Phase II Trial of Nivolumab for HTLV-Associated Adult T Cell Leukemia/Lymphoma
Phase: PHASE2
Conditions: Acute Adult T-Cell Leukemia/Lymphoma, Adult T-Cell Leukemia/Lymphoma, Chronic Adult T-Cell Leukemia/Lymphoma, HTLV-1 Infection, Lymphomatous Adult T-Cell Leukemia/Lymphoma, Smoldering Adult T-Cell Leukemia/Lymphoma
Sponsor: National Cancer Institute (NCI)

SUMMARY OF CHANGES – Protocol 
 
For Protocol Amendment #5 
 
NCI Protocol #: 9925 
Local Protocol #: 125462 
 
NCI Version Date: 10/27/2017 
Protocol Date: 10/27/2017 
 
# 
Section 
Page(s) 
Change 
1 
Global 
 
Updated protocol version number and date.   
Changed from: 
Version 9.0 / September 8, 2017 
 
Changed to: 
Version 10.0 / October 27, 2017 
2 
Cover 
page 
1 
Added the following Non-Member Collaborator: 
 
IL042 
John H Stroger Jr Hospital of 
Cook County 
Chicago, IL 
Paul Rubinstein, MD 
Telephone: 312-864-7277 
Fax: 312-864-9002 
prubinstein@cookcountyhhs.org 
3 
ICD 
 
Updated protocol version date.   
Changed from: 
September 8, 2017 
 
Changed to: 
October 27, 2017 

NCI Protocol #:  9925 
 
Local Protocol #: 125462 
 
ClinicalTrials.gov Identifier:  NCT02631746 
 
TITLE:  Phase II Trial of Nivolumab for HTLV-Associated Adult T Cell Leukemia/Lymphoma 
 
Corresponding Organization: LAO-NC010 / Duke University - Duke Cancer Institute LAO 
 
Principal Investigator: 
Lee Ratner, M.D., Ph.D. 
Washington University School of Medicine 
660 S. Euclid Ave., Campus Box 8056 
St Louis, MO 63110 
Telephone: 314-362-8836 
Fax: 314-747-2120 
E-mail: lratner@dom.wustl.edu  
 
Participating Organizations:  
LAO-11030 / University Health Network Princess Margaret Cancer Center LAO 
LAO-CA043 / City of Hope Comprehensive Cancer Center LAO 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-MN026 / Mayo Clinic Cancer Center LAO 
LAO-NJ066 / Rutgers University - Cancer Institute of New Jersey LAO 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / University of Pittsburgh Cancer Institute LAO 
LAO-TX035 / University of Texas MD Anderson Cancer Center LAO 
LAO-NCI / National Cancer Institute LAO 
EDDOP / Early Drug Development Opportunity Program 
 
Non-Member Collaborators:   
NY018 
Weill Medical College of Cornell 
University 
New York, NY 
Adrienne Phillips, M.D., MPH 
Telephone: 212-746-2048 
Fax: 212-746-6678 
E-mail: adp9002@med.cornell.edu  
IL042 
John H Stroger Jr Hospital of Cook County 
Chicago, IL 
Paul Rubinstein, MD 
Telephone: 312-864-7277 
Fax: 312-864-9002 
prubinstein@cookcountyhhs.org  

NCI Protocol #: 9925 
Version Date:  October 27, 2017 
 
 
2 
 
 
Statistician: 
Feng Gao Ph.D.  
 
 
Washington University School of Medicine 
 
660 S Euclid Ave, Campus Box 8067 
 
 
 
St Louis, MO 63110  
 
 
Telephone: 314-362-3682 
 
 
Fax: 314-362-2693 
 
 
 
E-mail: gaof@wudosis.wustl.edu  
 
Study Coordinator:               Sarah Larson 
Siteman Cancer Center, Division of Medical Oncology 
Washington University School of Medicine 
Telephone: 314-747-1864 
Pager: 314-253-1880 
Fax: 314-747-9211 
E-mail: salarson@dom.wustl.edu 
 
NCI-Supplied Agent: Nivolumab (BMS-936558) (NSC# 748726) 
 
IND #:  125462 
 
IND Sponsor:  DCTD NCI   
 
Protocol Type / Version # / Version Date:  Original / 1.0 / October 28, 2015  
 
 
 
 
Version 2.0 / December 26, 2015 
 
 
 
 
Version 3.0 / March 23, 2016 
 
 
 
      Version 4.0 / May 2, 2016 
 
 
 
      Version 5.0 / May 9, 2016 
 
 
 
      Version 6.0 / November 2, 2016 
 
 
 
      Version 7.0 / January 5, 2017 
 
 
 
      Version 8.0 / May 5, 2017 
 
 
 
      Version 9.0 / September 8, 2017 
 
 
 
      Version 10.0 / October 27, 2017 
 
 
 
 
 
 
 
 
 
 
 
 

NCI Protocol #: 9925 
Version Date:  October 27, 2017 
 
 
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SCHEMA 
 
Nivolumab will be given at 240 mg every 2 weeks for 4 initial doses, followed by up to 42 doses 
if tolerated.  Therapy is continued in each individual until sign of tumor progression or intolerable 
toxicity, or other endpoint is reached.  
 
Imaging will be performed every 12 weeks for individuals with abnormal imaging at study 
initiation or during the course of the study. 
 
 

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TABLE OF CONTENTS 
 
SCHEMA…………………………………………………………………………………………3 
 
1. 
OBJECTIVES. .....................................................................................................................6 
1.1 
Primary Objective ....................................................................................................6 
1.2 
Secondary Objectives...............................................................................................6 
 
2. 
BACKGROUND .................................................................................................................6 
2.1 
HTLV-1 Infection ....................................................................................................6 
2.2 
Nivolumab..............................................................................................................13 
2.3 
Rationale ................................................................................................................17 
2.4 
Correlative Studies Background ............................................................................17 
 
3. 
PATIENT SELECTION ....................................................................................................17 
3.1 
Inclusion Criteria ...................................................................................................17 
3.2 
Exclusion Criteria ..................................................................................................18 
3.3 
Inclusion of Women and Minorities ......................................................................20 
 
4. 
REGISTRATION PROCEDURES ...................................................................................20 
4.1 
Investigator and Research Associate Registration with CTEP ..............................20 
4.2 
Site Registration .....................................................................................................21 
4.3 
Patient Registration ................................................................................................23 
4.4 
General Guidelines.................................................................................................24 
 
5. 
TREATMENT PLAN ........................................................................................................24 
5.1 
Agent Administration.............................................................................................24 
5.2 
General Concomitant Medication and Supportive Care Guidelines ......................25 
5.3 
Duration of Therapy ...............................................................................................26 
5.4 
Duration of Follow Up ...........................................................................................26 
5.5 
Criteria for Removal from Study ...........................................................................27 
5.6 
Criteria to Resume Treatment ................................................................................27 
5.7 
Treatment of Nivolumab-Related Infusion Reactions ...........................................28 
5.8 
Treatment Beyond Progression ..............................................................................30 
 
6. 
DOSING DELAYS/DOSE MODIFICATIONS ...............................................................30 
 
7. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................35 
7.1 
Comprehensive Adverse Events and Potential Risks List (CAEPR) for 
Nivolumab..............................................................................................................35 
7.2 
Adverse Event Characteristics ...............................................................................40 
7.3 
Expedited Adverse Event Reporting ......................................................................40 
7.4 
Routine Adverse Event Reporting .........................................................................42 
7.5 
Secondary Malignancy...........................................................................................42 
7.6 
Second Malignancy ................................................................................................43 

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7.7 
Adverse Event Monitoring .....................................................................................43 
 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................43 
8.1 
Nivolumab (NSC 748726) .....................................................................................43 
8.2 
Agent Ordering and Agent Accountability ............................................................45 
 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................45 
9.1 
Integral Laboratory or Imaging Studies .................................................................45 
9.2 
Investigational Device Information .......................................................................46 
9.3 
Integrated Correlative Studies................................................................................46 
9.4 
Exploratory/Ancillary Correlative Studies ............................................................46 
 
10. 
STUDY CALENDAR .......................................................................................................63 
 
11. 
MEASUREMENT OF EFFECT........................................................................................64 
11.1 
Antitumor Effect ....................................................................................................64 
11.2 
Other Response Parameters ...................................................................................70 
 
12. 
DATA REPORTING / REGULATORY REQUIREMENTS ...........................................70 
12.1 
Data Reporting .......................................................................................................70 
12.2 
Collaborative Agreements Language .....................................................................72 
 
