Twenty mLs of blood will be the appropriate amount for our analyses (should yield ~10mL of plasma). At the same time, we will collect peripheral blood for immune monitoring. Ideally, we would like to have these blood samples collected: - (1) Prior to initiating vaccine therapy at the leukapheresis visit , - (2) Prior to surgical resection at the pre- op screening visit , - (3) Prior to first cycle of TMZ at the SOC clinic visit (confirmed Grade IIs), or prior to RT/TMZ at SOC clinic visit (higher Grade Gliomas) , - (4) Vaccine #6 - (5) End of Treatment ( follow -up visit 1 month after v accine #15). If a subject decides to stop participat ing in the study prior to vaccine #15, blood will be obtained at that time (if possible) . If a subject progresses prior to vaccine #15, blood will be obtained at that time (if possible). b) Study of 2 -Hydroxyglutarate levels in patients with gliomas with ID H1 R132H: The second approach to be used will be a mass spectrometry -based approach for detection of 2- hydroxyglutarate (2- HG), a metabolite specifically produced by tumors with the IDH1 c.395G>A (R132H) mutation. This metabolite can be sensitively detected by mass spectrometry and has been found to be elevated in the tissue of IDH1 R132H -containing gliomas as well as in the plasma of other solid tumors containing the same mutation (cholangiocarcinoma, subsets of breast carcinoma). A small portion of the Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 30 CONFIDENTIAL previously m entioned isolated plasma will be used for a LC -MS/MS based approach for sensitive detection of circulating 2- HG levels . Tumor tissue – we are planning to obtain a snap- frozen tumor tissue sample after the surgical resection for possible presence of IDH 1 mutation and gene up- regulation. Tumor Sampling Analyses: At the time of surgical resection, excess tumor tissue will be obtained through the Duke B iorepository, and IHC analyses will be performed to assess immunologic infiltrate which will be identified by cell type and reactivity state. Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 31 CONFIDENTIAL Table 2. Screening and On -Study Tests and Procedures Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 32 CONFIDENTIAL Screening Leukapheresis2 One d ay prior to vaccine #1 Vaccine #1 Vaccine #2 Vaccine #3 Pre- Surgery Surgery7 Post - Surgery Pre TMZ visit9 Radiation Therapy and TMZ8 TMZ Cycles 1-12 9,10 End of Treatment (1 month after Vaccine #15) Progression *followed for survival ICF X Medical History/ Baseline symptoms X X Tumor pathology X X X If possible Blood for Immune monitoring/Biomarker testing 5 X 3 red X 17 yellow, 1 red X 17 yellow, 1 red X 17 yellow, 1 red At vaccine #6 X 17 yellow, 1 red At vaccine #6 X 17 yellow, 1 red CBC/diff and CMP3 X X X X X8 X X Beta HCG (for WOCBP) X X X Ionized Ca X TD Booster4 X MRI1 X X X X every 2 -3 months MRS 2HG6 X X X X X Pre- conditioning TD11 X TMZ 50 -100 mg/m2 21 of 28 days x 12 cycles X Radiation Therapy8 X8 TMZ 75mg/m2/day for 42 days8 X8 Vaccine10 Total of 15 vaccines X X X X10 X10 Physical Exam, Neuro exam, KPS X X X X X X8 X X Con Meds X X X X X X X X X X8 X X AE/SAE collection X X X X X X X X X X8 X X Photo of injection site (Optional to subject)12 X If possible 1 Initial standard of care MRI report to confirm eligibility must be performed within 10 weeks (+/ - 4 weeks) of signing consent. MRI or contrasted CT, every 10 weeks (+/- 4 weeks ) per PRTBTC standard of care (may be adjusted by the treating neuro- oncologist). MRI will be done pre - and post -surgery per surgeon discretion and standard of care. 2 1-2 hour leukapheresis within 2 weeks of enrollment. Within 72 hours of leukapheresis, patients will have blood samples taken for the following tests as required by the Duke Apheresis Center: CBC, CMP, ionized Calcium, and β -HCG (for females of child -bearing potential). Total estimated blood volume required for these evaluations is 12- 15 mLs. An aliquot of PBMCs from this pheresis will be sent to UNC for HLA analysis. 3 CMP and CBC (with differential) to confirm eligibility, and as per standard of care prior to and following surgery, and durin g monthly cycles of TMZ. CBC and CMP will be repeated along with a physical examination 1 month following last vaccine to assess for delayed toxicity to v accine therapy. 4 Td booster will be given I.M. into the deltoid muscle after consent on all subjects. 5 Immune monitoring and Biomarker testing will be drawn before initiation of vaccine therapy (at leukapheresis visit), prior to surgical resection, p rior to RT/TMZ and vaccine #4 or cycles of TMZ (depending on tumor pathology), at vaccine # 6, and at end of treatment ( at the follow-up visit 1 month after vaccine #15, at the time come off study treatment , or at progression, whichever comes first ). Blood for i mmune monitoring and Biomarker testing will be placed in 14 yellow containing ACD and 1 red vacutainer tube for a total of 90 mLs delivered to the BTIP lab for processing (3 red top s will be drawn with leukapheresis instead) . Genomic proteomic analyses will include tumor sample at surgery and 20 mLs of blood (3 yellow ACD tubes) drawn at leukapheresis visit, at the pre- op scr eening visit prior to surgery, and depending on tumor pathology at the SOC clinic visit prior to starting either RT/TMZ (and receiving the 4th vaccine) or the 1st cycle of TMZ , at vaccine #6, and at end of t reatment ( at the follow- up visit 1 month after vaccine #15, at the time come off study treatment, or at progression, whichever comes first ). 