7. PHARMACEUTICAL INFORMATION 7.1 Cyclophosphamide (Cytoxan ®, CY) 7.1.1 Agent Accountability The IND Sponsor or the Sponsor’s represen tative shall take re sponsibility for and shall take all steps to maintain appropria te records and ensure appropriate supply, storage, handling, distribution and usage of investigational product in accordance with the protocol and any app licable laws and regulations. Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 42 7.1.2 Mode of Action CY is a synthetic antineoplastic drug chemically related to the nitrogen mustards. CY is biotransformed principally in the liver to active alkylating metabolites by a mixed function microsomal oxidase system. These metabolites interfere with the growth of susceptible rapidly proliferating malignant cells. The mechanism of action is thought to involve cross-linking of tumor cell DNA. 7.1.3 Description CY (CYTOXAN®; cyclophosphamide for injec tion, USP) is a sterile, white powder containing cyclophosphamide m onohydrate and is supplied in vials for single-dose use. 7.1.4 Packaging and Labeling Information CY is commercially available. 7.1.5 Preparation Parenteral drug products should be inspec ted visually for particulate matter and discoloration prior to admi nistration, whenever solution and container permit. Add the diluent to the vial and shake it vigor ously to dissolve. If the powder fails to dissolve immediately and comple tely, it is advisable to al low the vial to stand for a few minutes. Use the quantity of diluen t shown below to constitute the product: Dosage Strength CYTOXAN Contains Cyclophosphamide Monohydrate Quantity of Diluent 500 mg 534.5 mg 25 mL 1 g 1069.0 mg 50 mL 2 g 2138.0 mg 100 mL CY may be prepared for parenteral use by infusion using any of the following methods: 1. CY constituted with 0.9% sterile sodium chloride may be infused without further dilution. 2. CY constituted with 0.9% sterile sodium chloride may be infused following further dilution in the following:  Dextrose Injection, USP (5% dextrose)  Dextrose and Sodium Chlo ride Injection, USP (5% dextrose and 0.9% sterile sodium chloride)  5% Dextrose and Ringer’s Injection  Lactated Ringer’s Injection, USP  Sodium Chloride Injection, USP (0.45% sterile sodium chloride)  Sodium Lactate Injection, USP (1/6 molar sodium lactate) 7.1.6 Storage Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 43 Store vials at or below 77° F (25° C). 7.1.7 Stability CY (prepared for either direct injection or infusion) is chemically and physically stable for 24 hours at room temperature or for 6 days in the refr igerator; it does not contain any antimicrobial preservative and thus care must be taken to assure the sterility of prepared solutions. 7.1.8 Route of Administration CY is administered by IV injection over 30 minutes. 7.1.9 Subject Care Implications During treatment, the subject ’s hematologic profile (particularly neutrophils and platelets) should be monitored regularly to determine the degree of hematopoietic suppression. The rate of metabolism and th e leukopenic activity of CY reportedly are increased by chronic administration of high doses of phenobarbital. The physician should be alert for possible combined drug actions, desira ble or undesirable, involving CY even though CY has been used successfully concu rrently with other drugs, including other cytotoxic drugs. CY treatment, which cause s a marked and persis tent inhibition of cholinesterase activity, potentiates the e ffect of succinylcholine chloride. If a subject has been treated with CY within 10 days of general anesthesia, the anesthesiologist should be alerted. CY may interfere with normal wound healing. 7.1.10 Returns and Reconciliation N/A 7.2 GVAX 7.2.1 Agent Accountability The IND Sponsor or the Sponsor’s represen tative shall take re sponsibility for and shall take all steps to maintain appropria te records and ensure appropriate supply, storage, handling, distribution and usage of investigational product in accordance with the protocol and any app licable laws and regulations. 7.2.2 Mode of Action GM-CSF secreting whole cell vaccines recruit and activate tumor specific T-cells and induce a cytotoxic response through two mechanisms: 1. they deliver a range of peptide antigens (without the need for sp ecific knowledge of the relevant target Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 44antigens), and 2. GM-CSF is an important growth and differentiation factor for dendritic cells, which are pot ent antigen-presenting cells. 