13. 
STATISTICAL CONSIDERATIONS...............................................................................74 
13.1 
Study Objectives and Endpoints ............................................................................74 
13.2 
Study Design ..........................................................................................................74 
13.3 
Data Analysis .........................................................................................................75 
13.4 
Reporting and Exclusions ......................................................................................76 
 
14. 
REFERENCES ..................................................................................................................77 
 
APPENDIX A 
PERFORMANCE STATUS CRITERIA ..................................................81 
APPENDIX B 
LIST OF PROHIBITED MEDICATIONS ................................................82 
APPENDIX C 
IMAGING METHODOLOGIES...............................................................83 
APPENDIX D 
IMMUNE-RELATED RESPONSE CRITERIA .......................................84 
APPENDIX E 
ADVERSE EVENT MANAGEMENT ALGORITHMS ..........................88 
APPENDIX F 
PBMC SHIPMENT LOG ..........................................................................95 
APPENDIX G  
TISSUE SHIPMENT LOG ........................................................................96 
APPENDIX H 
BIOMARKER SHIPMENT LOG .............................................................97 
APPENDIX I              NEUROLOGICAL EXAMINATION .......................................................98 
APPENDIX J              PARTICIPANT INFORMATION AND ALERT CARD.........................99 
 
 
 
 

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1. OBJECTIVES 
 
1.1 
Primary Objective 
 
1. To determine the safety and tolerability of nivolumab for patients with HTLV-associated 
ATLL. 
  
2. To determine the efficacy of nivolumab for patients with HTLV-associated ATLL. 
 
1.2 
Secondary Objectives 
 
1. To determine effects of nivolumab on HTLV-1 proviral DNA and RNA loads. 
 
2. To determine the effects of nivolumab on anti-HTLV-1 and anti-ATLL immune responses. 
 
3. To determine effects of nivolumab on HTLV-1 integration site clonality. 
 
2. BACKGROUND 
 
2.1 
HTLV-1 Infection 
 
Human T-cell leukemia virus type 1 (HTLV-1) is a delta retrovirus [1].  It is closely related to 
simian T-cell leukemia virus type 1 (STLV-1) and phylogenetic trees show that STLV-1 and 
HTLV-1 strains are intermingled [2]. A somewhat more distantly related virus, with 60% 
nucleotide sequence homology to HTLV-1, is HTLV-2.  These infections can be distinguished by 
differences in antibody reactivity to recombinant proteins or by polymerase chain reaction assays.  
HTLV-1 infections are prevalent in southern Japan, the Caribbean, and many parts of Central and 
South America, the Middle East, and Africa, where 10-15% of the population is infected [1, 3].  In 
the United States, 0.25% of volunteer blood donors are infected with HTLV-1 or HTLV-2.  
Infections by both viruses are not unusual among intravenous drug abusers.  HTLV-2 is endemic 
in native North, Central, and South American populations.  The HTLV-1 genome includes gag, 
pro, pol, and env genes, encoding the inner capsid of the virion, the viral protease, the viral reverse 
transcriptase and integrase enzymes, and the glycoprotein on the virion surface necessary for viral 
entry [4]. Regulatory proteins include Tax, a potent transcriptional trans-activator, and Rex, a 
mediator of nuclear export of viral RNAs.  Accessory genes encode proteins designated, p12, p13, 
p27, p30, and HBZ whose functions remain to be fully characterized.   
 
There is considerable evidence that the Tax protein is critically important for the leukemogenic 
activity of the virus [5, 6]. Although most viral genes are not expressed in ATLL samples, Tax 
expression is usually detectable, although often at very low levels. Tax together with Ras is capable 
of transforming rodent fibroblasts, and when expressed in a retrovirus of Herpes samirii vector is 
capable of immortalizing human lymphocytes. Constitutive Tax expression in transgenic mice 
results in several different types of malignancies, whereas expression in the lymphoid 
compartment of a transgenic mouse results in a lymphoproliferative malignancy. Tax functions at 
transcriptional and post-transcriptional steps. Tax upregulates several transcriptional pathways to 

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enhance the expression of the viral promoter as well as several interleukins and their receptors 
(e.g. IL2, IL2Rα, IL15, IL15Rα), cytokines (e.g. IFNγ, GM-CSF), adhesion molecules (e.g. 
ICAM-1, VCAM-1, VLA-4), growth promoting factors (e.g. c-myc, c-sis, c-fos, egr-1, cyclin D2, 
and E2F-1), and apoptosis inhibiting factors (e.g. bcl xL, A20). Moreover, Tax can directly bind 
and enhance or inhibit the activity of several growth promoting (e.g. cyclins D2 and D3, E2F) or 
inhibiting factors (e.g. p15, p16, and p53 tumor suppressor proteins and cell cycle checkpoint 
protein MAD1), respectively. In addition Tax promotes the phosphorylation and inactivation of 
the p53 tumor suppressor protein. 
 
 
Figure 1. ATLL Classification 
 
 
 
 
Recent findings implicate HBZ as a maintenance factor in ATLL [7]. HBZ is ubiquitously 
expressed in ATLL cells and HTLV-1 infected cells in vivo. Moreover, HBZ promotes 
proliferation of HTLV-1 infected cells. Interactions between Tax and HBZ on HTLV-1 infected 
cells are complex, and in some cases opposite. For example, Tax activates the AP-1, NFAT, and 

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CREB pathways, whereas HBZ suppresses them. Conversely, Tax inhibits TGFbeta signaling, 
whereas HBZ activates it. Tax activates both the canonical and non-canonical NFkB pathways, 
whereas HBZ inhibits only the canonical NFkB pathway. Tax promotes cell proliferation but also 
induces cellular senescence by induction of p21 and p27, whereas HBZ prevents senescence by 
inhibiting p65. Lastly, HBZ suppresses the canonical Wnt pathway, but enhances the non-
canonical pathway, suggesting that HBZ modulates the intra-cellular environment of peripheral T 
cells targeted by the virus. 
 
2.1.1 HTLV-1 Associated Adult T-Cell Leukemia Lymphoma 
 
Although HTLV-2 is not clearly associated with a clinical disorder, HTLV-1 is closely associated 
with two clinical disorders [1]. About 5% of HTLV-1 infected individuals eventually develop a 
form of myelopathy known as HTLV-1 myelopathy (HAM) or tropical spastic paraparesis (TSP). 
It is characterized by lower limb spasticity, bowel and bladder disturbances, and slow but steady 
progression over several years. HTLV-1 has also been associated with other inflammatory clinical 
conditions, including uveitis, arthropathy, myopathy, pneumopathy, and a Sjogren’s disease-like 
syndrome [8]. Some investigators have suggested that these disorders are related to high virus load, 
overstimulation of dendritic cells, resulting in chronic production of high levels of type 1 
interferons and interferon-stimulated gene expression.  
 
About 5% of HTLV-1 infected individuals develop a T-cell non-Hodgkin’s lymphoma designated 
adult T-cell leukemia lymphoma (ATLL). It occurs almost exclusively in individuals who acquired 
HTLV-1 as a result of breast feeding, although four or five decades are generally required before 
development of disease. ATLL is characterized by frequent blood and bone marrow involvement, 
hypercalcemia, and lytic bone lesions. It is most commonly a CD4+ leukemia/lymphoma, although 
occasional examples of CD8+ lymphoma have been described. ATLL may fit into a variety of 
pathological subtypes as classified by the International Working Party Formulation. Clinical 
classifications of ATLL have included a “smoldering” disorder characterized by rash and minimal 
blood involvement, as well as a chronic form of ATLL, which have median survivals of two years 
or more (Fig 1) [9]. In contrast, a “lymphomatous” form of ATLL and an “acute” form of ATLL 
have median survivals of 3-6 months. 
 
2.1.2 HTLV-1 Proviral DNA and Cell-Associated and Virion RNA Load and Protein 
Expression 
 
Assays of HTLV-1 proviral DNA load using PCR techniques have been developed and applied to 
clinical samples. These studies demonstrated levels of about 0.02 copies/PBMC in asymptomatic 
individuals and 0.08 copies/PBMC in HAM patients [10]. RT-PCR assays of cell-associated viral 
and virion RNA have been developed and used to demonstrate that the majority of infected cells 
do not express viral products [11]. However, quantitative data on transcript levels has not been 
obtained with clinical samples. 
 