6 To demonstrate quantitative repeatable measures of metabolism change in IDH1+ gliomas via a standardized MRS protocol, patients will be scanned on the research MR scanner at up to 5 time points per subject: baseline (after consent and before PEP IDH1M vaccine #1 ), and up to 4 times prior to surgery. Up to 5 MRS scans can be scheduled between consent and surgery, but they are not required to be scheduled on the same day as PEP IDH1M vaccines #1-3. Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 33 CONFIDENTIAL 7 Tissue obtained will be used to reconfirm the Grade and assess immunologic cell infiltration, antigen expression, and biomark ers for immunologic response, specifically IDH1 T cell response. 8 Only for those whose pathology reveals transition from Grade II to Grade III at time of surgery. 9 Monthly cycles of TMZ will be initiated and adjusted at the discretion of the treating neuro -oncologist. 10 For higher grade gliomas undergoing RT, vaccine #4 will be given during SOC clinic visit prior to initiating RT, and vaccine # 5 will be given 4 weeks later (± 1 week) during RT. Vaccine #6 will be given at the end of RT during the SOC clinic visit to review MRI and begin post -RT TMZ, if MRI stable. Then, subjects in this treat ment group will receive vaccines monthly on day 22 (+2 days) with post -RT cycles of TMZ to a maximum of 15 vaccines. Subjects with a stable grade glioma at time of surgery will receive vaccines #4 -15 monthly on day 22 (+2 days) of TMZ cycles. 11Tetanus p re-conditioning will be done i.d. into the right groin one day before vaccine #1, as described in protocol. 12 Photo may be repeated at additional clinic visits at discretion of the treating physician or Principal Investigator 12.1 Screening Screening will take place at the Duke PRT BTC clinic visit . An informed consent must be signed by the patient before any study -specific procedure takes place. CMP and CBC with differential , and physical and neurologic examination with KPS score will be perform ed within 6 weeks prior to consent and may be taken from the previous standard of care Duke PRTBTC clinic visit . All subject data is standard of care evaluations that occur for all patients being seen in the PRTBTC. If the subject is considered a screen failure prior to initial protocol treatment, the source documents for electronic data entry will be stored in EPIC Electronic Medical Record or, if in paper form, a locked cabinet in a locked room in the PRTBTC . 12.2 Treat ment Period Patients that have consented onto this study will receive 3 vaccines as indicated above and then undergo surgical resection. Unless a patient is determined at the time of surgery to have transitioned to a higher grade brain tumor, v accines will then continue monthly along with adjuvant cycles of TMZ on day 22 (+ 2 days) for a maximum of 15 vaccines , unless the patient has tumor progression prior to completing 12 cycles of TMZ . Subjects that have transitioned to a higher grade glioma at the time of surgery will continue on study treatment, however, they will need to undergo standard of care chemoradiation therapy. Therefore, the vaccines will be given before, during and following RT as described above. Subjects will return one month following the last vaccine for blood work (CBC and CMP) and clinical assessment to monitor for delayed toxicity. 12.3 End of Tr eatment One month after final vaccination or once all the blood for immune monitoring has been collect ed following progression (whichever comes first) , the treatment phase of the study will be completed. 12.4 Follow -up Period Once the treatment phase has been completed, patients will be followed for OS , PFS, and subsequent therapies and data recorded by the study team . For recording of subsequent therapies, the type, agent, and duration of therapy(ies) that the subject receives will be recorded . 12.5 End of Study End of study will be declared after the death of the last subject on the study. However, one month after the last enrolled subject receives the final vaccine, the investigational vaccine treatment will be considered as complete and collected data will be analyzed for safety and toxicity. Subjec ts will be followed for OS , PFS, and subsequent therapies and d ata will be updated. Furthermore, in case of disease progression, every attempt will be made to obtain tissue for immune monitoring (if biopsy or resection performed) . 12.6 Early Withdrawal of Subject(s) 12.6.1 Criteria for Early Withdrawal Subjects may voluntarily w ithdraw from the study at any time. The PI may also withdraw a subject from the study at any time based on his/her discretion. Reasons for PI -initiated withdrawal may include, but are not limited to the following: • Progressive disease as documented by MRI or physical examination at any time after the initiation of post-op immunotherapy or post -RT immunotherapy (for those who’ve transitioned to a higher grade at time of surgery) Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 34 CONFIDENTIAL • Development of unacceptable toxicity , as defined in section 9.1.1 • Pregnancy • Need for corticosteroids > 4mg /day at time of 1st vaccine • Upon request of the subject • If, in the investigator’s medical judgment, further participation would be injurious to the subject’s health or wellbeing • Development of intolerable symptoms • Protocol deviation • Administrative reasons, such as a major violation of the clinical trial protocol • Non- compliance of the subject • Clinical decline or inability to be weaned off steroids following surgery • Failure to undergo surgery following the 3rd vaccine • Failure to tolerate TMZ therapy. 