, to reduce the risk of ADXS11- 001 persisting within a patient by attaching to the surface of a fixed medical device by establishing a biofilm, patients with indwelling medical devices require special consideration. Therefore, subjects with implanted medical device(s) that pose a high risk for colonization and/or cannot be easily removed are excluded from this study. In addition, all subjects will receive a course of oral antibiotics beginning on Day 4 (approximately 72 hours) after each dose of ADXS11 -001 and for 6 months following the last dose of ADXS11 - 001 to aid in the eradication of the bacteria. As of June 2016 , approximately 290 subjects have received approximately 722 doses of ADXS11 -001. During the course of treatment in this subject population, there has been one reported cas e of Grade 3 listeriosis . The subject was a 56 year old female who was enrolled in V11.2 (1/9/20 ) Page 31 of 50 November 2012 in Study GOG -0265. During the course of her participation in the study, she suffered a motor vehicle accident which required multiple orthopedic surgeries involving the placement of hardware and a bone graft. After completing her participation in the study, she went on to receive multiple other treatments for her metastatic cervical cancer including an investigational PI3K inhibitor. Two and a half years after completing her last adm inistration of ADXS11 -001, she presented to the hospital with mental confusion and a fever. Blood cultures were positive for Lm. Subsequent analyses revealed that the isolate was essentially the same as ADXS11 -001 but without the plasmid. The subject was admitted to the hospital and treated with IV Ampicillin. She became afebrile and was discharged home three days after her admission. Prior to her discharge a spinal tap and a CT of the brain were recommended but the subject refused. Two weeks later the subject presented with acute respiratory distress caused by her metastatic disease and died. The investigator ruled that cause of death was due to disease progression (metastatic cervical cancer). It is hypothesized that dosing of attenuated Lm soon after her bone graft may have resulted in biofilm formation, which could have protected the Lm from both the immune system and antibiotics. At no time while the subject was on study or during the 2.5 years post -study did she show signs or symptoms of listerios is. The Lm isolate also remained highly susceptible to multiple antibiotics. Following recognition of this case of persistent Listeria colonization and delayed infection, new exclusion criteria and long- term monitoring provisions were added to this protocol to minimize the chance of this adverse event. Complete information on the toxicity profile can be found in the ADXS11 -001 Investigator’s Brochure . 11 TRANSORAL SURGERY FOR OROPHARYNGEAL CANCER 1. Patients have previously been determined by an attending Head and Neck surgeon and the multidisciplinary tumor board at each site , to be eligible for transoral resection. 2. Standard- of-care transoral surgery with intent to perform complete resection of the primary tumor will be performed according to our previously described methods 50. In brief: surgery will include transoral robotic resection or transoral laser resection of the tumor with negative intraoperative frozen section margins ; in selected cases it may be appropriate to remove the tumor with hand -held electrocautery under direct vision. Appropriate reconstruction will be performed at the time of tumor resection as deemed necessary by the operating surgeon. 3. Selective neck dissection of levels II -IV will be performed routinely ipsilateral to the primary tonsillar tumors. Bilateral selective neck dissection of levels II -IV will be performed for all tongue base tumors. Additional levels (i.e. I, V) will be performed at the discretion of the operating surgeon if indicated on the size and location of the pri mary tumor. N+ patients will undergo a simultaneous appropriate therapeutic neck dissection. 11.1 POSTOPERATIVE ADJUVANT THERAPY AND CLINICAL FOLLOW -UP 1. Adjuvant radiation therapy or chemoradiation will be given to appropriate patients based on preoperative and pathological risk factors as per standard- of-care. Participation in this trial will in no way alter the decision to provide post -surgical radiation or chemoradiation. While there is some leeway based on clinical judgment, standard criteria for adjuvant therapy include: positive surgical margin; lymphovascular invasion (LVI); perineural V11.2 (1/9/20 ) Page 32 of 50 invasion (PNI); extracapsular spread (ECS) of lymph node metastases or matted lymph nodes; low (level IV) cervical lymph nodes; >2 positive lymph nodes. These criteria are fairly standard across many institutions. If adjuvant therapy is indicated, therapy usually begins 4 to 6 weeks after surgical resection. 