2.1.3 HTLV-1 Clonality 
 
In ATLL, there is a clonal expansion of T cells with clonal T-cell receptor gene rearrangements 

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and clonal sites of provirus integration into chromosomal DNA, as determined by Southern blot 
hybridization [12]. More recently, a ligation mediated PCR technique has been utilized as a more 
sensitive way to detect different clonal populations in asymptomatic infected individuals, HAM 
patients, and ATLL patients [13]. These studies have demonstrated that the expanded clone of 
malignant ATLL has arisen from an oligoclonal expansion of HTLV-1 infected cells. These studies 
suggest that HTLV-1 dissemination can occur by viral replication and clonal expansion of infected 
cells. 
 
A recent study examined the genomic characteristics of the integration sites in 197 ATL cases 
[14]. In 91% of cases, a single predominant provirus was present; in 11% of the total 2 proviruses 
were present in a single tumor clone. In 9% of cases, no significant difference in the abundance of 
two integration sites was seen. A complete provirus was present in 46% of cases, 39% of cases 
contained a defective provirus, 7% contained a nonsense mutation of the tax gene, and 8% 
contained a hypermethylated promoter in the 5’LTR. The host genomic characteristics of the 
integration site in the large ATL clones closely resembled those of low-abundance clones present 
in subjects with nonmalignant HTLV-1 infection. These authors concluded that the major 
determinant of the risk of ATL is the absolute number of clones, i.e. the larger the number, the 
greater the chance of malignant transformation. They also suggested that the number of HTLV-1 
infected clones present in an individual during chronic infection is determined chiefly by the 
efficiency of the host’s CTL response to the virus. 
 
Recently, whole genome/exome and RNA seq was performed on 50 paired ATL samples [15]. The 
mutation rate of 89 (44-227) per samples was found, significantly higher than in acute myeloid 
leukemia (7.3-13) and chronic lymphocytic leukemia (11.5). In addition to previously reported 
targets of mutation (p53, TCF8, and Fas), and known targets frequently mutated in other lymphoid 
malignancies (CARD11, GATA3, IRF4, POT1, and RHOA), they identified recurrent mutations 
in genes involved in T-cell development, activation and migration, VEGF and WNT signaling, 
immunosurveillance, and transcriptional regulation. Although Tax itself underwent gene silencing 
in most cases, alternative oncogenic mechanisms result in acquisition of somatic mutations or copy 
number alterations in Tax-related pathways.   
 
2.1.4 Apoptosis Markers in HTLV-1 Infected Cells 
 
HTLV-1 infected cells are resistant to inducers of apoptosis. This may be a result of Tax 
inactivation of the p53 gene, or up-regulation of apoptosis inhibitor A20 or bcl-XL [5, 6]. Arsenic 
trioxide and Interferon Alpha-2a have been used to induce apoptosis in HTLV-1 infected T-cell 
lines [16]. 
 
2.1.5 Treatment of HTLV-1 Associated non-Hodgkin’s Lymphoma 
 
Various chemotherapy regimens have been utilized to treat patients with ATLL with complete 
response rates of only about 30%, which are not durable [17-20]. In a large cooperative study in 
Japan, 4-year survival of patients with acute or lymphomatous forms of ATLL was only 4%. There 
is no standard therapy recommendation for smoldering or chronic forms of ATLL, and generally 
no therapy is recommended. Therapy recommendations are provided in Table 1 of ref 19, provided 

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below:  
 
 
Table 1. Recommended Strategy for the Treatment of ATL 
Smoldering- or favorable chronic-type ATL 
    Consider inclusion in prospective clinical trials 
    Symptomatic patients (skin lesions, opportunistic infections, and so on): consider AZT/IFN-α or watch and wait 
    Asymptomatic patients: consider watch and wait 
Unfavorable chronic- or acute-type ATL 
    Recommend: inclusion in prospective clinical trials 
    If outside clinical trials, check prognostic factors (including clinical and molecular factors if possible): 
        Good prognostic factors: consider chemotherapy (VCAP-AMP-VECP evaluated by a randomized phase III 
trial      against biweekly CHOP) or AZT/IFN-α (evaluated by a retrospective worldwide meta-analysis)  
        Poor prognostic factors: consider chemotherapy followed by conventional or reduced-intensity allogeneic 
HSCT (evaluated by retrospective or prospective Japanese analyses, respectively)  
        Poor response to initial therapy with chemotherapy or AZT/IFN-α: consider conventional or reduced-
intensity allogeneic HSCT  
Lymphoma-type ATL 
    Recommend: inclusion in prospective clinical trials 
    If outside clinical trials, consider chemotherapy (VCAP-AMP-VECP) 
    Check prognostic factors and response to chemotherapy (including clinical and molecular factors if possible): 
        Favorable prognostic profiles and good response to initial therapy: consider chemotherapy 
         Unfavorable prognostic profiles or poor response to initial therapy with chemotherapy: consider 
conventional or reduced-intensity allogeneic HSCT  
          Options for clinical trials (first line) 
    Test the effect of up-front allogeneic HSCT 
    Test promising targeted therapies such as arsenic trioxide + IFN-α, bortezomib + chemotherapy, or antiangiogenic 
therapy 
    Consider a phase II global study testing pegylated IFN and AZT 
         Options for clinical trials (relapse or progressive disease) 
       Test the effect of promising targeted therapies such as arsenic trioxide and IFN-α, bortezomib, a purine nucleotide 
phosphorylase inhibitor, histone deacetylase inhibitors, monoclonal antibodies, antiangiogenic therapy, and survivin, 
β-catenin, syk, and lyn inhibitors, etc.  
    Consider conventional or reduced-intensity allogeneic HSCT when possible 
Abbreviations: ATL, adult T-cell leukemia-lymphoma; AZT, zidovudine; IFN-α, interferon alfa; VCAP-AMP-VECP, vincristine, 
cyclophosphamide, doxorubicin, and prednisone; doxorubicin, ranimustine, and prednisone; and vindesine, etoposide, 
carboplatin, and prednisone; CHOP, cyclophosphamide, doxorubicin, vincristine, and prednisone; HSCT, hematopoietic stem-
cell transplantation.  
 
 
Two reports describe major response rates of 58% and 100%, respectively, in the acute form of 
ATLL, with the use of a combination of zidovudine and Interferon Alpha-2a [21, 22]. However, 
other investigators reported lower response rates with this approach [23]. One group reported an 
81% response rate with the use of interferon and zidovudine with concurrent chemotherapy in 73 
patients with aggressive ATLL [24]. Other approaches have included the use of antibodies to 
IL2Rα with or without conjugates to radioisotopes, or the use of an IL2-diptheria toxin product 
[25]. 
 

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A phase II trial of aurora kinase inhibitor MLN8237 (alisertib) is underway in PTCL, including 
ATLL. (NCT01466881) Also, a randomized phase 3 study of alisertib in patients with 
relapsed/refractory peripheral T cell lymphoma (NCT01482962) is underway.  
 
Mogamulizumab, or KW-0761, is a defucosylated humanized monoclonal antibody against CCR4. 
A phase II study of Mogamulizumab in CCR4-positive relapsed ATLL, given at 1.0 mg/kg/wk x 
8, showed a response rate of 50% [26]. The most common adverse reactions were lymphopenia 
(96%), neutropenia (52%), thrombocytopenia (52%), acute infusion reaction (89%), and skin 
eruption (63%). A phase I/II trial in relapsed or refractory PTCL showed a response rate of 42%. 
Global phase II trials of mogamulizumab are underway for relapsed/refractory ATLL and PTCL. 
A randomized phase II study of mogamulizumab plus VCAP-AMP-VECP (mLSG15) versus 
mLSG15 alone for newly diagnosed aggressive ATLL was recently presented [27]. Patients 
received 4 courses of chemotherapy with 8 courses of mogamulizumab. Complete response rates 
were 52% in patients treated with mogamulizumab plus chemotherapy compared to 33% in those 
treated with chemotherapy alone. Median overall survival was not reached, although length of 
follow up was not described. The most common treatment-related toxicities were neutropenia 
(100% vs 96%), thrombocytopenia (100% vs 90%), leukopenia (100% vs 92%), and febrile 
neutropenia (90% vs 88%).    
 
