Zaks TZ and Rosenberg SA. Immunization with a peptide epitope (p369-377) from HER-2/neu leads to peptide-specific cytotoxic T lymphocytes that fail to recognize HER-2/neu+ tumors. Cancer Res 1998;58:4902-4908. CONFIDENTIAL Page 56 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 APPENDIX A Herceptin and Vaccination Timeline \ CONFIDENTIAL Page 57 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017APPENDIX B NCI Common Terminology Criteria for Adverse Events, v4.03 obtained from http://ctep.cancer.gov/forms/CTCAEv4.03.pdf http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf CONFIDENTIAL Page 58 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 APPENDIX C.1 Study Flowchart Days –60 to –1 Week 1 (Day 0) DTH inoculations (4) 2 Every 3 Weeks Every 3 Months Every 6 Months If Clinically Indicated Final Visit in 36th month Hematology (CBC, diff., platelets) X Chemistry panel (CMP) X HLA blood draw for typing During study screening process/patient identification process. Immunological Samples1 X1 X1 X1 X1 Herceptin administration (q3 weeks x 18) 3 X3 DTH administration/Photos2 X2 Vaccine administration3 X3 Booster inoculations 4 X4 Post-Booster Immunological Samples1 X1 Complete medical history (treating physician) X X Complete physical exam (treating physician, based on SOC) X X X X Clinical assessment-Study nurse visit3,4,9 X X3 X3 X4 X9 Weight, height (treating physician) X X ECOG performance status X Toxicity evaluation8,9 X8 X8 X8 X8 X9 Vital signs8 X8 X8 X8 MUGA scan or ECHO, consistency required5 X5 X5 X5 X5 Chest X-ray (AP, lateral)/EKG X Urine pregnancy test (if applicable)6 X6 X6 X6 X6 CONFIDENTIAL Page 59 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 Tumor assessment (treating physician) X7 X Disease status monitoring7,9 X7 X7 X7 X7 X9 1Immunological samples will be drawn , prior to initiation of Herceptin, prior to DTH #1, prior to inoculation #4, prior to DTH #2 and every six months prior to each of 4 boosters. Samples are also drawn 3-4 weeks post each booster. 2DTH #1 given prior to third Herceptin infusion, DTH #2 given 3-4 weeks after 6th vaccine inoculation, DTH #3 given 3-4 weeks after booster #2 and DTH#4 given 3-4 weeks after booster #4. The final two will be given after the collection of the post booster blood sample at the same visit. DTHs do not need to be scheduled on day of Herceptin infusion. 3Vaccine inoculation administered every 3 weeks for 6 inoculations during Herceptin treatment schedule. Vaccine inoculations to begin after 3rd Herceptin infusion, except with prior approval from Sponsor to begin at 4th or 5th infusion time point. Vaccine inoculations given within 30-120 minutes after completion of infusion. (With prior approval from the Principal Investigator, the vaccine may be administered 15 minutes after completion of Herceptin infusion). 4Booster inoculations will be given after initial series, every 6 months x4, Booster #1 to be given with thefinal Herceptin infusion. Subsequent boosters will be given every 6 months (+/- 2 weeks) from Booster #1 5MUGA scans or ECHO, consistency required will be done at baseline prior to enrollment and at 3, 6, 12, and 24 months. If EF change > 10%, continue with MUGA or Echo every 6 months through trial. 6 Urine HCG waived if hysterectomy, bilateral oopherectomy, tubal ligation, documented absence of menses for two years, or FSH lab results verifying menopause. 7Must be free of disease “NED” prior to enrollment per physician. Disease status monitored every 3 months from consent for 18 months, then every 6 months until study completed by study coordinator/nurse 8Toxicity evaluation done with 30 minutes of observation following inoculation with vital signs as needed and during return visit or by phone call 48-72 hours after inoculation. Delayed adverse event reporting per protocol. 