7.2.3 Description 7.2.4 Storage 7.2.5 Preparation 7.2.6 Stability 7.2.7 Route of Administration Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 45 7.2.8 Subject Care Implications 7.2.9 Returns and Reconciliation The investigator is responsible for keeping accurate records of the clinical supplies, the amount dispensed to, and returned by the subjects and the amount remaining at the conclusion of the trial. Upon completion or termination of the st udy, all unused and/or partially used Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 46investigational product will be destroyed at the site per institutional policy. It is the Investigator’s responsibility to arrange for disposal of all empty containers, provided that procedures for proper disposal have been established according to applicable federal, state, local and in stitutional guidelines and procedures, and provided that appropriate reco rds of disposal are kept. 7.3 Pembrolizumab 7.3.1 Agent Accountability The sponsor/investigator shall take respons ibility for and shall take all steps to maintain appropriate records and ensure appropriate supply, storage, handling, distribution and usage of investigational pr oduct in accordance w ith the protocol and any applicable laws and regulations. 7.3.2 Mode of Action Pembrolizumab is a highly selective hu manized monoclonal antibody designed to block the interaction between PD-1 and its ligands, PD-L1 and PD-L2. Pembrolizumab is an IgG4/kappa isotype w ith a stabilizing sequen ce alteration in the Fc region. 7.3.3 Description Packaging and Labeling Information 7.3.5 Preparation Refer to Procedures Manual for preparation instructions. 7.3.6 Storage Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 477.3.7 Stability Refer to Procedures Manual for Stability information. 7.3.8 Route of Administration The reconstituted product is in tended for IV administration. 7.3.9 Patient Care Implications Based on results from the nonclinical studies , there are currentl y no specific safety 7.3.10 Agent Ordering Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 487.3.11 Returns and Reconciliation The investigator is re sponsible for keeping accurate r ecords of the cl inical supplies received from Merck or designee, the amount dispensed to, and returned by the subjects and the amount remaining at the conclusion of the trial. Upon completion or termination of the st udy, all unused and/or partially used investigational product will be destroyed at the site per institutional policy. It is the Investigator’s responsibility to arrange for disposal of all empty containers, provided that procedures for proper disposal have been established according to applicable federal, state, local and in stitutional guidelines and procedures, and provided that appropriate reco rds of disposal are kept. 8. CORRELATIVE/SPECIAL STUDIES Sample collection, processing, a nd storage instructions will be provided in the Laboratory Manual. The specimens below will be stored and evaluated in Dr. Zheng’s laboratory. 8.1 Tumor Tissue Studies Tumor biopsies will be performed on subjects with accessible tumor at baseline and during treatment (during week 6 or 7). Ho wever, tumor biopsy will not be performed either at baseline and/or during treatment if the tumor is not accessible or if biopsy is considered not in patient’s best interest. An additional biopsy at the time of response and/or progression is optional. Tumor sample s will be collected by core biopsy from accessible tumor tissue. A maximum of 6 core biopsies (or fine needle aspirates, if cores are considered unsafe) will be obtained from each subject. Attempts will be made to obtain archived tissue samples from all subjects 8.2 Whole Blood Peripheral Blood Lym phocytes (PBLs) and Circulating Tumor Cells (CTCs) Up to 180 cc of whole blood w ill be collected for isolation of PBL at baseline (C1D1) and at every 6 weeks (with every other cycl e of treatment) up to and including C5D1. After C5D1, blood will then be collected every 12 weeks (every 4 th cycle; C9D1) and at the off study visit. In additi on, up to 20 cc of whole blood may be collected/aliquoted for circul ating tumor cell analyses. 8.3 Serum and Plasma Marker Studies Whole blood for serum (20 cc) and plasma (20 cc) will be collected at baseline (C1D1) and at every 6 weeks (with ever y other cycle of treatment) up to and including C5D1. After C5D1, blood with then be collected ever y 12 weeks (every 4th cycle; C9D1) and at the off study visit to identify potential therapeutic targets, biomarkers, circulating DNA analyses, and predictors of response and autoimmune toxicity through proteomic approaches. 