12.6.2 Follow -up Requirements for Early Withdrawal Subjects treated on this study that are withdrawn by the PI for any of the aforementioned reasons will continue to be followed for survival by the study coordinator until death or are lost to follow up. Subjects that voluntarily withdraw will be asked permission to follow for survival. Subjects that are withdrawn prior to vaccine treatment for any of the aforementioned reasons will be considered eligibility failures and thus will not be followed for survival. 12.6.3 Replacement of Early Withdrawal (s) Subjects who voluntarily withdraw prematur ely (i.e. before receiving the first 3 vaccinations) or who are withdrawn by the PI prior to treatment will be replaced unless the subject experienced a n unacceptable toxicity as defined in section 9.1.1 . 12.7 Study Assessments 12.7.1 Medical History Medical history will be obtained from the Duke e lectronic medical records system and from the subject and/or family at the screening visit and reviewed at each study visit . This data may include the following: • All past medical and surgical history • Current medications • Changes in physical or neurologic symptoms • Any adverse events 12.7.2 Physical Exam Vital signs and physical and neurologic examinations will be assessed and recorded along with a KPS score prior to enrollment , at the Td pre- conditioning i.d. visit, and at each vaccine visit (with the exception of vaccine #1 where only vital signs will be assessed) . 12.7.3 Use of Antihistamines Subjects will be advised to avoid antihistamine use 4 8 hours prior to each vaccine administration, the day of vaccine administration, and for 48 hours following each vaccine administration. If the subject has a pre-existing condition that requires antihistamine usage, the PI and the treating oncologist will decide if it is safe and appropriate for the subject’s antihistamines to be held before and following vaccine administrations . Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 35 CONFIDENTIAL 12.7.4 Radiologic Evaluations Patients with progressive Grade II LGGs will be imaged by MRI as per standard of care for eligibility and baseline measurements, and to assess progr ession prior to vaccine therapy. Although the purpose of this study is not to detect tumor responses, any evidence of tumor response will be determined according to the Duke PRTBTC SOP ( available upon request ). RANO criteria82 will be used for overall assessment of tumor response and pseudoprogres sion versus progression. Progression by RANO response criteria is defined as follows: 1) New contrast -enhancing lesion outside of radiation field on decreasing, stable, or increasing doses of corticosteroids; 2) ≥ 25% increase in the sum of the products of perpendicular diameters between the first post radiotherapy scan, or a subsequent scan with smaller tumor size, and the scan at 12 weeks or later on stable or increasing doses of corticosteroids; 3) Clinical deterioration not attributable to concurrent m edication or comorbid conditions is sufficient to declare progression on current treatment but not for entry onto a clinical trial for recurrence; 4) For patients receiving antiangiogenic therapy, significant increase in T2/FLAIR non- enhancing lesion may a lso be considered progressive disease. The increased T2/FLAIR must have occurred with the patient on stable or increasing doses of corticosteroids compared with baseline scan or best response after initiation of therapy and not be a result of comorbid events ( e.g., effects of radiation therapy, demyelination, ischemic injury, infection, seizures, postoperative changes, or other treatment effects ). Since some of these subjects will not be undergoing radiation therapy, and the possibility to exhibit pseudoprogression is likely due to inflammation from immune response at the site of the tumor , RANO criteria will be used to monitor for pseudoprogression versus progression. If pseudoprogression is suspected, the subject will continue with vaccine therapy for a mi nimum of 2- 3 subsequent months so long as subject remains clinically and radiographically stable compared to the MRI showing suspected pseudoprogression as long as the following criteria are met: 1) the subject experiences investigator -assessed clinical benefit (i.e., no new clinical symptoms contributed to disease progression) and 2) the subject is tolerating the study treatment (i.e., no expected toxicities higher than grade 3 or unexpected toxicities) . If the subject continues to do well beyond the 3 months, they will continue on study as planned. 12.8 Risk/Benefit Assessment 12.8.1 Potential Benef its The potential benefits may include reduction or remission of the subject’s brain cancer . Because this procedure is experimental, it cannot be guaranteed that subjects will receive any benefit as a result of participating in this research study . The information collected in this research may help scientists better understand the mechanisms involved in the immune system’s ability to fight cancer . If such an understanding comes from this research, then it may benefit society by furthering the development of improved treatment methods for human malignant brain tumors in the future. 