9Final study assessment in month 36 by study nurse with toxicity assessment and disease status update CONFIDENTIAL Page 60 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 APPENDIX C.2 Patient Visit Chart CLINIC VISIT PROCEDURES TOTAL Visit # Time Req (hr) Time Point Purpose Herceptin IV Infusion MUGA SCAN or EjCHO Toxicity Eval Nursing Visit UrineHCG1 Blood Draws Inoc DTH Test # of Shots This Visit Time for Inoc + Follow-Up •Pre CBC/CMP Informed Consent Document • Gather baseline data. • Draw blood for HLA typing . Pre-Inoc Post-Inoc 1 2 Baseline X X X X 0 N/A START HERCEPTIN INFUSIONS 2 2 Starting Time Point R0 (1) immunology sample then First Herceptin infusion X X 0 N/A 3 1 Approx q3 weeks Herceptin infusion X 0 START PRE-INOCULATION BLOOD DRAWS AND INOCULATIONS AFTER HERCEPTIN INFUSIONS X6 4 0.5 1-2 wks prior to Herceptin #3 • Draw blood R0 (2) to record immunologic activity before DTH skin test #1. • Administer DTH skin test #1. X X X X X 1 0.5 hrs over 1 day 5 0.25 48-72 hrs later • Examine DTH skin test site for any local reaction and photograph. X X 0.25 hrs 62 2.5 Approx q3 weeks • Administer inoculation #1 after Herceptin infusion #32 X X X X X 4 2.75 hrs over 2-3 days 74 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 8 2.5 Approx q3 weeks • Administer inoculation #2 after Herceptin infusion. X X X X X 4 2.75 hrs over 2-3 days 94 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 10 2.5 Approx q3 weeks • Administer inoculation #3 after Herceptin infusion. X X X X X X 4 2.75 hrs over 2-3 days 114 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 12 2.5 Approx q3 weeks • Draw blood to record immunologic response to inoculation #3. • Administer inoculation #4 after Herceptin infusion. X X X X X X 4 2.75 hrs over 2-3 days 134 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 14 2.5 Approx q3 weeks • Administer inoculation #5 after Herceptin infusion. X X X X X 4 2.75 hrs over 2-3 days 154 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 16 2.5 Approx q3 weeks • • Administer inoculation #6 after Herceptin infusion. X X X X X 4 2.75 hrs over 2-3 days 174 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 18 1 Approx q3 weeks • Draw blood to record immunologic response to #6. • Administer DTH skin test #2 after Herceptin infusion. X X X X X X 1 0.75 hrs over 2-3 days CONFIDENTIAL Page 61 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 19 0.25 48-72 hrs later • Examine the DTH skin test site for any local reaction and photograph. X X 0 20 1 Approx q3 weeks Herceptin infusion X 0 21 1 Approx q3 weeks Herceptin infusion X 0 N/A 22 1 Approx q3 weeks Herceptin infusion X 0 23 1 Approx q3 weeks Herceptin infusion X 0 24 1 Approx q3 weeks Herceptin infusion X 0 25 1 Approx q3 weeks Herceptin infusion X 0 26 1 Approx q3 weeks Herceptin infusion X 0 27 1 Approx q3 weeks Herceptin infusion X 0 RESUME IMMUNOLOGY BLOOD DRAWS AND ADMINISTRATION OF BOOSTER INOCULATIONS 283 2.5 Month 12 from Starting Time Point (±2 weeks) • Draw blood to record immunologic levels pre-Booster #1 inoculation. • Final Herceptin infusion (see comment 3 below). • Administer Booster #1 inoculation. X X X X X X X 4 3.25 hrs over 4 weeks 294 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 30 0.5 3-4 weeks later • Draw blood to record immunologic response to Booster #1 inoculation. X X 0 31 1.5 Month 18 (±2 weeks) • Draw blood to record immunologic levels pre-Booster #2 inoculation. • Administer Booster #2 inoculation. X X X X X 4 3 hrs over 4 weeks 324 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 33 1 3-4 weeks later • Draw blood to record immunologic response to Booster #2 inoculation then administer DTH #3. X X X X 1 34 .25 48-72 hrs later • Examine DTH skin test site for any local reaction and photograph X 0 35 1.5 Month 24 (±2 weeks) • Draw blood to record immunologic levels pre-Booster #3 inoculation. • Administer Booster #3 inoculation. X X X X X X 4 2.25 hrs over 4 weeks 364 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 37 0.5 3-4 weeks later • Draw blood to record immunologic response to Booster #3 inoculation. X X 0 38 1.5 Month 30 (±2 weeks) • Draw blood to record immunologic levels pre-Booster #4 inoculation. • Administer