2. Patients will undergo routine post -treatment clinical follow -up, which usually involves monthly visits for the first year and q2- 3 month visits in the second year following treatment. Imaging is obtained at the discretion of the treatment team, but is generally obtained no less than q 3 months for the first 2 years after treat ment. 3. Assessment of disease status (no evidence of disease / NED; recurrent disease; second primary upper aerodigestive tumor; other second primary cancer) is performed by the attending surgeon at each follow -up appointment, and recorded in the electronic medical record (EMR). 12.0 SCHEDULE OF BLOOD AND SAMPLE COLLECTION 12.1 TREATMENT GROUP 1. The day of the first dose of vaccination will be considered “day 1”. 2. Standard- of-care pre -treatment tumor biopsy will be performed in a timely fashion for those patients without a prior biopsy, whose prior biopsy is inadequate for clinical planning, or for whom prior biopsy material adequate for immunophenotyping by immunohistochemistry (IHC) is not available. 3. Initial blood draw (Draw 1) will be obtained prior to the first vaccination usually during screening visit . 4. Draw #2 will be performed on the day of the first vaccination (e.g. day 1) before vaccine infusion . 5. Draw #3 will be performed on the day of the second vaccination (day 15) before vaccine infusion . 6. Surgery, and harvest of tumor and TIL, will be performed on day 35 +/ - 7 days following entry into the study and baseline blood draw. 7. Draw # 4 will be performed preoperatively , on the day of surgery prior to induction of anesthesia, or up to 72 hours prior to the surgery . 8. Draw # 5 will be performed 3 week s (+/- 1 week ) after surgery. 9. Draw # 6 will be performed 6 weeks (+/ - 1 week) after surgery, before radiation. 10. Draw # 7 will be performed 3 months (+/- 3 weeks ) post-surgery . 11. Draw # 8 will be performed 6 months (+/- 3 weeks ) post-surgery . 12. Draw # 9 will be performed 12 months (+/- 4 weeks) post-surgery . 12.1.1 LISTERIA SURVEILLANCE MONITORING BLOOD DRAW: Up to 45 ml of additional blood will be collected for safety follow up testing as Listeria surveillance monitoring. It will include CBC, CMP, including CRP and ESR and blood cultures for the detection of Listeria. V11.2 (1/9/20 ) Page 33 of 50 Patients in the control group will NOT undergo additional blood draw or monitoring. These blood draws will be performed at 3 months (+/- 2 weeks) , 6 months (+/- 3 weeks) , 9 months (+/- 1 Month) , 12 months (+/- 1 Month), and every 4 months (+/- 1 Month) for year 2 and year 3 as mentioned in schedule above. 12.2 OBSERVATIONAL GROUP 1. The day of screening will be considered “day 0”. Initial blood draw (Draw 1) will be obtained at screening. 2. Standard- of-care pre -treatment tumor biopsy will be performed in a timely fashion for those patients without a prior biopsy, whose prior biopsy is inadequate for clinical planning, or for whom prior biopsy material adequate for immunophenotyping by immunohistochemistry (IHC) is not available. 3. Draw # 2: Observational patients will NOT undergo this blood draw. 4. Draw # 3: Observational patients will NOT undergo this blood draw. 5. Draw # 4 will be performed preoperatively, on the day of surgery prior to induction of anesthesia, or up to 72 hours prior to surgery. 6. Draw # 5 will be performed 3 weeks (+/ - 1 week) after surgery. 7. Draw # 6 will be performed 6 weeks (+/ - 1 week) after surgery, befor e radiation. 8. Draw # 7 will be performed 3 months (+/ - 3 weeks) after surgery. 9. Draw # 8 will be performed 6 months (+/ - 3 weeks) after surgery. 10. Draw # 9 will be performed 12 months (+/ - 4 weeks) after surgery. 12.3 COLLECTION AND PROCESSING OF PERIPHERAL BLOOD SAMPLES 1. Baseline blood samples will be collected either immediately after consent or prior to the first vaccination. Samples will be collected at baseline, on the day of surgery (following two rounds of vaccination), and according to the schedule des cribed above. 