8.4 Diagnostic Tissue Samples Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 49Tissue, fluid, or blood may be collected from standard of care procedures used to treat or diagnoses immune related toxicities. Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 509. STUDY CALENDAR Screening Cycles 1-4 Week 6 Week 12Cycles 5 and Above21 Off Treatment16Off Study19 Day 1 Day 2 Every Cycle Every 4th cycle Visit Window1 -14 to -1 +/- 3 +/-7 +/-7 +/-7 +/-7 +/-7 +/- 7 TREATMENT Cyclophosphamide X X21 GVAX X X21 Pembrolizumab X X CLINICAL ASSESSMENTS/TESTS Informed consent X Inclusion/exclusion criteria X Demographics X Medical History2 X Concurrent medications X X X X X Physical Exam3 X X X X Vital Signs and pulse ox4 X X X X X Height X Weight X X X X Performance Status X X X X CBC with differential 5,6 X X X X X Complete Metabolic Profile5-7 X X X X X TSH5, 8 X X X X X Serum or Urine Preg9 X X X Urinalysis and microscopic exam5 X INR and pTT5 X MRI brain with contrast X20 Adverse event evaluation10 X X X X Vaccine Site Assessment11 X X X X ASSESSMENT OF RESPONSE AND CORRELATIVE STUDIES Archival tumor sample X CEA5,6 X X X X X X X Tumor measurements12 X X X X17X Research Blood13 X15 X15 X18X Tumor Biopsy14 X X X 1) Longer delays to be approved by the sponsor 2) Includes history of lung disease, HIV, hepatitis B or C infecti on, and complete cancer history, including primary site of cancer, gross location of primary tumor, secondary sites of cancer, histology, histologic grade, date of initial diag nosis, date of metastat ic diagnosis, and prior cancer therapy regimens. 3) Complete physical exam will be completed at baseline; focused physical examinations will be conducted thereafter. Exams, concomitant medicati on, AE assessments can be made up to 3 days prior to infusion. 4) Temperature, respiration rate, blood pressure, pulse, and pulse ox should be taken prior to the administration of each of the drugs: CY, G VAX, and pembrolizumab. Vitals will also be collected post-GVAX. 5) Labs may be collected within a window of up to 4 days prior to dosing. Unexpected Grade 3 or greater laboratory abnormalities should be repeat ed within 24-72 hours if clinically indicated and monitored as necessary to determin e if event meets toxicity criteria. 6) Screening bloodwork does not need to be repe ated if performed within 7 days of C1D1 7) Albumin, alkaline phosphatase, total bili rubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, potassi um, total protein, SGOT [AST ], SGPT [ALT], sodium. 8) Free T3/T4 to be checked reflexively if TSH is abnormal 9) Serum or urine pregnancy for women of childb earing potential Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5 / January 17, 2018 5110) Baseline adverse event evaluatio n may be performed either at th e screening visit or at C1D1 prior to the admini stration of therapy. 11) Not applicable for first cycle, but app licable for day 1 of all subsequent cycles 12) Tumor measurement will be performed with contrast CT chest/abdome n/pelvis. Noncontrast CT chest/abdomen/pelvis or CT Chest and MRI A bdomen/pelvis will be performed in subjects with contrast allergies. Baseline scans may be pe rformed within 28 days prior to first treatment. If patients remain on study after initial progression, a repeat CT scan will be obtained at 6 weeks after progression (+/- 7 day window), 12 weeks after progression (+/- 7 days), and every 12 weeks thereafter (+/- 7 days). If the off study visit occurs early, s cans do not need to be repeated if one has been perfor med within 6 weeks. 13) Baseline serum and plasma collection should be performed at C1D1 prior to the administration of therapy. Please see sect ion on correlative studies (section 8). 14) Only for subjects with tumor that is sa fely accessible for biopsy, a biopsy should be performed prior to initiation of therapy, and again at 6-7 weeks after initiation of therapy, and (optional) at the time of progr ession. Refer to section on corre lative studies. Optional tumor biopsies may be performed at the time of clinical response as well. 15) Follow-up peripheral blood collection will be performed at every other cycle of immunotherapy, (e.g. at C1D1, C3D1, C5D1) prior to the administration of therapy, up to and including C5D1 and then only on cycles wher e the patient receives GVAX therapy (e.g. every 4 th cycle). 