12.8.2 Potential Risks Td Injection of Td toxoid may produce inflammation, edema, induration, erythem a, or pruritus at the injection site. A dministration may cause occasional pain and discomfort up to three days after the vaccine is given. Allergic Reactions to PEP IDH1M Injection of antigen presenting cells may result in an allergic reaction, which could include redness and swelling at the injection site, itching, hives, low blood pressure, difficulty breathing, or in the most extreme circumstances, death. In addition, if the immune system becomes overly activated, potential discomforts may include pain, r edness and swelling at the injection site. Injection Site EMLA ® cream, or equivalent topical analgesic, can be offered to subjects who experience local pain at the injection site. Cerebral Edema Cerebral edema may be secondary to the disease process itself, the surgical procedure, radiation therapy, necrosis from previous radiation, or inflammation due to immune infiltration of the brain or destruction of tumor cells . Symptoms may include, but are not limited to, severe headache, confusion, Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 36 CONFIDENTIAL lethargy, unresponsiveness, coma, or focal neurological deficits . Patients will be monitored throughout the course of the study and those patients with any signs or symptoms of cerebral edema may need their steroid doses increased, treatment with an osmotic diuretic, or surgical decompression. Edema that fails to respond to aggressive therapy may lead to permanent neurological impairment . The probability of this risk can be predicted to some degree based upon tumor size, location, pre- operative neurological impairment, and post -operative course prior and after PEP IDH1M injections. Patients will be monitored throughout the course of the study. Infection The PEP IDH1M vaccine injections may include the risk of infection due to potential contamination of the peptides in the laboratory . This may result in localized redness, swelling, or induration at the injection site . In the most extreme situation, this may lead to systemic bacterial/fungal sepsis and possibly death. The probability of this risk is relatively low, given the small injection volume (1 mL divided between >2 intradermal locations) and the fact that the peptides will be strictly tested for sterility prior to each injection . The risk of infection due to potential contamination of the peptides in the laboratory will be minimized by biosafety quality assurance and testing. All cell cultures will be handled under sterile conditions in a core tissue culture facility dedicated to the processing of human cells . Prior to injection into patients, peptides must pass sterilit y tests in thiglycolate broth, tryptic soy blood agar, and inhibitory Sabouraud agar . Following injections, patients will be monitored throughout the course of the study for any signs and symptoms of infection. There have been no infections to date in the recent VICTORI (IRB #3108- 05-9R4) or ACTIVATE (IRB #5421- 05-1R1) clinical trials testing similar approaches in a similar patient population. If an active infection is suspected, patients will be cultured and treated with appropriate antibiotics. Delayed Autoimmune Diseases It is possible that delayed autoimmune disease(s) may develop as a result of injection with PEP IDH1M vaccine . This means that the immune system may be stimulated to attack natural tissue in the body . Animal studies have reported the devel opment of autoimmunity in the context of vaccination and recovery from lymphopenia. However, our current experience with peptide vaccination in glioma patients has not demonstrated evidence of autoimmunity in treated patients . Furthermore, the doses of TMZ used in this study for induction of lymphopenia are standard doses administered to patients with gliomas . It therefore, is unknown what the risk of delayed autoimmune disease is for this study. Phlebotomy Drawing blood or inserting an intravenous catheter into an arm vein may result in bruising or swelling in the area of the insertion, bleeding at the site of the needle puncture, light headedness, fainting and very rarely, local infection, which may be severe. These risks are reduced by the fact that the blood will be drawn by a qualified physician, nurse or phlebotomist (a professional trained to draw blood). Leukapheresis As with any donation of blood, a variety of minor reactions may occur with leukapharesis, which include fainting, dizziness, or nausea. Uncommon but serious complications may also result, which include bleeding, infection, an adverse reaction to the anticoagulant or replacement fluids, hypocalcemia, hypotension, shock, convulsions, air emboli, heart failure, or the inability to transfuse blood back into the patient . These risks are reduced by the fact that the procedure will be performed by qualified staff at a specialized clinical hemapheresis unit . Patients will be carefully monitored throughout the procedure by trained nursing and medic al staff . Calcium gluconate (2 gm) will be given to minimize the risks of hypocalcemia, fluid supplementation will be given to minimize hypotension. MRI The risks and/or discomforts associated with the performance of MRI include the anxiety produced from b eing in a tight, enclosed space (claustrophobia) . In addition, the machine operates using a large and powerful magnet . The magnetism of the machine attracts certain metals: therefore, people with these metals in their bodies (specifically pacemakers, infus ion pumps, metal aneurysm clips, metal prostheses, joints, rods or plates) will be excluded from the study if they are unable to undergo MRI imaging. Patients will also be checked to make sure that they do not bring any metal objects into the MRI facility . Dental fillings are less affected by the magnetic fields generated and are therefore permitted. It will be asked that patients let the physicians conducting this study know of any metal in their bodies other than dental fillings . Allergic Reactions to Contrast Agents Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 37 CONFIDENTIAL During the MRI, patients will be given a contrast agent . The agent is given routinely to obtain enhanced MRI scans of the brain. The agent is administered through the vein and requires the placement of an IV catheter . The catheter placement is similar to drawing blood except that the catheter remains in the vein during the time the agent is actively