Dendritic Cell Vaccine With or Without Gemcitabine Pre-Treatment for Adults and Children With Sarcoma

This is a dose finding / dose escalation study of dendritic cell (DC) vaccination
administered through imiquimod (Aldara®) treated skin for refractory sarcoma patients, which
includes a subsequent cohort of subjects who will receive DC and gemcitabine (Gemzar®)
therapy. There are three intended dose levels for cell number of DC per treatment - 3, 6 and
12 million cells per treatment. There will be 5 subjects accrued per dose level. If one
subject in the first 5 patients per dose level experiences a dose limiting toxicity (DLT),
then the dose level will be expanded to 8 subjects. If 2 or more of the subjects at a given
dose level experience a DLT, then the maximum tolerated dose (MTD) will be considered to have
been exceeded. The MTD will be the cell dose level at which less than 1 in 5 or less than 2
in 8 subjects experience a DLT. Provision will be made to de-escalate to dose level 0, or 1.5
million cells per treatment, should dose level 1 be too toxic. This is a 5+3 design modified
from the conventional 3+3 dose escalation schema used for testing cytotoxic agents in Phase I
trials. A lower rate of DLTs is therefore potentially to be accepted on this study than on
such a conventional dose escalation trial of a cytotoxic agent. If no MTD is reached, we will
consider the third dose level to be the recommended phase 2 dose (RP2D) going forward and
expand this dose level to 8 subjects in total.

After the MTD/RP2D is reached, we will commence with the addition of gemcitabine
pre-treatment to the study therapy with the cell dose held at the dose determined for the DC
alone. This will include weekly gemcitabine infusion for three weeks out of four before the
initiation of vaccination. Gemcitabine treatment will commence as soon as the subject has
safely recovered from pheresis, but within 2 weeks of completion of pheresis. DC vaccination
will begin two weeks after the third administration of gemcitabine. Gemcitabine dosing will
be constant, but should the combination of gemcitabine with the MTD/RP2D of DC alone prove
too toxic, we will de-escalate the dose of DC on the gemcitabine containing levels. This
de-escalation will mirror the dose escalation for DC alone, and the MTD for the DC plus
gemcitabine will be defined as the dose level at which less than 1 in 5 or less than 2 in 8
subjects experience a DLT.

Subjects will undergo resection of tumor followed by pheresis to acquire monocytes which will
be separated and used to grow out DC. Subjects not undergoing gemcitabine therapy will begin
vaccination approximately two weeks after pheresis, depending on the manufacture time of
their DC. All subjects will undergo lysate boost administration.

Inclusion Criteria:

1. Age: 1 - 100 years old.

2. Histologically or cytologically confirmed sarcoma either relapsed or without known
curative therapies. Both bone sarcomas and soft tissue sarcomas are eligible.
Osteosarcoma, chondrosarcoma, Ewing's sarcoma and any other diagnoses of sarcoma are
eligible as long as there is soft tissue that can be excised and be used to prepare
lysate. Subjects presenting only with lesions that are only comprised of bone are
excluded. Any number of prior therapies is allowed, including zero.

3. No radiotherapy to other sites planned and/or other chemotherapy planned for the study
period. No radiotherapy or chemotherapy to have been received for at least 4 weeks
before first vaccine administration. To allow for better local control without
introducing undue toxicity into the trial, brachytherapy at time of surgery scheduled
to end by one week before first vaccination is allowed if the radioactive source is to
be removed (e.g. catheters can be placed if removable but implanted seeds are not
allowed). In the event of positive margins being determined after surgical resection,
but not determined in time for the placement of brachytherapy catheters, external beam
radiotherapy may start after the last DC vaccination is administered but before the
lysate boosts begin, and radiation must be planned to be complete before the first
lysate boost.

4. No treatment with corticosteroids, antihistamines or salicylates for at least 1 week
before first vaccination.

5. Adequate organ function (to be measured at enrollment)

- Absolute neutrophil count (ANC) ≥ 0.75* 10^3/µL

- Lymphocytes ≥ 0.5 * 10^3/µL

- Platelets ≥ 75 * 10^3/µL

- Hemoglobin ≥ 9 g/dL

- Aspartate aminotransferase (AST)/Alanine transaminase (ALT) ≤ 2.5 X upper limit
of normal (ULN); if liver metastases, ≤ 5 X ULN

- Serum Creatinine ≤ 1.5 X ULN

- Total Bilirubin ≤ 3 X ULN

- Albumin > 2 g/dL

6. Karnofsky/Lansky score of ≥ 70% or Eastern Cooperative Oncology Group (ECOG)
performance status of 0 or 1

7. Subjects must agree to use adequate method of contraception or abstinence throughout
and up to 4 weeks after the study treatment completion.

8. Life expectancy of > 3 months.

9. Written consent by patient or parent(s) (if patient is < 18 years) on an institutional
review board (IRB)-approved informed consent form prior to any study-specific
evaluation. Assent is required from children as per University of Miami (UM) IRB
guidelines. Subject must be capable of understanding the investigational nature,
potential risks and benefits of the study and able to provide valid informed consent.

Exclusion Criteria:

1. Pregnancy

2. Breast feeding females.

3. Any concomitant participation in other therapeutic trials

4. Virus serology known to be positive for HIV (testing is not required in the absence of
clinical suspicion)

5. Documented immunodeficiency or autoimmune disease

6. Concomitant treatment with corticosteroids, antihistamines (H1 and H2 inhibitors) or
salicylates. Patients may be eligible if the treatment is stopped at least 1 week
before the first vaccination.

7. Brain metastases unless they have been stable for 3 months off of treatment directed
specifically at them.

8. Known allergy to gemcitabine or its formulation components. Intolerant to gemcitabine

- Does not apply to cohorts to be treated without gemcitabine

- Prior therapy with gemcitabine is allowed on all cohorts

9. Refusal to use adequate contraception for fertile patients (females and males) during
the study and for 30 days after the last dose of study treatment.

10. Any serious or uncontrolled medical or psychiatric condition that in the opinion of
the investigator makes the patient not able to participate in the study.