Peptide Targets for Glioblastoma Against Novel Cytomegalovirus Antigens

Patients may be enrolled following radiation therapy and prior to initiation of
post-radiation therapy cycles of TMZ provided they meet all eligibility criteria (a screening
consent will be obtained for CMV screen only to confirm eligibility, this can be done prior
to chemoradiation). At time of enrollment, after signing consent, patients will undergo
immune monitoring blood work and Tetanus-diphtheria booster vaccination with 0.5 mL of Td
(tetanus, diphtheria toxoid, adsorbed). Six patients will participate in a study drug safety
cohort that receives standard 5-day TMZ, all other patients will be randomized to receive (1)
standard TMZ (150-200 mg/m^2/day on days 1-5 of each 28 day cycle) with vaccination on Day 23
(±1 day) of each TMZ cycle, or (2) dose-intensified TMZ (75-100 mg/m^2/day on days 1-21 of
each 28 day cycle) with vaccination on day 23 (±1 day) of each TMZ cycle. Each randomized arm
will have 18 patients.

Patients must be screened at Duke within 3 +/- 1 weeks after completion of standard of care
radiation. For patients receiving 5-day TMZ, the initial cycle of TMZ will begin 3 (±1) weeks
after completing radiation therapy (RT) at a standard targeted dose of 150-200 mg/m^2/d for 5
days. For patients receiving 21-day TMZ, the initial cycle will be at the dose-intensified
dose of 75-100 mg/m^2/d for 21 days. All patients will receive a tetanus pre-conditioning
injection in the right groin (as described below) on day 22 (±1 day) and the following day
receive the vaccine prepared as follows: 500 µg of PEP-CMV Component A mixed with Montanide
ISA-51 (Incomplete Freund's Adjuvant) intradermally administered in the right groin and, 2
hours later, 500 µg of PEP-CMV Component B mixed in 150 µg of Granulocyte Macrophage Colony
Stimulating Factor (GM-CSF) intradermally administered in the left groin. Vaccines #2 and #3
will be given at 2 week intervals, which will result in a ~35-day delay before starting TMZ
cycle 2. The study drug safety cohort will have the first vaccine with just Component A or
Component B and all subsequent vaccinations with both components will have Component A and
Component B administered with a 2-hour delay.

An unacceptable toxicity will be defined as any vaccine-related or any non-neurologic ≥ Grade
3 toxicity of any duration not attributable to TMZ, bevacizumab, and/or disease progression;
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. Although not considered an unacceptable toxicity, any patient with ≥ Grade 2
urticaria will not receive further vaccines, will be withdrawn from the study, and will be
replaced if less than 3 vaccines have been administered without unacceptable toxicity. The
prevalence of unacceptable toxicities occurring during the vaccinations administered
concurrently with temozolomide will be continuously monitored. If more than 25% of accrued
patients experience unacceptable toxicities, then accrual will be suspended and reported
toxicity will be carefully reviewed to determine if modifications to the protocol treatment
should occur. Peptide vaccinations employing GM-CSF and Montanide ISA-51 as adjuvants have
generally been well tolerated in human patients in numerous phase I-III trials.

Treatment Plan: Patients will be vaccinated in conjunction with subsequent 28-day TMZ cycles
for a total of 6 to 12 cycles of TMZ after RT. Cycles may be given every 5 (± 1) weeks in
order to adjust for slight delays on startup of each 28-day cycle and the total number of
cycles are given at the discretion of the treating oncologist. During TMZ cycles,
vaccinations will occur on day 22 (+ 1 day) of each TMZ cycle. All vaccines will be given
i.d. approximately 10 cm below the inguinal ligament bilaterally (Component A will be
administered in the right groin and Component B will be administered in the left groin). A
target of six cycles with maximum of twelve cycles of TMZ may be given at the discretion of
the treating neuro-oncologist. Vaccines will continue after the completion of TMZ cycles
beginning 5 (± 1) weeks after completion of the last TMZ cycle to a maximum number of 20
vaccines (unless tumor progression occurs).