Booster #4 inoculation. X* X X X X X 4 3 hrs over 4 weeks 394 0.25 48-72 hrs later • Examine the inoculation site for a local reaction.4 X X 0 40 1 3-4 weeks later • Draw blood to record immunologic response to Booster #4 inoculation then administer DTH#4. X X X X 1 41 .25 48-72 hrs later • Examine DTH skin test site for any local reaction and photograph X 0 42 .5-1 Month 36 • Final study assessment X* X X 0 End Study CONFIDENTIAL Page 62 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 # VISITS: 30-424# INOCULATIONS: 48 # BLOOD DRAWS: 12 1 Urine HCG if applicable per protocol 2 Herceptin/vaccine combination may begin at 4th or 5th infusion time point if clinically indicated with prior Sponsor approval 3 To allow PI flexibility in scheduling, total Herceptin infusions will be 17-18, approximately every three weeks 4 Patients have the option to 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. *NOTE: If ejection fraction >10% reduction from baseline, then continue MUGA or ECHO every 6 months for duration of study CONFIDENTIAL Page 63 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 APPENDIX D HFSA Guidelines Recommendations for Pharmacological Therapy: Left Ventricular Systolic Dysfunction ß-Adrenergic Receptor Blockers Background for Recommendations The single most significant addition to the pharmacological management of heart failure since the publication of previous guidelines involves the use of ß-receptor antagonists. This represents a noteworthy departure from traditional doctrine in which ß-blocking agents were classified as contraindicated in the setting of left ventricular systolic dysfunction. A solid foundation of both clinical and experimental evidence now firmly supports their use in heart failure with the aim of reducing both morbidity and mortality (16,22,23). ß-Blocker therapy for heart failure has been advocated by some investigators since the 1970s (24). During the subsequent 2 decades, many small- to medium-sized placebo-controlled trials, which used a variety of agents, showed several common findings: 1) the use of ß-blockers in mild to moderate heart failure was generally safe when initiated at low doses and gradually uptitrated under close observation; 2) improvement in left ventricular ejection fraction was observed in all trials that lasted at least 3 months; and 3) there was wide variability in the effects of ßblockade on exercise tolerance but improvement in outcome and symptomatic benefits was noted in many studies. These generally positive findings stimulated additional, large-scale clinical trials that have provided an impressive body of evidence that supports the use of ß-blockers in patients with heart failure caused by left ventricular systolic dysfunction. The recommendations that follow are derived from nearly 2 decades of research that include basic science data, animal models, and clinical trial experience in over 10,000 patients (25,26). Although this is a major advance in efficacy, identification of appropriate candidates for ßblocker therapy is essential to ensure safe and effective treatment. Prescribing physicians should understand the potential risks of ß-blocker therapy, as well as the benefits. The interested practitioner who is unfamiliar with ß-blocker initiation and titration may first seek further education and counsel from sources such as the Heart Failure Society of America or local and regional heart failure specialty centers. Recommendation 1. ß-blocker therapy should be routinely administered to clinically stable patients with left ventricular systolic dysfunction (left ventricular ejection fraction less than or equal to 40%) and mild to moderate heart failure symptoms (ie, NYHA class II-III, AppendixD.1) who are on standard therapy, which typically includes ACE inhibitors, diuretics as needed to control fluid retention, and digoxin (Strength of Evidence = A). CONFIDENTIAL Page 64 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 The most persuasive outcome in heart failure