A Pilot Study of a Personalized Neoantigen Cancer Vaccine Following Front-Line Rituximab in Follicular Lymphoma

This research study is a Pilot Study, which is the first time investigators are examining the
Personalized Neoantigen Vaccine (NeoVax) in patients diagnosed with follicular lymphoma. The
FDA (the U.S. Food and Drug Administration) has not approved the Personalized Neoantigen
Vaccine as a treatment for any disease.

The purpose of this study is to determine if it is possible to make and safely administer a
vaccine against FL by using information gained from specific genetic characteristics of the
participant own FL. The investigators plan to analyze the specific genetic characteristics of
the participant own FL (mutations) and use that information to produce proteins that may help
the participant's immune system recognize and fight FL cells.

This vaccine is also being tested in clinical trials in patients with advanced melanoma (a
type of skin cancer) or glioblastoma (a type of brain cancer). The current study will examine
the ability of the vaccine to stimulate the participant's immune system when given at several
different timepoints, and will examine the participant's blood cells for signs that the FL
has changed or decreased.

FL cells will be obtained from lymph node biopsy, blood draws or effusion. The genetic
material contained in the FL cells will be examined for the presence of tumor-specific
mutations. This information will be used to prepare small protein fragments, which are called
"peptides." The vaccine will consist of up to 20 of these peptides as well as a drug called
Poly-ICLC. A peptide from the tetanus vaccine will also be included to boost the immune
response.

Poly-ICLC (also called Hiltonol) is an experimental "viral mimic" and an activator of
immunity. Poly-ICLC binds proteins on the surface of certain immune cells to make it appear
as if a virus is present. When the cells detect the vaccine, they think it is a virus and
turn on the immune system. Poly-ICLC will be mixed with NeoAntigen peptides and administered
as an injection given underneath the skin. Poly-ICLC is an investigational drug, meaning the
FDA has not approved it as a treatment for any disease.

Inclusion Criteria:

- Diagnosis of grade I-IIIA follicular lymphoma (pathology must be confirmed at
DFCI/BWH)

- Planned treatment with 4 weekly doses of rituximab.

- No prior systemic therapy for follicular lymphoma; prior radiation with palliative or
curative intent is allowed if radiation occurred more than 3 months prior to study
entry

- Patient must have measurable disease by Cheson criteria

- Age ≥ 18 years.

- ECOG performance status < 2.

- Participants must have normal organ and marrow function as defined below:

- total bilirubin less than institutional ULN (<1.5 x ULN if patient has a history
of Gilbert's disease

- AST(SGOT)/ALT(SGPT) ≤2.5 × institutional upper limit of normal

- ANC >500 (for secondary screening only)

- Platelet count >75,000 (for secondary screening only)

- The effects of NeoVax and poly-ICLC on the developing human fetus are unknown. For
this reason, women of childbearing potential (WOCBP) must have a negative pregnancy
test (serum) before entry onto the trial and within 7 days prior to start of study
vaccination.

- Female patients enrolled in the study, who are not free from menses for >2 years, post
hysterectomy / oophorectomy, or surgically sterilized, must be willing to use either 2
adequate barrier methods or a barrier method plus a hormonal method of contraception
to prevent pregnancy or to abstain from sexual activity throughout the study, starting
with visit 1 through 4 weeks after the last dose of study therapy. Approved
contraceptive methods include for example; intra uterine device, diaphragm with
spermicide, cervical cap with spermicide, male condoms, or female condom with
spermicide. Spermicides alone are not an acceptable method of contraception. Male
participants need to agree to use an adequate method of contraception

- Patient is agreeable to allow tumor (from peripheral blood, lymph node, or effusion)
and normal tissue (from saliva) samples to be submitted for complete exome and
transcriptome sequencing.

- Ability to understand and the willingness to sign a written informed consent document.

- Additional Inclusion Criteria for Treatment Registration

- Participants must meet the following criteria (in addition to the above) to be
eligible to proceed to receive vaccine treatment on the study:

- At least 7 immunizing peptides can be designed

- Continue to meet inclusion and exclusion criteria for Screening Registration (note:
hepatitis B and hepatitis C serologies do not need to be repeated unless there is a
clinical concern that an exposure has occurred since the screening phase).

- Achieved a CR, PR, or SD with no residual mass greater than 5 cm per Lugano criteria
following single agent rituximab per

Exclusion Criteria:

- Prior systemic therapy for follicular lymphoma with the exception of 4 weekly doses of
rituximab as proscribed per protocol

- Radiation with palliative or curative intent within 90 days of study screening

- Participants who are receiving any other investigational agents.

- Previous bone marrow or stem cell transplant

- Concomitant therapy with immunosuppressive or immunomodulatory agents; chronic use of
systemic corticosteroids at doses of 10 mg of prednisone (or equivalent) for
indications other than treatment of follicular lymphoma is acceptable. Use of higher
doses of corticosteroids after initial registration is acceptable if tapered to 10 mg
of prednisone (or equivalent) or les at least 7 days prior to NeoVax administration so
long as the corticosteroids were not administered for follicular lymphoma.

- Use of a non-oncology vaccine therapy for prevention of infectious diseases within 2
weeks prior to any NeoVax administration.

- History of severe allergic reactions attributed to any vaccine therapy for the
prevention of infectious diseases.

- Active, known, or suspected autoimmune disease or immunosuppressive conditions with
the exception of vitiligo, type 1 diabetes, residual autoimmune-related hypothyroidism
requiring hormone replacement, or psoriasis not requiring systemic treatment.

- Progressive disease or stable disease with residual tumor mass > 5 cm by CT scan
(measured as long axis) following 4 weekly doses of rituximab (for treatment phase
only).

- Any documented transformation to diffuse large B cell lymphoma or grade 3Bfollicular
lymphoma.

- Currently requiring chronic intravenous immunoglobulin G (IVIG)

- Active infection with hepatitis B or C (see Study Calendar in Section 10 for screening
assays).

- Uncontrolled intercurrent illness including, but not limited to ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia.

- Any underlying medical condition, psychiatric condition or social situation that in
the opinion of the investigator would compromise study administration as per protocol
or compromise the assessment of AEs.

- Pregnant women are excluded from this study because personalized neoantigen peptides
and poly-ICLC are agents with unknown risks to the developing fetus. Because there is
an unknown but potential risk of adverse events in nursing infants secondary to
treatment of the mother with personalized neoantigen peptides and poly-ICLC, nursing
women are excluded from this study.

- Individuals with history of an invasive malignancy are ineligible except for the
following circumstances: a) individuals with a history of invasive malignancy are
eligible if they have been disease -free for at least 3 years and are deemed by the
investigator to be at low risk for recurrence of that malignancy; b) individuals with
the following cancers are eligible if diagnosed and treated: carcinoma in situ of the
breast, oral cavity or cervix and basal cell or squamous cell carcinoma of the skin;
c) individuals with prostate cancer managed with active surveillance that is not
expected to limit their survival to <10 years.

- Participants with known CNS involvement

- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to poly-ICLC.

- HIV-positive participants including those on combination antiretroviral therapy are
ineligible because assessment of immunologic endpoints may be confounded by
HIV-induced alterations in patient immune status and functio