delivered. The risks of a blood draw and insertion of a catheter are similar . There have been a few, rare cases of allergies to the agent used i n MRI contrast enhanced scans. Patients with any known severe allergies to contrast agents will be excluded from the study . Patients with mild allergies (i.e., rash only) will be pretreated with Tylenol and Benadryl prior to injection of the contrast agent . Radiation Therapy Early side effects of radiation include hair loss, scalp redness, inflammation of the ear canals, and fatigue. In a few patients, radiation contributes to headaches or nausea. Rarely, tumors may swell during radiation causing neurologic al symptoms such as weakness on one side, visual loss, or changes in mental function. There is a small chance of long- term effects from radiation, occurring months or years after completion. These may include worsening of mental function, hearing, vision, strength and coordination. Rarely, radiation may cause the development of benign or malignant tumors around the brain or skull. It is unknown whether temozolomide increases the risk of any of the early or late side effects of radiation. Temozolomide TMZ has been well tolerated by both adults and children with the most common toxicity being mild myelosuppression. Other, less likely, potential toxicities include nausea and vomiting, constipation, headache, alopecia, rash, burning sensation of skin, esophagi tis, pain, diarrhea, lethargy, hepatotoxicity, anorexia, fatigue and hyperglycemia. Hypersensitivity reactions have not yet been noted with TMZ . As in the case with many anti -cancer drugs, TMZ may be carcinogenic . Rats given TMZ have developed breast cancer . The significance of this finding for human is not presently known. TMZ therapy will be followed but given as standard of care. If toxicities occur, the Principle investigator and primary physician will titrate therapy based on standard clinical guidelines as outlined above. GM-CSF Injection of GM- CSF may increase the risk of infection, lower platelets, or cause fluid retention. GM-CSF also may result in an allergic reaction, which could include redness and swelling at the injection site, itching, hives, flushing, syncope, low blood pressure, difficulty breathing, or in the most extreme circumstances, death. In addition, if the immune system becomes overly activated, potential discomforts may include pain, redness and swelling at the injection site. Montanide ISA 51 Montanide ISA 51 adjuvant is well tolerated. Local reactions may include granuloma, local pain, tenderness and erythema. Montanide ISA 51 may also cause flu like symptoms, nausea and vomiting. Unknown Risks The overall risk classification of thi s research is unknown. Clinical trials using peptide- based immunizations on brain tumor patients have only recently been published. From our experience with 40 patients in ongoing and previous trials we have not seen any toxicities or serious unexpected adverse events . 13 SAFETY MONITORING AND REPORTING The PI is responsible for the identification and documentation of adverse events and serious adverse events, as defined below . At each study visit, the PI or designee must assess, through non- suggestive inquiries of the subject or evaluation of study assessments, whether an AE or SAE has occurred. 13.1 Adverse Events An AE is any untoward medical occurrence in a subject receiving study drug and which does not necessarily have a causal relationship with this treatment . For this protocol, the definition of AE also includes worsening of any pre- existing medical condition. An AE can therefore be any unfavorable and unintended or worsening s ign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of the PEP IDH1M and GM- CSF, whether or not related to use of the vaccine . Abnormal laboratory findings without clinical significance (based on the PI’s j udgment) should not be Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 38 CONFIDENTIAL recorded as AEs . But laboratory value changes that require therapy or adjustment in therapy are considered adverse events. All lab values that are not deemed AEs by the PI will be noted to be Non- Clinically Significant in the subject record and source documents. From the time the subject signs the informed consent form through the End of Treatment visit (as defined in Sections 12.3, 12.5 and 12.6), all AEs must be recorded in the subject medical record and electronic adverse events case report form. AEs will be assessed according to the CTCAE version 4.0. If CTCAE grading does not exist for an AE, the severity of the AE will be graded as mild (1), moderate (2), severe (3), life-threaten ing (4), or fatal (5). Attribution of AEs will be indicated as follows: • Definite : The AE is clearly related to the study drug • Probably : The AE is likely related to the study drug • Possible : The AE may be related to the study drug • Unlikely : The AE is doubtfully related to the study drug • Unrelated : The AE is clearly NOT related to the study drug 13.1.1 Reporting of AEs A summary of all adverse events (not just those considered related to the study drug) will be kept which will categorize the event by organ system, relationship to treatment, its grade of severity, and resolution. The PI will periodically review the collective adverse events with the intention of identifying any trends or patterns in toxicity on a monthly basis . If any such trends are identified, depending on their severity and frequency, a protocol amendment will be considered. 