Experience with mLSG15 is limited outside of Japan as several components are unavailable.  
Additionally, the rates of myelosuppression and febrile neutropenia are very high [28]. Moreover, 
it is not clear that LSG15 is superior to other combination chemotherapy regimens used for 
lymphoma treatment. Experience with DA-EPOCH infusional chemotherapy in two US multi-
investigator trials of ATLL, as well as its use in HIV-associated lymphomas, Burkitt lymphomas, 
and relapsed diffuse large B cell lymphomas suggests this is an appropriate chemotherapy regimen 
for use in aggressive ATLL. In a study of 19 patients treated with EPOCH (not dose-adjusted, 
using 750mg/m2 cyclophosphamide) followed by zidovudine, lamivudine, and alpha interferon 2a, 
4 patients came off study before completion of 2 cycles of therapy due to toxicity, 3 patients had 
progressive disease, and 12 patients had responses (including 2 CRs; 67% ORR; 11% CR) [29]. 
In our ongoing trial of aggressive ATLL, treated with DA-EPOCH (375 mg/m2 cyclophosphamide 
starting dose, all myelosuppressive drugs dose increased or decreased each cycle) combined with 
bortezomib and raltegravir, two subjects achieved complete remission lasting for >12 mos, 10 
subjects had a partial remission, and 3 subjects had stable disease as their best response.  
 
2.1.6 Antiviral Therapy for HTLV-1 Infection 
 
Although the AZT/Interferon Alpha-2a combination was used in ATLL patients, it is unclear 
whether this combination had antiviral, antitumor, and/or immunomodulatory activity towards 
HTLV-1. A report of the use of lamivudine in 5 HAM patients suggested antiviral activity, as 
demonstrated by a 1 log median decrease in virus load [30]. This was associated with clinical 
improvement in one patient. Use of anti-retroviral agents has recently been shown to decrease 
HTLV-1 proviral DNA [31].  Our studies have examined various diketone integrase inhibitors for 
HTLV-1 infection [32]. We found that raltegravir inhibited HTLV-1 replication with IC50 of 35 
nM.  
 

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In addition to direct anti-viral effects, viral suppression may be necessary in the treatment of 
cancer.  We demonstrated this in our recent phase II clinical trial of infusional chemotherapy with 
etoposide, doxorubicin, and vincristine, daily prednisone, and bolus cyclophosphamide (EPOCH) 
given for two to six cycles until maximal clinical response, and followed by antiviral therapy with 
daily zidovudine, lamivudine, and alpha interferon-2a for up to one year. Seven patients were on 
study for less than one month due to progressive disease or chemotherapy toxicity. Eleven patients 
achieved an objective response with median duration of response of thirteen months, and two 
complete remissions. During chemotherapy induction, viral RNA expression increased (median 
190-fold), and virus replication occurred, coincident with development of disease progression.  
Thus, while EPOCH chemotherapy followed by antiretroviral therapy is an active therapeutic 
regimen for adult T-cell leukemia-lymphoma, viral reactivation during induction chemotherapy 
may contribute to treatment failure. Alternative therapies are sorely needed in this disease that 
simultaneously prevent virus expression, and are cytocidal for malignant cells. 
 
2.1.7 HTLV-1 Immune Responses 
 
Although the HTLV-I-specific antibody titer is high in infected individuals, antibody surveillance 
is thought to be largely ineffective [33]. Similarly, there is little evidence that natural killer cells 
play an important role in controlling HTLV-1 infection. CD56+CD3- NK cells have no detectable 
lytic activity against HTLV-1 infected target cells. This is consistent with the finding that HTLV-
1, unlike other viruses, does not down-modulate inhibitory NK ligands or upregulate activating 
ligands. In addition, MHC class I expression is not down regulated in primary HTLV-1-infected 
cells. Lastly, ligands for NK cell activating receptors are not expressed by HTLV-1 infected cells.  
 
In contrast, there is compelling evidence that the CD8+ cytotoxic T lymphocyte (CTL) response 
is an important determinant of the outcome of HTLV-1 infection [33]. There is a strong association 
between certain human leukocyte antigens alleles and the outcome of infections. HTLV-1 is 
genetically stable, and while viral variants that can escape CTLs do occur, there is little evidence 
that these variants have a net selective advantage in patients. It has been possible to rank HTLV-1 
proteins by whether binding their peptides was associated with a reduced viral load. Thus, protein 
targets associated with reduced proviral load include Gag, Pol, and HBZ, whereas, Env, is least 
associated. The Tax protein is intermediate in this rank order list.  
 
Although, CTLs are frequently chronically activated and have immediate effector function ex vivo, 
HTLV-1 is rarely, if ever, cleared. Several explanations have been offered for the lack of 
immunogenicity of infected cells. First, HBZ interacts with cellular factors to suppress Tax-
mediated transactivation, thereby inhibiting expression of HTLV-1 genes. In addition, HBZ has 
been shown to inhibit IFN-gamma production, enhance sensitivity to TGFbeta, and enhance the 
expression of the regulatory transcription factor Fox P3, critical for Treg cells. Second, the HTLV-
1 provirus acquires mutations which prevent expression of viral proteins. Third, ATL cells often 
have a hypermethylated or deleted 5’LTR, thus preventing transcription of genes on the forward 
strand.  
 
Histone deacetylase inhibitor, valproate, activates Tax and Gag expression, enhances CTL activity, 
and results in reduced proviral load [33]. Other recent data suggest that HTLV-1 specific CTLs 

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13 
 
can be induced in patients with aggressive types of ATLL, and that these CTLs can contribute to 
treatment and inhibit relapse [34].  
 
2.1.8 Immune Check Point Blockade 
 
Tumors are able to evade detection and destruction by the immune system, despite the fact that 
many tumors appear to elicit a strong immune response that is evident in lymphocyte infiltrates of 
the primary lesion. Tumor immune evasion can be divided into 2 main mechanisms: 1) the 
induction of immune tolerance and 2) resistance to killing by activated immune effector cells [35]. 
The concept of ‘‘immunoediting’’ relates to the manner in which tumors manipulate their 
microenvironment through tumor-derived cytokines, chemokines, and other soluble factors [36]. 
By the time tumors have become clinically detectable, they have already evolved mechanisms to 
evade immune response mounted by the host that must be overcome to create effective and durable 
antitumor immunity. 
 
Antigen-induced activation and proliferation of T cells are regulated by the temporal expression 
and binding of both co-stimulatory and co-inhibitory receptors. The signaling through these 
receptors in adaptive cellular immunity modulates the initiation, escalation, and subsequent 
resolution of host immune responses. In the absence of co-inhibitory signaling, persistent T cell 
activation can lead to excessive tissue damage in the setting of infection as well as autoimmunity. 
In the context of cancer immunology, in which immune responses are directed against antigens 
specifically or selectively expressed by cancer cells, these immune checkpoints can represent 
major obstacles to overcoming tumor-specific tolerance and generating clinically meaningful 
tumor control. Therefore, efforts have been made in the clinical arena to investigate blockade of 
immune checkpoints as novel therapeutic approaches to tumors which may exploit several distinct 
pathways to actively evade immune destruction, including endogenous “immune checkpoints” that 
normally terminate immune responses after antigen activation. 
 
These observations have resulted in intensive efforts to develop immunotherapeutic approaches 
for cancer, including immune-checkpoint-pathway inhibitors such as anti–CTLA-4 antibody 
(ipilimumab) and anti-PD1 antibody (nivolumab). 
 
2.2 
Nivolumab 
 
Nivolumab (BMS-936558, MDX-1106, and ONO-4538) is a fully human monoclonal 
immunoglobulin G4 (IgG4) antibody (HuMAb) that is specific for human programmed death-1 
(PD-1, cluster of differentiation 279 [CD279]) cell surface membrane receptor (Investigator 
Brochure, 2014). PD-1 is a negative regulatory molecule that is expressed transiently following T-
cell activation and on chronically stimulated T cells characterized by an “exhausted” phenotype. 
Nivolumab binds to cynomolgus monkey PD-1 but not mouse, rat, or rabbit molecules. Clinical 
activity of nivolumab has been observed in patients with melanoma, non-small cell lung cancer 
(NSCLC), and renal cell carcinoma (RCC).  
 
The clinical use of monoclonal antibodies to T-cell inhibitory receptors has provided 
transformative information on the nature of the immune system and cancer. An emerging picture 

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suggests that endogenous immune responses can mediate effective tumor regression and/or 
improved survival even in patients with large volume tumors resistant to other forms of therapy. 
Some of the unique features of this type of therapy, based largely on experience in advanced 
melanoma, include: improved overall survival (OS) with or without radiographic responses or 
improved progression-free survival (PFS); responses that may be delayed or occur after 
radiographic disease progression; combinations of immune modulators with enhanced or novel 
activities (in the example of ipilimumab and nivolumab); and toxicity that is almost exclusively 
immune or inflammatory in nature. It is not yet clear what factors determine responses and which 
components of the immune system are needed for this to occur. It seems likely that both memory 
helper and effector cells would be needed to sustain long-term responses. Increasing emphasis has 
been placed on understanding the relationships of the tumor, cellular infiltrate, and immunologic 
milieu surrounding each tumor. 
 