management remains all-cause mortality. Combined endpoints, including mortality or hospitalization and mortality or hospitalization for heart failure, have also emerged as key outcomes. These latter endpoints reflect a more comprehensive assessment of the influence of therapy on quality of life and disease progression and are assuming more importance as mortality rates decline with treatment advances. The substantial beneficial effect of ß-blocker therapy on these endpoints has been well shown in clinical trials of symptomatic patients (NYHA class II - III) treated with carvedilol, bisoprolol, or metoprolol controlled release/extended release (CR/XL) (27-29). Trials with these agents encompass the combined, worldwide experience with ß-blocker therapy in patients with chronic heart failure who were stable on background therapy, including ACE inhibitors (over 90%) and diuretics (over 90%). Digoxin was common as background therapy, particularly in studies conducted in the United States. Trial results indicate that both selective and nonselective ßblockers, with and without ancillary properties, have significant efficacy in heart failure. ß-Blocking agents with intrinsic sympathomimetic activity appear to have a negative impact on survival and should not be used in heart failure patients. Metoprolol. The MDC Study was an early trial that included 383 patients with heart failure caused by nonischemic causes, NYHA class II-III symptoms, and a left ventricular ejection fraction of less than or equal to 40% (30). Patients with coronary artery disease were excluded. Study results showed a 34% reduction in risk in patients treated with metoprolol, although this strong trend toward benefit (P = .058) was entirely attributable to a reduction in the frequency of cardiac transplantation listing in the treatment group. In fact, the absolute number of deaths in the metoprolol group was higher than in the placebo group (23 v 19, P = .69). The MERIT-HF Trial evaluated the effect of metoprolol CR/XL with all-cause mortality as the primary endpoint. The trial included 3,991 patients with NYHA class II-IV heart failure, although 96% of the study patients were functional class II or III (31). In this study, investigators were allowed to select the starting dose of metoprolol CR/XL. Seventy-nine percent chose 25 mg as the starting dose for class II patients, and 77% chose 12.5 mg for class III-IV patients. The target dose was 200 mg and doses were up-titrated over a period of 8 weeks. Premature discontinuation of blinded therapy occurred in 13.9% of those treated with metoprolol CR/XL and 15.3% of those in the placebo group (P = .90). The study results revealed a 34% reduction in mortality in the metoprolol group (relative risk of .66; 95% confidence interval [CI], .53 to .81; p=.0062 after adjustment for interim analyses), with annual mortality rates of 11% in the placebo and 7.2% in the metoprolol CR/XL group (29). Bisoprolol. The CIBIS Study evaluated the effects of bisoprolol in 641 patients with left ventricular systolic dysfunction caused by ischemic or nonischemic causes and NYHA class III-IV heart failure (32). The primary endpoint was all-cause mortality, and CONFIDENTIAL Page 65 of 102 Protocol: HERCEPTIN® + E75/GM-CSF Version 3.1 ML25749 05 March 2017 hospitalization for worsening heart failure was one of the secondary outcomes of interest. The initial bisoprolol dose was 1.25 mg/day, which was increased to a maximum dose of 5 mg/day. The trial found no significant reduction in all-cause mortality in patients treated with bisoprolol (20% reduction bisoprolol v placebo, P = .22) (32). The risk of hospitalization was significantly reduced by 34% (28% placebo group v 19% bisoprolol group, P < .01). The favorable trends seen in CIBIS led to the larger CIBIS II Study, which ultimately was prematurely terminated as a result of a significant reduction in mortality in the bisoprolol arm (28). These results were obtained in 2,647 patients who were followed for an average of 1.3 years.