2. At each collection, peripheral blood samples ( eight 7mL tubes, 56 mL total) will be withdrawn by a clinical research coordinator, a medical assistant or a clinic nurse and promptly transported to the designated laboratory for processing. Immediately prior to drawing blood, the person in charge of the procedure will verify the subject‘s identity. Immediately after the blood has been collected, a label containing the appropriate subject identification number and the subject‘s initials is to be affixed to the vial. 3. Serum will be obtained by centrifugation, and stored in 250uL aliquots at -80°C. Whole blood will be processed over a Ficoll gradient to obtain PBMC, and PBMC will be washed, counted, aliquotted and frozen in DMSO -containing freezing medium prior to long -term storage in liquid nitrogen. All tubes will bear self -adhesive labels that clearly identify the trial code, the patient number, the patient initials, and the visit number. Sterile technique will be maintained throughout so that viable cells may be cultured and assayed after thawing. V11.2 (1/9/20 ) Page 34 of 50 12.4 COLLECTION AND PROCESSING OF TUMOR SPECIMENS 1. Following resection, tumor specimens will be expeditiously transported to the pathology suite, where a pathologist will evaluate and identify the portion of the specimen in excess of that required for pathological analysis. 2. A small piece will be flash -frozen and transported to each institution’s designated banking resource facility as is routinely performed for all head and neck cancer specimens. 3. Where tumor size and quality permit, the remainder of the specimen will be transported on ice to the designated l aboratory for harvesting tumor -infiltrating lymphocytes (TIL) according to a standard protocol . Briefly, after removal of fat, blood and necrotic areas, tumor tissue will be washed in RPMI -1640 containing 50 µg/ml gentamycin, and cut into 1 mm 3 pieces in a petri dish covered with RPMI -1640. The sample is washed again with RPMI -1640 and upon transfer to flasks, dissociated using 0.05% collagenase type IV and 0.02% DNase type I in RPMI -1640 supplemented with 5% (v/v) fetal calf serum and antibiotics. Tissues will then be dissociated for up to 4 h using a magnetic stirrer at 37° C. The digest will then be passed through 90 µm and 50 µm nylon mesh to remove clumps, and the filtrate washed in 2–3· mL medium followed by centrifugation at 350· g for 10 min and resuspension in 2 mL medium . 4. PBMC will be washed, counted, aliquotted and frozen in DMSO -containing freezing medium prior to long- term storage in liquid nitrogen. All tubes will bear self -adhesive labels that clearly identify the trial code, the patient number, the patient initials, and the visit number. Sterile technique will be maintained throughout so that viable cells may be cultured and assayed after thawing. 12.5 IMMUNOPHENOTYPING AND CHARACTERIZATION OF HPV -SPECIFIC T CELL RESPONSES 1. Following purificatio n from whole blood or tumor, mononuclear cells will be cultured 48 hours in the presence or absence of pools of 15- 20-mer overlapping peptides encompassing the full -length HPV16 E6 and E7 antigens, or control (CMV, EBV and Flu virus) peptide mixtures. 2. After 48 hrs of stimulation, an aliquot of supernatant from the culture will be harvested and frozen at -80°C for future studies of cytokine production. 3. E6/E7 -specific T cell responses will be determined by ELISPOT, flow- cytometry for intracellular IFN -γ staining, or other comparable method. In brief, staining for T cell surface markers (CD3, CD4, CD8) with labeled antibodies is performed prior to fixation/permeablization of cells. Fix/permed cells are then stained with labeled antibody to IFN -γ, a marker of activated cytotoxic T cells. Multicolor flow cytometric analysis is then performed on an LSR II flow cytometer. 4. Additional flow cytometry staining panels to characterize NK cells (CD56), T cell activation and exhaustion markers (granzyme, perforin, CTLA -4, PD -1), regulatory T cell (CD127, CD25), and myeloid populations (CD11c, CD11b, CD33, HLA -DR) will be used to perform multi- dimensional immunophenotyping of effector and regulatory cell populations. V11.2 (1/9/20 ) Page 35 of 50 12.6 IMMUNOHISTOCHEMISTRY (IHC) AND MOLECULAR PROFILING OF TUMOR SPECIMENS 1. Tumor specimens obtained during standard -of-care resection will be harvested for preparation of tissue microarrays (TMA) from formalin -fixed, paraffin- embedded (FFPE) tissue specimens, according to each site’s routine protocols. Histological slides which include tumor tissue and surrounding normal tissue from the tumor margin will be created with the help of the designated pathology facility at each site. 2. Histological slides will be subjected to immunofluorescent staining and analysis . These data are quantified using image analysis instrumentation and software. This approach has allowed successful characterization and quantification of up to 5 -7 antigens in single sections54. 