PD-1, a 55-kDa type 1 transmembrane protein, is a member of the CD28 family of T-cell co-
stimulatory receptors that include Ig super family member CD28, CTLA-4, inducible co-stimulator 
(ICOS), and B and T lymphocyte attenuator (BTLA) (Investigator Brochure, 2014). PD-1 is 
transiently but highly expressed on activated T cells functioning to limit immune effectors at the 
site of activation. Chronic stimulation may prevent methylation of the PD-1 gene leading to 
continuous expression and characterizes a state of “exhausted” T cells that lose function and 
proliferative capacity while enhancing a suppressive tumor microenvironment. PD-1 may act 
together with other T-cell modulating molecules, including CTLA-4, TIM-3, lymphocyte-
activation gene 3 (LAG-3) as well as indoleamine-pyrrole 2,3-dioxygenase 1 (IDO-1), cytokines, 
and transforming growth factor beta (TGF-beta). 
 
Two ligands specific for PD-1 have been identified: PD-ligand 1 (PD-L1, also known as B7-H1 
or CD274, expressed on tumor, antigen-presenting cells [APCs], and dendritic cells [DCs]) and 
PD-L2 (also known as B7-DC or CD273, expressed on endothelial cells). The interaction of PD-1 
with PD-L1 and PD-L2 results in negative regulatory stimuli that down-modulate the activated T-
cell immune response through SHP-1 phosphatase. 
 
PD-1 knockout mice develop strain-specific lupus-like glomerulonephritis (C57BL/6) and 
cardiomyopathy (BALB/c). In transplantable tumor models that expressed PD-1 and LAG-3 on 
tumor-infiltrating CD4+ and CD8+ T cells dual anti-LAG-3/anti-PD-1 antibody treatment cured 
most mice of established tumors that were largely resistant to single antibody treatment (Woo et 
al., 2012). Despite minimal immunopathologic sequelae in PD-1 and LAG-3 single knockout 
mice, dual knockout mice abrogated self-tolerance with resultant autoimmune infiltrates in 
multiple organs, leading to eventual lethality. 
 
PD-L1 expression is found on a number of tumors, and is associated with poor prognoses based 
on survival in many tumors, including melanoma [37], renal [37], esophageal [38], gastric [39] 
2006), ovarian [40], pancreatic [41], lung [42], and other cancers (Investigator Brochure, 2014). 
 
The PD-1/PD-L1 axis plays a role in human infections, particularly in hepatitis C virus (HCV) and 
human immunodeficiency virus (HIV). In these cases, high expression levels of PD-1 were found 
in viral-specific CD8+ T cells that also display a non-responsive or exhausted phenotype. Non-

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responsive PD-1-high T cells were observed in simian immunodeficiency virus (SIV) infection in 
rhesus macaques. Treatment of SIV-infected macaques with an anti-PD-1 mAb (3 mg/kg x4) 
resulted in decreased viral loads and increased survival along with expanded T cells with increased 
T-cell functionality. Recent work suggests that PD1 expression on infected T cells contributes to 
the impairment or exhaustion of CTL function in HTLV-1 infected individuals [43]. 
 
2.2.1 Pre-Clinical Development 
 
In intravenous (IV) repeat-dose toxicology studies in cynomolgus monkeys, nivolumab alone was 
well tolerated (Investigator Brochure, 2014). Nivolumab bound specifically to PD-1 (and not to 
related members of the CD28 family such as CD28, ICOS, CTLA-4, and BTLA) with a Kd = 3.06 
nM. A surrogate rat anti-mouse PD-1 antibody (4H2) was derived and expressed as chimeric IgG1 
murine antibody. Antitumor activity was seen for several tumor models, including colon 
carcinoma and fibrosarcoma. 
 
2.2.2 Clinical Development 
 
Nivolumab is being evaluated as monotherapy and in combination with cytotoxic chemotherapy, 
other immunotherapy (such as ipilimumab), anti-angiogenesis therapy, and targeted therapies in 
completed and ongoing BMS-sponsored clinical trials in NSCLC, melanoma, RCC, hepatocellular 
carcinoma (HCC), gastrointestinal (GI) malignancies including microsatellite instability (MSI) in 
colorectal cancer, and triple-negative breast cancer (TNBC) with an expanding group of 
indications (Investigator Brochure, 2014). In addition, two investigator-sponsored trials (ISTs) of 
nivolumab in combination with a peptide vaccine in melanoma are being conducted in the adjuvant 
setting and advanced disease. Seven nivolumab studies were conducted in Japan, including six 
studies in advanced solid tumors and recurrent or unresectable stage III/IV melanoma sponsored 
by Ono Pharmaceuticals Co. Ltd., and one IST in recurrent or advanced platinum-refractory 
ovarian cancer. 
 
2.2.3 Pharmacokinetics 
 
Pharmacokinetics (PK) of nivolumab were linear in the range of 0.3 to 10 mg/kg, with dose-
proportional increases in maximum serum concentration (Cmax) and area under the concentration-
time curve from time zero to infinity (AUC0-∞), with low to moderate inter-subject variability 
observed at each dose level (Investigator Brochure, 2014). Clearance of nivolumab is independent 
of dose in the dose range (0.1 to 10 mg/kg) and tumor types studied. Body weight normalized 
dosing showed approximately constant trough concentrations over a wide range of body weights. 
The mean terminal elimination half-life of BMS-936558 is 17 to 25 days consistent with the half-
life of endogenous IgG4. 
 
2.2.4 Efficacy 
 
In a phase 1 (1, 3, and 10 mg/kg nivolumab doses) dose-escalation study the 3 mg/kg dose was 
chosen for expanded cohorts. Among 236 patients, objective responses (ORs) (complete or partial 
responses [CR or PR]) were seen in NSCLC, melanoma, and RCC. ORs were observed at all doses 

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[44]. Median OS was 16.8 months across doses and 20.3 months at the 3 mg/kg dose. Median OS 
across all dose cohorts was 9.2 months and 9.6 months for squamous and non-squamous NSCLC, 
respectively [45]. In the RCC cohort, median duration of response was 12.9 months for both doses 
with 5 of the 10 responses lasting ≥1 year (Drake et al., 2013).  
 
In a phase 1 study of nivolumab plus platinum-based doublet chemotherapy (PT-doublet) in 
chemotherapy-naïve NSCLC patients, 43 patients were treated with nivolumab + PT-doublet [46]. 
No dose-limiting toxicities (DLTs) were reported and total/confirmed ORRs were 43/33%, 
40/33%, and 31/31% in nivolumab/gemcitabine/cisplatin, nivolumab/pemetrexed/cisplatin, and 
nivolumab/carboplatin/paclitaxel arms, respectively. 
 
2.2.4.1 
Activity in Lymphomas 
 
In a phase 1 study of 23 heavily treated patients with relapsed or refractory Hodgkin’s lymphoma 
were treated with 3 mg/kg nivolumab every 2 wks [47]. This resulted in an objective response in 
20 subjects, including 4 subjects with a complete response, and progression-free survival of 86% 
at 24 wks. Copy-number gains in PDL1 and PDL2 gene resulted in enhanced JAK-STAT activity, 
which may explain the activity seen. 
 
A phase I study of nivolumab in patients with relapsed or refractory lymphoid malignancies 
included 29 subjects with B-NHL and 23 patients with T-NHL, resulting in overall response rates 
of 28% and 17%, respectively [48]. This study, as well as two previous studies with pidilizumab 
in subjects with follicular lymphoma or diffuse large B cell lymphoma confirm the safety of this 
approach [49, 50]. 
 
2.2.5 Toxicology 
 
A maximum tolerated dose (MTD) of nivolumab was not defined [51]. Serious adverse events 
(SAEs) occurred in 32 of 296 patients (11%) similar to the immune-related inflammatory events 
seen with ipilimumab: pneumonitis, vitiligo, colitis, hepatitis, hypophysitis, and thyroiditis (with 
noted pulmonary toxicity resulting in 3 deaths. Renal failure, symptomatic pancreatic and DM, 
neurologic events, and vasculitis have also been reported.).  
 