13.2 Serious Adverse Events An AE is considered “serious” if in the opinion of the investigator it is one of the following outcomes : • Death, • A life-threatening adverse event, • A congenital anomaly or birth defect , • Inpatient hospitalization or prolongation of existing hospitalization, • A persistent or significant incapacity or substantial disruption in the ability to conduct normal life functions. Important medical events that may not result in death, be life- threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgement, the event may jeopardize the subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition. Furthermore, an important medical event that is not otherwise an SAE may be considered serious if the event may jeopardize the subject and may require medic al or surgical intervention to prevent one of the outcomes listed in this definition. 13.2.1 Reporting of SAEs All SAEs should be reported immediately to Dr. Katherine Peters (Pager: 919 -970-7591) or her designee (919- 684-8111) and to the FDA . Fatal or life- threatening, unexpected adverse events will be reported to the FDA by telephone, facsimile, or in writing as soon as possible, but no later than 7 calendar days after first knowledge by the PI -sponsor followed by as complete a report as possible within 8 additi onal calendar days . Serious, unexpected adverse events that are not fatal or life- threatening will be reported to the FDA by telephone, facsimile, or in writing as soon as possible, but no later than 15 calendar days after first knowledge by the sponsor. All adverse events that are considered serious, unanticipated, and related or possibly related to the research (as defined by 21CRF312.32[a]) will be reported to the FDA and the Duke University Medical Center IRB using the appropriate SAE report form . At th e time of the annual progress report to the FDA and the Duke University Medical Center IRB, a summary of the overall toxicity experience will be provided. 13.3 Safety Oversight Committee The Duke Cancer Institute Safety Oversight Committee is responsible for annual data and safety monitoring of DUHS sponsor -investigator phase I and II, therapeutic interventional studies that do not have an independent DSMB. The primary focus of the Safety Oversight Committee is review of safety data, Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 39 CONFIDENTIAL toxicit ies and new information that may affect subject safety or efficacy. Annual safety reviews includes but may not be limited to review of safety data, enrollment status, stopping rules if applicable, accrual, toxicities, reference literature, and interim anal yses as provided by the sponsor -investigator . The Safety Oversight Committee in concert with the DCI Monitoring Team (see Section 14.1 for Monitoring Team descripti on) oversees the conduct of DUHS cancer -related, sponsor -investigator therapeutic intervention and prevention intervention studies that do not have an external monitoring plan, ensuring subject safety and that the protocol is conducted, recorded and report ed in accordance with the protocol, SOPs, GCP, and applicable regulatory requirements. 14 QUALITY CONTROL AND QUALITY ASSURANCE 14.1 Monitoring The DCI Monitoring Team will conduct monitoring visits to ensure subject safety and to ensure that the protocol is conducted, recorded, and reported in accordance with the protocol, standard operating procedures, good clinical practice, and applicable regulatory requirements . As specified in the DCI Data and Safety Monitoring Plan, the DCI Monitoring Team will conduct routi ne monitoring after the third subject is enrolled, followed by annual monitoring of 1– 3 subjects until the study is closed to enrollment and subjects are no longer receiving study interventions that are more than minimal risk . Additional monitoring may be prompted by findings from monitoring visits, unexpected frequency of serious and/or unexpected toxicities, or other concerns and may be initiated upon request of DUHS and DCI leadership, the DCI Cancer Protocol Committee, the Safety Oversight Committee, the sponsor, the Principal Investigator, or the IRB . All study documents must be made available upon request to the DCI Monitoring Team and other authorized regulatory authorities, including but not limited to the National Institute of Health, National Canc er Institute, and the FDA . Every reasonable effort will be made to maintain confidentiality during study monitoring. 14.2 Audits The Duke School of Medicine Office of Audits, Risk, and Compliance (OARC) office may conduct audits to evaluate compliance with the protocol and the principles of GCP . The PI agrees to allow the OARC auditor(s) direct access to all relevant documents and to allocate his/her time and the time of the study team to the OARC audito r(s) in order to discuss findings and any relevant issues. OARC audits are designed to protect the rights and well -being of human research subjects. OARC audits may be routine or directed (for cause). Routine audits are selected based upon risk metrics generally geared towards high subject enrollment, studies with limited oversight or monitoring, Investigator initiated Investigational Drugs or Devices, federally -funded studies, high degree of risk (based upon adverse events, type of study, or vulnerable populations), Phase I studies, or studies that involve Medicare populations. Directed audits occur at the directive of the IRB or an authorized Institutional Official. OARC audits examine research studies/clinical trials methodology, processes and systems to assess whether the research is conducted according to the protocol approved by the DUHS IRB. The primary purpose of the audit/review is to verify that the standards for safety of human subjects in clinical trials and the quality of data produced by the cli nical trial research are met. The audit/review will serve as a quality assurance measure, internal to the institution. Additional goals of such audits are to detect both random and systemic errors occurring during the conduct of clinical research and to em phasize “best practices” in the research/clinical trials environment. 