3. We will utilize a comprehensive panel of IHC markers including markers for myeloid cells; Treg (CD4/FOXP3); NK cells (CD56); and CD3+, CD4+ and CD8+ T cells . Staining for these markers will be examined by multiplex immunofluorescence and their density in tumor quantitated by digital image analysis. Tumor infiltrating myeloid cells will be identified with the markers CD33 (myeloid- derived suppressor cells, MDSC), CD11b (MDSC, some macrophages , some DCs), and CD68 (macrophages), and neutrophils (CD66b). 4. A portion of the tumor specimen will be flash frozen according to each site’s routine protocols, and cryopreserved for future molecular biology analyses of immune and cancer -related gene expression. 13.0 CRITERIA FOR REMOVAL FROM STUDY Subjects may withdraw consent at any time for any reason or be discontinued from the trial at the discr etion of the investigator, should any untoward effect occur. In addition, a subject may be withdrawn by the investigator or the sponsor/Study Chair if enrollment into the trial is inappropriate, the trial plan is violated, or for administrative and/or other safety reasons. Patients will be removed from the study, and notified of this fact, under the following circumstances: 1. Failure to obtain at least one baseline blood draw. 2. Failure to receive at least one vaccination (if in vaccine arm). 3. The patient experiences a grade IV toxicity. If a patient is removed from the study or if the patient wishes to discontinue participation before all visits and monitoring are complete, the following will occur: - For patients in the treatment group, 3 years of Lm surveillance monitoring will be offered. - Patients in the treatment group will be provided with sufficient antibiotics to complete the 6 months of post -vaccine treatment as described above. V11.2 (1/9/20 ) Page 36 of 50 14.0 Concurrent Therapies and Procedures All prescription and nonprescription medication (excluding vitamins, nutritional supplements and hormone replacement therapy) taken by the subject from 30 days prior to screening and up to and including completion of the 3 -year Lm surveillance period will be recorded in the medical record and on the eCRF. Any addition, deletion, or change in the dose of these medications will also be recorded. Generic names should be used to eliminate confusion that may result from trade names. Protocol -mandated prophylactic medications, antibiotics and procedures administered/performed following the completion of study treatment, including during the 3- year Lm surveillance period, should also be captured in the eCRF. Study subjects should be reminded that acetaminophen should not be used for pretreatment prophylaxis associated with the foreseeable AEs related to the study treatment since this medication can interfere with treatment. Medications specifically prohibited in the exclusion criteria are not allowed during the ongoing trial. If there is a clinical indication for one of these or other medications specifically prohibited during the trial, discontinuation from trial therapy may be required. The Investigator should discuss any questions regarding this with the Sponsor. The final decision on any supportive therapy rests with the Investigator and/or the subject’s primary physician. However, the decision to continue the subject’s on- trial therapy requires the mutual agreement of the Investigator, the Sponsor, and the subject. Subjects are prohibited from receiving the following therapies during the screening and treatment phases (including retreatment for post -complete response relapse) of this trial: • Anti-cancer systemic chemotherapy or biological therapy • Surgical treatment as per consultation with the sponsor • PI3K and TNFα inhibitors • Immunotherapy not specified in this protocol • Investigational agents other than ADXS11- 001 • Radiation therapy (except palliative radiation therapy for disease -related pain with a consult with the sponsor's medical monitor) • Live vaccines within 30 days prior to the first dose of trial treatment and while participating in the trial. Examples of live vaccines include, but are not limited to, the following: measles, mumps, rubella, chicken pox, yellow fever, rabies, BCG, and typhoid (oral) vaccine. Seasonal influenza vaccines for injection are generally killed virus vaccines and are allowed; however, intranasal influenza vaccines (e.g., Flu- Mist®) are live attenuated vaccines and are not allowed. • Acetaminophen is not to be used for premedication but may be used for supportive care measures. NSAIDs, such as naproxen and ibuprofen have been evaluated and are confirmed not to interfere with efficacy. Subjects who, in the assessment by the Investigator, require the use of any of the aforementioned treatments for clinical management should be removed from the trial. Subjects may receive other medications