16) Patients will undergo the Off Treatment Eval uation if they completed 24 months of study medication ( Section 4.9 ). 17) Patients should continue to be monitored for disease status by radiologic imaging and tumor marker(s) every 12 weeks (+/- 2 weeks). 18) Peripheral blood, serum, and plasma samples s hould continue to be co llected every 12 weeks (+/- 2 weeks). 19) 30 days after their last dose of study drug or within 7 days pr ior to initiation of a new anti- cancer treatment, whichever comes first. Patie nts who discontinue from treatment should be contacted every three months to monitor overall su rvival. Information of other cancer therapies after discontinuation from the study treatment will be collected. SAEs that occur within 90 days of the last infusion of pembrolizumab or before initiation of a new antineoplastic treatment should also be followed and recorded. 20) MRI brain with contrast performed in the 8 w eeks prior to day 1 can be used to fulfill these criteria. 21) After cycle 4, cyclophosphamide and GVAX will be administered with every 4th cycle (12 weeks), restarting with cycle 8. Similar to cycles 1-4, pembrolizumab will administered on cycle day 1. For cycles that include cyclophospha mide and GVAX, cyclophosphamide will also be administered on day 1 and GVAX on day 2. The treatment window for cycles beyond 4 is +/- 7 days. Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5/ January 17, 2018 5210. MEASUREMENT OF EFFECT 10.1 Antitumor Effect – Solid Tumors 10.1.1 Definitions Evaluable for toxicity. All subjects are ev aluable for toxicity after receiving first dose of combined immunotherapy. Evaluable for objective response. All pa tients who have rece ived at least two doses of immunotherapy and have had th eir disease re-evalu ated with imaging will be considered evaluable for response. Response criteria will be classified by RECIST and irRECIST criteria ( Appendix E and F) 10.1.2 Methods for Evaluation of Measurable Disease All measurements should be taken and record ed in metric notation using a ruler or calipers. All baseline evaluations should be performed as closely as possible to the beginning of treatment and never more than 14 days before the beginning of the treatment. Subjects will be eval uated for anti-tumor effect by follow-up imaging (CT chest/abdomen/pelvis w ith IV contrast; noncontrast CT chest/abdomen/pelvis or CT Chest and MR I Abdomen/pelvis will be performed in subjects with contrast allergies, into lerance, elevated creatinine, or other contraindication). All subsequent scans (pos t-treatment) will be compared to the same pretreatment scan that was used prior to initiating of study treatment. The same method of assessment and the same technique should be used to characterize each identified and reported lesion at baseline an d during follow-up. Imaging-based evaluation is preferred to evaluation by clinical examination unless the lesion(s) being followed cannot be imaged but are assessable by clinical exam. CT Chest/Abdomen/Pelvis: This guideline has defined measurability of lesions on CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice thickness. Use of MRI remains a complex issue. MR I has excellent contrast, spatial, and temporal resolution; however, ther e are many image acquisition variables involved in MRI, which greatly impact image quality, lesion conspicuity, and measurement. Furthermore, the availability of MRI is variable globally. As with CT, if an MRI is performed, the tec hnical specifications of the scanning sequences used should be optimized for th e evaluation of the type and site of disease. Furthermore, as with CT, the modality used at follow-up should be the Phase 2 Study of GVAX (with CY) and pembrolizum ab in MMR-p advanced colorectal cancer J16154/Version 5/ January 17, 2018 53same as was used at baseline and the le sions should be measured/assessed on the same pulse sequence. It is beyond th e scope of the RECIST guidelines to prescribe specific MRI pulse sequence para meters for all scanners, body parts, and diseases. Ideally, the same type of scanner should be used and the image acquisition protocol should be followed as closely as possible to prior scans. Body scans should be performed with breath- hold scanning techniques, if possible. 10.1.3 Overall Survival (OS) OS is defined as the duration of time from start of study treatment to time of death. Individuals will be censored at the date of the last study visit if no event occurs.