It is recognized that HTLV-1 is associated with inflammatory diseases, whose etiology is unclear. 
These include forms of myelopathy, uveitis, arthropathy, pneumonitis, and Sjogren’s disease-like 
manifestations. Aberrant immune responses resulting in cross-reaction between virus-induced 
antigens and cellular antigens may be at least partially responsible. Thus, there is a theoretical risk 
that immune checkpoint inhibitors may promote these disorders, to which there will be careful 
attention.  
 
2.2.6 Pharmacodynamics/Biomarkers 
 
Tumor-cell expression (melanoma) of PD-L1 was characterized with the use of IHC staining and 
pharmacodynamics changes in the peripheral-blood absolute lymphocyte count (Wolchok et al., 
2013). With PD-L1 positivity defined as expression in at least 5% of tumor cells, biopsy specimens 

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from 21 of 56 patients (38%) were PD-L1–positive. Among patients treated with the concurrent 
regimen of nivolumab and ipilimumab, ORs were observed in patients with either PD-L1–positive 
tumor samples (6 of 13 patients) or PD-L1–negative tumor samples (9 of 22). In the sequenced 
regimen cohorts, a higher number of overall responses was seen among patients with PD-L1–
positive tumor samples (4 of 8 patients) than among patients with PD-L1–negative tumor samples 
(1 of 13) suggesting the possibility that these tumors have higher response rates to the combination. 
Tissue expression of PDL-2, interferon-γ (IFN- γ), IDO, and T cell CD8+ are of current interest. 
Until more reliable data based on standardized procedures for tissue collection and assays are 
available, PD-L1 status cannot be used to select patients for treatment at this time. Recent findings 
suggest a possible correlation to higher mutational load and expression of a subset of mutant 
tetrapeptide motifs in tumor antigens [52]. 
 
2.3 
Rationale 
 
The rationale for the use of nivolumab in HTLV-1 associated ATLL is to enhance immune 
clearance of infected malignant cells.  
 
2.4 
Correlative Studies Background 
 
See Section 2.1 for HTLV-1 Proviral DNA and Cell-Associated and Virion RNA Load and Protein 
Expression (2.1.2), HTLV-1 Clonality (2.1.3) and HTLV-1 Immune Responses (2.1.7). 
   
See Section 2.2 for Pharmacodynamics/Biomarkers (2.2.6).   
 
3. PATIENT SELECTION 
 
3.1 
Inclusion Criteria  
 
1. Patients with any stage of pathologically confirmed CD3+ acute, lymphoma, chronic, or 
smoldering subtypes of ATLL. 
 
2. Documentation of HTLV infection (ELISA) in individual with confirmation of HTLV-1 
infection (by immunoblot or PCR) or a consistent clinical picture [including two of the 
following: 1) CD4+ leukemia or lymphoma, 2) hypercalcemia, and/or 3) Japanese, 
Caribbean or South American birthplace].  
 
3. Patients with acute or lymphoma forms must have received at least one cycle of 
combination chemotherapy (with or without mogamulizumab) or interferon (with or 
without zidovudine and/or arsenic). Individuals with chronic or smoldering ATL are not 
required to have had prior treatment or could have received any number of previous 
courses of therapy. 
 
4. ECOG performance status 0-2 (Karnofsky ≥60%, see Appendix A). 
 
5. Age at least 18. Because no dosing or adverse event data are currently available on the 

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use of nivolumab in patients <18 years of age, children are excluded from this study, but 
will be eligible for future pediatric trials. 
 
6. Life expectancy >12 weeks. 
 
7. Patients must have normal organ and marrow function as defined below: 
a. leukocytes ≥ 3,000/mcL 
b. absolute neutrophil count ≥ 1,500/mcL 
c. platelets ≥ 100,000/mcL 
d. total bilirubin within normal institutional limits 
e. AST(SGOT)/ALT(SGPT) ≤ 2.5 × institutional upper limit of normal 
f. creatinine within normal institutional limits 
OR 
creatinine clearance ≥ 60 mL/min/1.73 m2 for patients with creatinine levels above 
institutional normal. 
 
8. The effects of nivolumab on the developing human fetus are unknown.  For this reason, 
women of child-bearing potential and men must agree to use adequate contraception 
(hormonal or 2 barrier methods of birth control; or abstinence) prior to study entry and 
for the duration of study participation. Women should continue birth control for 23 weeks 
after stopping nivolumab, and men should continue birth control for 31 weeks after 
stopping nivolumab.  Should a woman become pregnant or suspect she is pregnant while 
she or her partner is participating in this study, she should inform her treating physician 
immediately.  Men treated or enrolled on this protocol must also agree to use adequate 
contraception prior to the study, for the duration of study participation, and 31 weeks 
after completion of nivolumab administration. 
 
9. Ability to understand and the willingness to sign a written informed consent document. 
 
3.2 
Exclusion Criteria 
 
1. Patients who have had chemotherapy or radiotherapy within 4 weeks (6 weeks for 
nitrosoureas or mitomycin C) prior to entering the study or those who have not recovered 
from adverse events due to agents administered more than 4 weeks earlier. 
 
2. Patients who are receiving any other investigational agents. 
 
3. History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to nivolumab. 
 
4. Prior allogeneic transplantation, since such individuals have increased risk of 
complications from nivolumab. 
 
5. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or 

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psychiatric illness/social situations that would limit compliance with study requirements. 
 
6. Any condition requiring >10 mg/d prednisone equivalents 
 
7. Current or prior HTLV-1 associated inflammatory diseases, including but not limited to 
myelopathy, uveitis, arthropathy, pneumonitis, or a Sjögren’s disease-like disorder. 
 
8. Prior treatment with anti-PD-1, anti-PD-L1, anti-PD-L2 antibody. 
 
9. Grade 2 or greater toxicity from prior therapy. 
 
10. Grade 2 or greater diarrhea. 
 
11. Autoimmune disease: Patients with active autoimmune disease or history of autoimmune 
disease that might recur, which may affect vital organ function or require immune 
suppressive treatment including systemic corticosteroids, should be excluded. These 
include but are not limited to patients with a history of immune related neurologic disease, 
multiple sclerosis, autoimmune (demyelinating) neuropathy, Guillain-Barré syndrome, 
myasthenia gravis; systemic autoimmune disease such as SLE, connective tissue diseases, 
scleroderma, inflammatory bowel disease (IBD), Crohn’s, ulcerative colitis, hepatitis; and 
patients with a history of toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome, or 
phospholipid syndrome should be excluded because of the risk of recurrence or 
exacerbation of disease. Patients with vitiligo, endocrine deficiencies including thyroiditis 
managed with replacement hormones including physiologic corticosteroids are eligible. 
Patients with rheumatoid arthritis and other arthropathies (other than HTLV-associated 
arthropathy), and psoriasis controlled with topical medication and patients with positive 
serology, such as antinuclear antibodies (ANA), anti-thyroid antibodies should be 
evaluated for the presence of target organ involvement and potential need for systemic 
treatment but should otherwise be eligible. 
 
Patients are permitted to enroll if they have vitiligo, type I diabetes mellitus, residual 
hypothyroidism due to autoimmune condition only requiring hormone replacement, 
psoriasis not requiring systemic treatment, or conditions not expected to recur in the 
absence of an external trigger (precipitating event). 
 
12. Patients who have had evidence of active or acute diverticulitis, intra-abdominal abscess, 
GI obstruction and abdominal carcinomatosis which are known risk factors for bowel 
perforation should be evaluated for the potential need for additional treatment before 
coming on study. 
 
13. Patients who have Hepatitis C (both reactive anti-HCV antibody and detectable HCV 
RNA) and Hepatitis B (HBsAg positive and anti-HBc-Total positive), may be enrolled, 
provided their total bilirubin: ≤1.5× institutional upper limit of normal (ULN) AST (SGOT) 
/ALT (SGPT): <2.5 X institutional upper limit of normal. 
 

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14. Patients with concurrent HIV infection may be enrolled if compliant with 3 or more drug 
anti-retroviral regimen and virus load less than 50 copies/ml and CD4 count greater than 
250 cells/ml, and no concurrent opportunistic infection or other malignancy. 
 
15. Any other prior malignancy from which the patient has been disease free for less than 3 
years, with the exception of adequately treated and cured basal or squamous cell skin 
cancer, superficial bladder cancer, carcinoma in situ of any site or any other cancer. 
 
16. Pregnant women are excluded from this study because nivolumab is an agent with the 
potential for teratogenic or abortifacient effects.  Because there is an unknown but potential 
risk for adverse events in nursing infants secondary to treatment of the mother with 
nivolumab, breastfeeding should be discontinued if the mother is treated with nivolumab. 
 