that the Investigator deems to be medically necessary. V11.2 (1/9/20 ) Page 37 of 50 15 Treatment Discontinuation: Surveillance monitoring for the detection of Lm will be initiated at the completion of study treatment according to the protocol or at the time of study discontinuation if earlier. This surveillance monitoring phase will consist of a 6 month course of oral antibiotics, obtaining a blood sample to monitor CBC, CMP, including CRP and ESR, and blood cultures at regular intervals. This testing will be performed on all subjects who have received at least one dose of ADXS11 -001. It will occur at 3 months(+/ - 3 weeks), 6 months(+/ - 3 weeks), 9 months(+/ - 1 Mon th), 12 months(+/ - 1 Month), and every 4 months(+/ - 1 Month) for 2nd and 3rd year beginning after the last dose of study treatment. If a persistent increase in CRP and/or ESR is observed with negative blood cultures for Listeria during this time the subject should be evaluated and treated, as appropriate, for another possible cause. In the event that a definite cause has not been identified then subjects must continue to be monitored closely, including another additional testing and a blood culture, for possible signs/symptoms of listeriosis. This testing may be performed at the investigative site or at another acceptable location following consultation with the Sponsor. 16.0 STATISTICAL CONSIDERATIONS We will employ the Simon’s two- stage design for the phase II clinical trials. (Simon R. Optimal two-stage designs for phase II clinical trials. Control Clin Trials 1989; 10: 1- 10.) This trial design maximizes the chances of detecting a true difference in the HPV -specific T cell frequencies in pre- and post -vaccination samples while minimizing the number of patients treated if there is no difference. We plan to enroll and vaccinate up to 2 2 HPV+ OPC patient s. In parallel we also plan to enroll and collect samples from up to 10 un -vaccinated HPVOPC patients in the observational group. (a) Definition of primary outcome/endpoint: We will determine the rate of vaccine- induced T cell responses at the time of surgical resection. For evaluation of immune responses in the peripheral blood, for each patient, a vaccine- induced T cell response will be considered: 1. Any post -vaccination E6- or E7 -specific T cell response frequency (response to E6 or E7 peptide pool, minus nonspecific background, measured by ELISPOT or intracellular cytokine staining) equal or greater to two times the initial pre -vaccination baseline response. Where two baseline measurements are available, the mean value will be used. 2. When pre -vaccination E6/E7- specific T cell responses are not observed, any post - vaccination response at least two- fold greater than the average value of nonspecific background (for ELISPOT, approx. 10- 15 spots/well) will be considered a positive response. Toxicity will be scored using the NCI CTCAE 4.0 criteria, with any grade 3 or 4 toxicity considered as an adverse outcome. V11.2 (1/9/20 ) Page 38 of 50 (b) Definition of secondary outcomes/endpoints: 1. We will determine the rate of vaccine- induced T cell responses at various time- points after surgery (3W, 6W, 3M, 6M, 12M). Otherwise as per the primary outcome/endpoint (c) Analytic plan for primary objective: For each patient, the baseline mean frequency +/ - SD of peptide- specific IFN -γ and/or TNFα expressing T cells in the peripheral blood will be determined by averaging the results of 3 replicate assays. At each subsequent blood draw, the mean frequency +/ - SD of IFN - γ positive T cells will be determined in an identical fashion, and vaccine- induced T cell responses determined as described above. The response to each peptide will be evaluated separately. While the ADXS 11- 001 vaccine contains the HPV E7 protein, cross -reactive responses to E6 and other HPV proteins can be observed following vaccination (personal communication, Robert Petit, Advaxis Pharmaceuticals) so we will monitor respons es to E6, E7 and E 2 peptides. The trial is designed to conclude that ADXS 11- 001 vaccination is likely highly immunogenic and worth further investigation if the overall rate of vaccine- induced T cell responses is 75% or more. ADXS 11 -001 vaccination will be deemed not worthy of further investigation if the overall rate of vaccine- induced T cell responses is less than 50%. For this trial, we propose a maximum sample size of 22 subjects, with 9 eligible subjects accrued in the first stage and 13 eligible subjects accrued in the second stage. One interim monitoring will be performed at the end of the first stage. T he trial will be terminated early if it is evident that the T cell response