14.3 Data Management and Processing 14.3.1 Study Documentation Study documentation includes but is not limited to source documents, case report forms, monitoring logs, appointment schedules, study t eam correspondence with sponsors or regulatory bodies/committees, and regulatory documents that can be found in the DCI -mandated “Regulatory Binder ,” which includes but is not limited to signed protocol and amendments, approved and signed informed consent forms, FDA Form 1572, CAP and CLIA laboratory certifications, and clinical supplies receipts and distribution records. Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 40 CONFIDENTIAL Source documents are original records that contain source data, which is all information in original records of clinical findings, observ ations, or other activities in a clinical trial necessary for the reconstruction and evaluation of the trial . Source documents include but are not limited to hospital records, clinical and office charts, laboratory notes, memoranda, subjects’ diaries or ev aluation checklists, pharmacy dispensing records, recorded data from automated instruments, copies or transcriptions certified after verification as being accurate copies, microfiches, photographic negatives, microfilm or magnetic media, x -rays, subject files, and records kept at the pharmacy, at the laboratories and at medico- technical departments involved in the clinical trial . When possible, the original record should be retained as the source document . However, a photocopy is acceptable provided that it is a clear, legible, and an exact duplication of the original document. 14.3.2 Data Management The subject’s medical records will be the primary source document for the study. Source documents include all information in original records and certified copies of original records of clinical findings, observations, or other activities in a clinical investigation used for reconstructing and evaluating the investigation 1. Source document ations may also include paper eligibility checklists, data flowsheets, patient reported outcomes and other paper documents. The PI, study coordinator, study research nurse, data management team and all associated study key personnel, are permitted to make entries, changes, or corrections in the source documents or database per the st udy delegation of authority log. Errors on the source documents will be crossed out with a single line, and this line will not obscure the original entry. Changes or corrections will be dated, signed, initialed, and explained (if necessary). Database changes will be tracked via electronic trail automatically . 14.3.3 Data Management and Data Verification The DCI I T Shared Resource has developed Title 21 CFR Part 11 compliant databases for cancer clinical trials. DCI IT has extensive expertise in database quality as surance, data standards, and use of caBIG tools to support cancer researchers. Data queries will be generated automatically by the eCRF system . These data queries signify the presence of data inconsistencies. The study and data management team will cross -reference the data to verify accuracy. Missing or implausible data will be highlighted for the PI requiring appropriate responses (i.e. confirmation of data, correction of data, completion or confirmation that data is not available, etc.). The database wil l be reviewed and discussed prior to database closure, and will be closed only after resolution of all remaining queries . 14.3.4 Coding of Adverse Events All adverse events will be coded using CTC AE (version 4.0) . 14.3.5 Study Closure Following completion of the studies, the PI will be responsible for ensuring the following activities: • Data clarification and/or resolution • Accounting, reconciliation, and destruction/return of used and unused study drugs • Review of site study records for completeness • Shipment of all remaining laboratory samples to the designated laboratories 1 In 21 CFR 312.62(b), reference is made to records that are part of case histories as “supporting data”; the ICH guidance for industry E6 Good Clinical Practice: Consolidated Guidance (the ICH E6 guidance) (available at http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm or http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htm ) uses the term “source data/documents.” For the purpose of this guidance, these terms describe the same information and have been used interchangeably. Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 41 CONFIDENTIAL 15 STATISTICAL METHODS AND DATA ANALYSIS All statistical analys es will be performed under the direction of the statistician designated in key personnel . Any data analysis carried out independently by the investigator must be approved by the statistician before publication or presentation. 15.1 Analysis Sets Subject to the availability of data, a ll patients who receive any protocol treatment will be included in analyses addressing secondary objectives. Statistical analyses for the primary objective will exclude patients who terminate protocol treatment prematurely (i.e. less than 6 vaccinations) without a n unacceptable toxicity . 15.2 Patient Demographics and Other Baseline Characteristics Summaries of clinical a nd socio- demographic characteristics will be generated for all patients who receive vaccine treatment. Categorical descriptors will be summarized using frequency distributions; whereas, interval variables will be summarized using percentiles, as well as means and standard deviations. 