3.3 
Inclusion of Women and Minorities 
 
Women and members of minority groups and their subpopulations will be included in this study. 
 
4. REGISTRATION PROCEDURES 
 
4.1 
Investigator and Research Associate Registration with CTEP 
 
4.1.1 CTEP Registration Procedures 
 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) policy 
require all investigators participating in any NCI-sponsored clinical trial to register and to renew 
their registration annually. 
 
Registration requires the submission of: 
 
• a completed Statement of Investigator Form (FDA Form 1572) with an original signature 
• a current Curriculum Vitae (CV) 
• a completed and signed Supplemental Investigator Data Form (IDF) 
• a completed Financial Disclosure Form (FDF) with an original signature 
 
Fillable PDF forms and additional information can be found on the CTEP website at 
http://ctep.cancer.gov/investigatorResources/investigator_registration.htm. 
 
For questions about Investigator Registration, please contact the CTEP Investigator Registration 
Help Desk by email at pmbregpend@ctep.nci.nih.gov. 
 
4.1.2 CTEP Associate Registration Procedures / CTEP-IAM Account 
 
The Cancer Therapy Evaluation Program (CTEP) Identity and Access Management (IAM) 
application is a web-based application intended for use by both Investigators (i.e., all physicians 
involved in the conduct of NCI-sponsored clinical trials) and Associates (i.e., all staff involved in 

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21 
 
the conduct of NCI-sponsored clinical trials). 
 
Associates will use the CTEP-IAM application to register (both initial registration and annual re-
registration) with CTEP and to obtain a user account. 
 
Investigators will use the CTEP-IAM application to obtain a user account only.  (See CTEP 
Investigator Registration Procedures above for information on registering with CTEP as an 
Investigator, which must be completed before a CTEP-IAM account can be requested.) 
 
An active CTEP-IAM user account is required to access all CTEP applications and, if applicable 
(e.g., all Network trials), all Cancer Trials Support Unit (CTSU) applications and websites. 
 
Additional 
information 
can 
be 
found 
on 
the 
CTEP 
website 
at 
http://ctep.cancer.gov/branches/pmb/associate_registration.htm. 
 
For questions about Associate Registration or CTEP-IAM Account Creation, please contact the 
CTEP Associate Registration Help Desk by email at ctepreghelp@ctep.nci.nih.gov. 
 
4.2 
Site Registration 
 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
Each investigator or group of investigators at a clinical site must obtain Institutional Review Board 
(IRB) approval for this protocol and submit all required regulatory documents (including any 
protocol specific documents) to the CTSU Regulatory Office before they can be approved to enroll 
patients. 
 
The CTSU Regulatory Office tracks receipt of these documents in the CTSU Regulatory Support 
System (RSS), reviews for compliance, and transmits site approval data to CTEP. 
 
Sites participating on the NCI Central IRB (CIRB)-Early Phase initiative and accepting CIRB 
approval for the study are not required to submit separate IRB approval documentation to the 
CTSU Regulatory Office for initial, continuing, or amendment review.  However, sites must 
submit a Study Specific Worksheet for Local Context (SSW) to the CIRB (via IRBManager) to 
indicate their intention to open the study locally.  The CIRB’s approval of the SSW is then 
communicated to the CTSU Regulatory Office for compliance in the RSS.  The Signatory 
Institution must inform the CTSU which CIRB-approved institutions aligned with the Signatory 
Institution are participating in the study so that the study approval can be applied to those 
institutions.  Other site registration requirements (e.g., laboratory certifications, protocol-specific 
training certifications, or modality credentialing) must be submitted to the CTSU Regulatory 
Office or compliance communicated per protocol instructions. 
 
4.2.1 Requirements for 9925 Site Registration 
 
• CTSU IRB Certification (for sites not participating via the NCI CIRB) 

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22 
 
• CTSU IRB/Regulatory Approval Transmittal Sheet (for sites not participating via the 
NCI CIRB) 
• Local informed consent document (if required by LPO) 
 
4.2.2 Downloading Regulatory Documents 
 
Site registration forms may be downloaded from the NCI #9925 protocol page located on the 
CTSU Web site.  Permission to view and download this protocol is restricted and is based on 
person and site roster data housed in the CTSU RSS. To participate, Investigators and Associates 
must be associated with the Corresponding or Participating protocol organization in the RSS.  
 
• Go to https://www.ctsu.org and log in using your CTEP IAM username and password. 
• Click on the Protocols tab in the upper left of your screen.  
• Click on the ETCTN link to expand, then select Phase 1 Grants, followed by LAO- NC010 
and protocol #9925. 
• Click on LPO Documents, select the Site Registration documents link, and download and 
complete the forms provided.  (Note: For sites under the CIRB initiative, IRB data will 
automatically load to RSS.) 
 
4.2.3 Submitting Regulatory Documents 
 
Submit required forms and documents to the CTSU Regulatory Office, where they will be entered 
and tracked in the CTSU RSS.   
CTSU Regulatory Office 
1818 Market Street, Suite 1100 
Philadelphia, PA 19103 
Phone:  1-866-651-2878 
Fax:  215-569-0206 
E-mail:  CTSURegulatory@ctsu.coccg.org (for regulatory document submission only) 
 
4.2.4 Checking Site Registration Status 
 
Sites can check the status of their registration packets by querying the Site Registration subtab of 
the members’ section of the CTSU Web site.  (Note: Sites will not receive formal notification of 
regulatory approval from the CTSU Regulatory Office.) 
 
• Go to https://www.ctsu.org and log in using your CTEP IAM username and password. 
• Click on the Regulatory tab at the top of your screen. 
• Click on the Site Registration subtab. 
• Enter your 5-character CTEP Institution Code and click on Go. 
 
Note: If possible, please allow three working days for site registration approval before attempting 
to enroll your first patient. 
 

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4.3 
Patient Registration 
 
In cooperation with the Corresponding Organization (Duke Cancer Institute LAO), the Lead 
Protocol Organization or LPO (Washington University School of Medicine) is utilizing an online 
‘study portal’ for key study communication from participating sites to the Lead Principal 
Investigator and Study Coordinator. The study portal operates through REDCap, a secure, web-
based application, managed by the Duke Cancer Institute LAO. Participating sites will not 
require REDCap user accounts or passwords to access the study portal for this study.  
 
The 9925 Study Portal may be accessed through the following link: http://j.mp/2g4kpUG .  
 
Prior to registering patients into Oncology Patient Enrollment Network (OPEN), participating 
sites are instructed to access the 9925 Study Portal for the following:  
 
• Subject Consent – Within 24 business hours of subject signing consent for the study, the 
Site Coordinator accesses the study portal to upload consents and notify the Study 
Coordinator of subject consent. Upon receipt of consent notification, the Study 
Coordinator will email the Site Coordinator with a subject screening ID number.  
 
• Eligibility Confirmation – After completion of all screening evaluations and if possible, 
within at least 48 business hours of anticipated study treatment start, the Site Coordinator 
accesses the study portal to upload completed eligibility checklist and de-identified 
supporting source documentation including sufficient tumor tissue pathology 
confirmation documentation. After review of eligibility documents by the Lead Principal 
Investigator or designee(s), the Study Coordinator will email the Site Coordinator with 
confirmation or questions/comments regarding subject eligibility. If eligibility is 
confirmed, the Site Coordinator will be instructed by the Study Coordinator via email to 
proceed to patient registration in OPEN.  
 
4.3.1 OPEN / IWRS 
 
Patient enrollment will be facilitated using the Oncology Patient Enrollment Network (OPEN).  
OPEN is a web-based registration system available to users on a 24/7 basis.  It is integrated with 
the CTSU Enterprise System for regulatory and roster data interchange and with the Theradex 
Interactive Web Response System (IWRS) for retrieval of patient registration/randomization 
assignment.  Patient enrollment data entered by Registrars in OPEN / IWRS will automatically 
transfer to the NCI’s clinical data management system, Medidata Rave. 
 
The OPEN system will provide the site with a printable confirmation of registration and treatment 
information. Please print this confirmation for your records.  
 
4.3.2 OPEN/IWRS User Requirements 
 
OPEN/IWRS users must meet the following requirements: 
• Have a valid CTEP-IAM account (i.e., CTEP username and password). 

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24 
 
• To enroll patients:  Be on an ETCTN Corresponding or Participating Organization roster 
with the role of Registrar. 
• Have regulatory approval for the conduct of the study at their site. 
 