rate is lower than the acceptable level. Since we do not yet know when the peak effect of vaccination will be , we will consider any responses at time of surgery or at 3 or 6 weeks after surgery to “count” as positive vaccine- induced T cell responses. If responses in five (5) or fewer patients are observed during the first stage, we will conclude that ADXS 11- 001 vaccination does not merit continued investigation due to lack of immunologic efficacy. Otherwise accrual will continue until a total of 22 evaluable patients have been vaccinated and assessed for T cell response and toxicity. If after completion of accrual more than fourteen (14/22) patients have vaccine- induced T cell responses, we will conclude that ADXS 11- 001 vaccination is sufficiently active to justify recommendation for future studies. (d) Analytic plan for secondary objectives: The frequency of ELISPOT -positive T cells in the peripheral blood will be determined as described above for each patient at baseline and at different time points after surgery (3W, 6W, 3M, 6M, 12M). The average number of ELISPOT -positive T cells in the baseline and post -surgical samples will be compared, with p<0.05 by two- sided paired student ’s T test considered a statistically significant difference. (e) Sample size justification: Using this design for the primary objective, the type -I error is 10%, and the power is 80.7%. If the T cell response rate is indeed only 50%, then the probability to stop the trial at the end of first stage is 75%, and the expected sample size of 13. V11.2 (1/9/20 ) Page 39 of 50 17.0 DATA AND PROTOCOL MANAGEMENT The study chairperson, and IND holder Dr. Sikora , the site principal investigator and the site co - investigator will be jointly responsible for the management of the protocol. All patients will be treated according to the recommendations of the institutional Head and Neck tumor board, and the standard - of-care for their disease. 17.1 DATA CONFIDENTIALITY All efforts will be made to ensure patient confidentiality and assurance of HIPAA compliance. Immediately after obtaining any specimens and microscopic images, subjects will be assigned a protocol specific unique code that will be used for all further data management. A list matching the patient medical record number to the protocol specific unique code will be kept in a locked cabinet in the office of the site PIs. The names of the patient s will not be released to any outside organizations or to persons not involved with the study. They will not be revealed in written reports or publications detailing the research findings. All electronic data with patient identifying information will be maintained on password- protected computers at the respective institut ion. Use of portable media devices (external hard drives, USB drives, etc.) will be discouraged; if use of portable media devices is required for transfer of data, these devices are to be password protected and encrypted. 17.2 PROTOCOL COMPLIANCE The primary research coordinator for this protocol will be responsible for accurate implementation of the protocol. Any deviations from the protocol will be reported to Dr. Sikora and the site PIs , who will determine the appropriate course of action. 17.3 PRO CEDURE TO OBTAIN INFORMED CONSENT Patients to undergo transoral surgical resection of oropharyngeal cancer will be identified by the study team at weekly tumor board conference, or on their initial visit to the clinic at each institut ion. Participation in the trial will be discussed with the patient by a study investigator or approved delegate prior to the initiation of treatment. Consent will be obtained by a study investigator or study coordinator. All patient confidentiality will be strictly maintained in accordance with HIPAA regulations. The principal investigators, all co- investigators, and study coordinators have taken the NIH approved Institutional Instructional Course for Studies Involving Human Tissues and must have completed Human Research Protection Education requirements by their institut ion. 17.4 REPORTING REQUIREMENTS - ADVERSE EVENTS 17.4.1 Adverse event (AE): any untoward medical occurrence in a subject or clinical investigation subject administered a pharmaceutical product and which does not necessarily have to have a causal relationship with this treatment. An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory finding, for example), symptom, or disease temporally associated with the use of a medicinal product or protocol -specified procedure, whether or not considered related to the medicinal product or protocol -specified procedure. Any worsening (i.e., any clinically significant adverse