15.3 Treatments A frequency distribution will be generated for the number of v accines received by patients . 15.4 Primary Objective To assess the safety of the PEP IDH1M vaccine alone and in combination with adjuvant TMZ and/or RT in adult patients with progressive, resectable WHO Grade II gliomas that are confirmed Grade II or transition to a higher grade glioma at the time of surgery . 15.4.1 Variable The percentage of patients with an unacceptable toxicity will be estimated, where unacceptable toxicity is defined as any Grade 3 toxicity at least possibly attributed to the vaccine (or vaccine + TMZ and/or RT ) that does not resolve to baseline within 3 weeks , any Grade 3 hypersensitivity reactions requiring steroids, any Grade 4 toxicity, including neurologic events not due to progressive disease, or any life threatening-event not attributable to concomitant medication, co- morbid event, or disease progression. 15.4.2 Statistical Hypothesis, Model, and Method of Analysis Up to 28 patients will be enrolled and treated with the goal of accruing 20 patients that will receive at least 6 vaccines (3 pre- surger y and 3 post -surgery) . Less than 20% of patients are expected to drop out between enrollment and the 6th vaccin ation. Initial Study Monitoring For Adverse Events : Initially 6 subjects will be accrued to the study after which accrual will be suspended unti l the last patient enrolled undergoes surgical resection to review the toxicity experienced by these subjects during the first 3 vaccinations . During this period of time, some of the 6 patients may have initiated post -surgery treatment with TMZ and IDH1 vaccine . If 2 or less of these subjects experience an unacceptable toxicity , accrual will continue. Otherwise, modifications of the protocol will be considered before accruing additional subjects . If a patient who has not experienced an unacceptable toxicity does not complete 3 vaccinations, that patient will be replaced for initial study monitoring. Overall Adverse Event Monitoring: Rigorous monitoring of long- and short -term toxicities in a manner similar to that found in many phase I dose- escalatio n studies would require accrual suspension between stages of patient accrual while relevant data matures . After the initial 6 patients are accrued and safely receive vaccine treatment, accrual will not be suspended to formally assess the toxicity profile unless the following guidelines are satisfied. Rather, the study will be monitored continuously for the occurrence of unacceptable adverse events . Once accrual is resumed after the initial monitoring of the first 6 subjects, aggregate summaries of adverse experiences will be generated and reviewed by the clinical team every 6- 12 months. The following are considered adequate documentation of review: Pro00054746: RESIST Study Version: 20171011 PT-PhI-II v05.22.12 Duke Cancer Institute Page 42 CONFIDENTIAL • PI review of the aggregate summary of adverse events that is generated every 6 months for the DSMBplus meeting. • PI signature of the collective AE listing after review with the clinical research team. As described in Section 13.1.1, the PI will periodically review the collective adverse event listing with the clinical research team with the intention of identifying any trends or patterns in toxicity on a monthly basis. Tabulated below are the conditions under which accrual will be temporarily suspended and data carefully reviewed to determine the appropriate action, including permanent study termination, continuation with patient accrual after appropriate amendment, or continuation with patient accrual with no modification of the protocol (Table 3). Accrual will also be suspended whenever a death occurs that is possibly, probably, or definitely related to treatment with vaccine alone or vaccine and TMZ . Table 3. Conditions under W hich Accrual will be Suspended Number of patients accrued Number of patients with unacceptable toxicity requiring accrual suspension 6-7 ≥3 8-10 ≥4 11-14 ≥5 >14 ≥5 These guidelines have not been adjusted for differential length of follow -up of accrued patients . The probability of accrual suspension as a function of the true unacceptable toxicity rate is tabulated below based upon simulation studies (Table 4). These statistics were generated assuming toxicity outcome was known at the time of accrual, and ignored issues such as time to toxicity, accrual rate, and length of follow - up. Table 4. Probability of Accrual Suspension as a F unction of the T rue Unacceptable Toxicity Rate Underlying unacceptable toxicity rate Probability of accrual suspension Expected # of Patients 0.01 0.0002 20 0.05 0.005 19.9 0.1 0.034 19.6 0.15 0.12 18.8 0.2 0.27 17.5 0.25 0.46 15.6 0.3 0.65 13.6 0.35 0.80 11.7 0.4 0.90 10.0 0.45 0.96 8.6 0.5 0.98 7.8 Though few or no u nacceptable toxicities are expected during pre- surgery vaccine treatment , unacceptable toxicities possibly attributable to either TMZ or vaccine post -surgery are expected. Yung84 reports that 18% of patients treated with TMZ alone experienced a grade 3 or 4 adverse event . Assuming vaccine does not increase the chances of unacceptable toxicity and a n unacceptable toxicity rate of 18% with TMZ, the probability of study suspension due to excessive unacceptable toxicity is 0.21 . If the chances of unacceptable toxicity increase the overall true unacceptable toxicity rate, then the chances of study suspension due to excessive unacceptable toxicity increases to 0.80 with an underlying unacceptable toxicity rate of 35%. Any patient who discontinues vaccination prior to the receipt of 6 vaccines will not be evaluable for the primary endpoint, unless the patient experienced an unacceptable toxicity. Per Section 12.6.