Patients will be imaged with contrast-enhanced MRI pre & post-surgical resection (prior to
initiation of chemoradiation), post-chemoradiation and every 2 months after starting TMZ. The
modified Revised Assessment in Neuro-Oncology (RANO) criteria will be used for assessment of
pseudoprogression and patients demonstrating definitive progression will be removed from
study. Any patient removed prior to immune monitoring post vaccine 3 will be replaced for
immunologic endpoints. Clinical endpoint comparisons will be made among patients successfully
randomized to adjuvant TMZ treatment arms.

Blood for immune monitoring will be obtained, prior to Td pre-conditioning, during vaccine 1
(just prior to Component A, 1 hour after Component A, just prior to Component B, and 1 and 2
hours after Component B), during vaccine 2 (just prior to Component A, 1 hour after Component
A, just prior to Component B, and 1 and 2 hours after Component B), prior to vaccine 3, after
vaccine 3 (at the clinic visit before the second cycle TMZ), and prior to vaccines 4, and 6.
Finally, blood for immune monitoring will be obtained at tumor progression (if feasible).

As part of standard care for these patients, upon tumor progression, participants may undergo
stereotactic biopsy or resection. As this is not a research procedure, consent will be
obtained separately. Patients that have this procedure done here at Duke University Health
System, may be approached to participate in the Duke Brain Tumor Center Bio-repository study
(Pro00007434). Tissue obtained from patients who consented to the Duke Brain Tumor Center
Bio-repository will be used to assess immunologic cell infiltration, antigen expression, and
bio-markers for immunologic response.

Inclusion Criteria:

1. Age ≥ 18 years.

2. Histopathologically proven newly-diagnosed primary glioblastoma with complete or
partial surgical resection. Biopsy not acceptable.

3. Patients must be CMV seropositive.

4. The tumor must be supratentorial.

5. Karnofsky performance status of ≥ 70.

6. Stable or decreasing steroid dose (≤ 4 mg/day) at time of post-XRT adjuvant TMZ
initiation. If patients are decreasing steroid use, once they are at 2 mg/day, they
may be supplemented with physiologic replacement hydrocortisone therapy (20-30 mg/day
in divided doses), at the discretion of the treating oncologist.

7. Hematology: ANC ≥ 1500 cells/µL, Platelet count ≥ 100,000 cells/µL, Hemoglobin ≥ 9.0
g/dl

8. Chemistry: ALT/AST ≤ 2.5 times the upper limit of normal, Total bilirubin ≤ 1.5 mg/dl.

Exclusion Criteria:

1. Radiographic or cytologic evidence of leptomeningeal or multifocal disease at any time
prior to study entry.

2. Prior conventional antitumor therapy, other than steroids, RT or TMZ therapy given for
glioblastoma.

3. Pregnant or need to breast feed during the study period.

4. Not adhering to pregnancy prevention recommendations.

5. Active infection requiring intravenous antibiotics or an unexplained febrile (> 101.5
F) illness.

6. Immunosuppressive disease or human immunodeficiency virus infection.

7. Patients with unstable or severe intercurrent medical conditions such as severe heart
or lung disease.

8. Allergic or unable to tolerate TMZ for any reason. Any patient that successfully
completed at least 5 weeks of Temodar during standard of care XRT/TMZ and whose blood
counts meet the eligibility requirements (inclusion #7) within 4 weeks post XRT/TMZ is
eligible.

9. Known allergy or hypersensitivity to KLH, GM-CSF or yeast derived products, or a
history of anaphylactic reactions to shellfish proteins.

10. Patients with previous inguinal lymph node dissection, radiosurgery, brachytherapy, or
radiolabeled monoclonal antibodies.

11. Prior allogeneic solid organ transplant.

12. Currently receiving or ever received immunosuppressive therapy for an autoimmune
disorder or an organ transplant.