change in frequency and/or intensity) of a preexisting condition that is temporally associated with the use of study treatment (ADXS11 -001 or Placebo) is also an AE. A serious AE ( SAE) is any AE occurring at any dose or during any use of Advaxis’ product that: V11.2 (1/9/20 ) Page 40 of 50 • Results in death; • Is life threatening; • Results in persistent or significant disability/incapacity; • Results in or prolongs an existing inpatient hospitalization; • Is a congenital anomaly/birth defect; • Is a new cancer (that is not a condition of the study); • Is associated with an overdose; • Is another important medical event All adverse clinical experiences, whether observed by the investigator or reported by the patient, must be recorded, with details about the duration and intensity of each episode, the action taken with respect to the test drug, and the patient’s outcome. The investigator must evaluate each adverse experience for its relationship to the test drug and for its seriousness. The PIs, co -Investigator, or a delegate will query the patient about adverse event ( AE) at each follow - up visit , and notify the PIs, who will be responsible for maintaining records of all AE s. Reporting will follow the descriptions and grading scales found in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. Any unanticipated adverse events resulting from this study will be reported to the study chair . Additionally, unanticipated and SAEs should be reported to each site’s institutional review boards as per their requirements and by the IND holder to the FDA according to the 21CFR312.32. Post 30 day AE assessment and for 3 year safety observation period: It is required that sites submit all SAEs that are thought to be possibly related to ADSX11- 001 or which have any potential relationship or correlation to Listeria. This requirement is applicable for the ENTIRE Lm follow -up period of 3 years. All other SAEs or AEs not related to ADXS11- 001 or with no relation to, suspicion of or possibility of being late listeriosis, do not need to be reported. To provide an enhanced opportunity to detect any adverse events, a 2 week delay (stagger) will be implemented between enrollment of patient #1 and #2 and patient #2 and #3. 17.4.2 Expected adverse events include: 1. Minor, self -limiting pain due to the injection. 2. Minor, self -limiting, localized injection- site reaction <2cm and lasting for less than 72 hours . 3. Fever (>100.9° F) with or without chills for up to 24 hours. 4. Anemia, Headache, Vomiting and Nausea 5. Tender cervical lymphadenopathy (possible). Please refer to the ADXS11- 001 IB for a current list of expected adverse events. Progression of the cancer under study is not considered an AE unless it results in hospitalization or death. If known, the diagnosis of the underlying illness or disorder should be recorded, rather than its individual symptoms. The following information should be captured for all AEs: onset and end dates, severity (grade of the event), Investigator’s opinion of the relationship to ADXS11- 001 (see definitions below), treatment/action required for the AE, and information regarding resolution/outcome. V11.2 (1/9/20 ) Page 41 of 50 17.4.3 Reporting Abnormal Test Findings The criteria for determining whether an abnormal test finding should be reported as an AE are as follows: • Test result is associated with accompanying symptoms; and/or • Test result requires additional diagnostic testing or medical/surgical intervention: and/or • Test result leads to a change in study dosing or discontinuation from the study, significant additional concomitant drug treatments, or other; and or • Test result is considered to be an AE by the Investigator or sponsor Merely repeating an abnormal test, in the absence of any of the above conditions does not constitute an AE. An abnormal test result that is determined to be an error does not require reporting as an AE. 17.4.4 Reporting Cytokine Release Syndrome As per NCI CTCAE v 4.03, CRS is defined as a disorder characterized by nausea, headache, tachycardia, hypotension, rash, and shortness of breath. Subjects must have experienced ALL symptoms for an AE to be documented as CRS. Individual symptoms associated with CRS should not be reported as CRS, but should be reported as separate AEs. 17.5 Data/Safety Monitoring AE reporting and data and protocol monitoring will be performed in accordance with the protocol - specific Data Monitoring and Reporting Plan and current Data Safety Monitoring Plan for investigator - initiated Phase I and II studies in the Dan L Duncan Cancer Center at Baylor College of Medici ne. V11.2 (1/9/20 ) Page 42 of 50 18.0 REFERENCES 1.