Prior to accessing OPEN/IWRS, site staff should verify the following: 
• All eligibility criteria have been met within the protocol stated timeframes.  
• If applicable, all patients have signed an appropriate consent form and HIPAA 
authorization form. 
 
4.3.3 OPEN/IWRS Questions? 
 
Further instructional information on OPEN is provided on the OPEN tab of the CTSU website at 
https://www.ctsu.org or at https://open.ctsu.org.  For any additional questions contact the CTSU 
Help Desk at 1-888-823-5923 or ctsucontact@westat.com.  
 
4.4 
General Guidelines 
 
Following registration, patients should begin protocol treatment within 7 days. Issues that would 
cause treatment delays should be discussed with the Principal Investigator. If a patient does not 
receive protocol therapy following registration, the patient’s registration on the study may be 
canceled. The Study Coordinator should be notified of cancellations as soon as possible. 
 
5. TREATMENT PLAN 
 
5.1 
Agent Administration 
 
Treatment will be administered on an outpatient basis.  Reported adverse events and potential risks 
are described in Section 7. Appropriate dose modifications are described in Section 6.  No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the patient's malignancy. 
 
Regimen Description 
Agent 
Premedications; 
Precautions 
Dose 
Route 
Schedule 
Cycle 
Length 
Nivolumab 
None 
in 100 ml 
NS 
IV over 60 
minutes (+/- 10 
minutes) 
Every 2 
weeks 
14 days 
 
**Doses as appropriate for assigned dose level. 
 
A flat dose of 240 mg will be administered.  There will be no dose modifications allowed. 
 
Nivolumab is to be administered as a 60-minute (+/- 10 minutes) IV infusion, using a volumetric 
pump with a 0.2/1.2 micron in-line filter at the protocol-specified dose. The drug can be diluted 
with 0.9% normal saline for delivery but the total drug concentration of the solution cannot be 

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25 
 
below 1.0 mg/mL. It is not to be administered as an IV push or bolus injection. At the end of the 
infusion, flush the line with a sufficient quantity of normal saline. 
 
5.2 
General Concomitant Medication and Supportive Care Guidelines 
 
5.2.1 Supportive Care 
 
All supportive measures consistent with optimal patient care will be given throughout the study. 
 
See Section 5.1 for supportive care considerations for nivolumab administration. 
 
Patients requiring chemotherapy or radiation therapy during the study will be taken off study 
treatment. Any exceptions must be discussed with the Principal Investigator. 
 
5.2.2 Other Medications 
 
Recommended prophylaxis for opportunistic infections includes Bactrim DS every other day. 
Subjects must be instructed to inform the investigators of the current or planned use or all other 
medications during the study (including prescription medications, over-the-counter medications, 
vitamins and herbal and nutritional supplements). It is the responsibility of the investigator to 
ensure that details regarding all medications are documented. Bisphosphonates started prior to 
screening activities or initiated during the course of the study to control bone pain may be used 
with caution. 
 
Prophylactic growth factor (G-CSF) administration is not recommended. Based on observed 
toxicities, protocol-specified dose modification guidelines should be followed for subsequent 
therapy cycles. Management of anemia will be at the discretion of the treating physician, No 
concurrent investigational agents are permitted. 
 
5.2.3 Prohibited Therapies 
 
Patients in this study may not use vaccines for the treatment of cancer for up to one month pre and 
post dosing with nivolumab. Concomitant systemic or local anti-cancer medications including 
biologics, or radiation therapy treatments are prohibited in this study while receiving nivolumab. 
 
Patients may not use any of the following therapies during the study:  
• Any non-study anti-cancer agent (investigational or non-investigational)  
• Any other investigational agents  
• CTLA4 antagonists, CD137 agonists, PD-1 inhibitors  
• Immunosuppressive agents, unless indicated to manage study therapy induced immune- 
related adverse events (irAEs)  
• Chronic systemic corticosteroids, unless indicated to manage study therapy induced irAEs 
or chronic graft-versus-host disease (GVHD) at a stable dose prior to study entry  

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• Any non-oncology vaccine therapies used for the prevention of infectious diseases (for up 
to 30 days prior to or after any dose of study drug, however it is suggested that routine 
vaccinations, including seasonal influenza, be given at least 2 weeks prior to study 
treatment).  
 
5.3 
Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue for the 4 starting 
doses plus 42 cycles (approximately 23 months) or until one of the following criteria applies: 
• Disease progression, 
• Intercurrent illness that prevents further administration of treatment,  
• Patient decides to withdraw from the study, 
• General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator, or 
• Unacceptable adverse event(s) which include the following (see also Section 6 for dosing 
delays/dose modifications and Appendix E for specific algorithms): 
o Any toxicity requiring high dose corticosteroids except patients with grade 2 or 3 
skin lesions, pruritis, thyroiditis, or n. VII palsy can be restarted after a tapered 
dose of corticosteroids.  
o Any dosing interruption lasting more than 6 weeks, with the following exceptions: 
• Patients being tapered after high dose corticosteroids over one month 
followed by a two-week observation period will be allowed an additional 
two weeks to restart treatment (a maximum eight week interruption).  
 
• Dosing interruptions more than 6 weeks that occur for non-drug-related 
reasons may be allowed if approved by the Principal Investigator. Prior 
to re-initiating treatment in a subject with a dosing interruption lasting 
more than 6 weeks, the Principal Investigator must be consulted. 
 
o Any adverse event, laboratory abnormality, or intercurrent illness which, in the 
judgment of the investigator, presents a substantial clinical risk to the subject with 
continued study drug dosing 
 
o Requiring additional immune suppressive treatment beyond steroids 
 
Tumor assessments should continue as per protocol even if dosing is interrupted.  
 
5.4 
Duration of Follow Up 
 

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Patients will be followed for 1 year after removal from study or until death, whichever occurs first. 
Patients removed from study for unacceptable adverse event(s) will be followed until resolution 
or stabilization of the adverse event 
 
5.5 
Criteria for Removal from Study 
 
Patients will be removed from study when any of the criteria listed in Section 5.3 applies.  The 
reason for study removal and the date the patient was removed must be documented in the Case 
Report Form. 
 
 
5.6 
Criteria to Resume Treatment 
 
Some patients may continue to benefit from treatment, maintaining or improving responses after 
progression including those treated with steroids. 
 
Restarting applies only to Grade 2 events and some Grade 3 events (skin rash and thyroiditis).  
 
For non-autoimmune or non-inflammatory events, patients may resume treatment with study drug 
when the drug-related AE(s) resolve to Grade ≤ 1 or baseline value, with the following exceptions: 
• Patients may resume treatment in the presence of Grade 2 fatigue. 
• Evaluation to exclude any additional immune mediated events endocrine, GI, and liver / 
pancreas function as clinically indicated must be made prior to restarting.  
• Non-drug-related toxicity including hepatic, pulmonary toxicity, diarrhea, or colitis, must 
have resolved to baseline before treatment is resumed. 
 
If the criteria to resume treatment are met, the patient should restart treatment no sooner than the 
next scheduled time point per protocol. However, if the treatment is delayed past the next 
scheduled time point per protocol the treatment should resume at the earliest convenient point that 
is within the 6 week delay period.  
 
If treatment is delayed for > 6 weeks, (> 8 weeks for patients on a steroid taper), the patient must 
be permanently discontinued from study therapy, except as specified in Section 5.3. 
 
For patients treated with corticosteroids:   
• Grade 2 events must resolve to ≤ Grade 1 before considering retreatment.  
• Grade ≥ 2 events should have nivolumab held until resolution to ≤ Grade 1 for at least 2 
weeks following complete removal from steroid treatment except for maintenance 
replacement doses for adrenal insufficiency (preferably no greater than 10mg prednisone 
equivalent daily). 
• Grade ≥ 3 events should have nivolumab discontinued. Patients with Grade 3 thyroiditis 
and skin rash may continue therapy as for Grade 2 events with resolution and stable 

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28 
 
replacement treatment. 
 
Patients with hepatitis, pancreatitis, pneumonitis, and colitis are at risk for exacerbation with 
retreatment if there is residual inflammation and should resolve to Grade 0 or baseline before 
retreatment. Baseline can mean the initial grade i.e. Grade <1 where permitted on study. 
 
Patients with thyroiditis or hypopituitarism who are stable as above may be restarted with 
replacement hormones including thyroid hormone and physiologic doses only of corticosteroids. 
Please note that grading for hypophysitis with symptoms of headache, visual or neurologic changes 
or radiologic evidence of pituitary enlargement and other CNS events such as aseptic meningitis 
or encephalitis should be considered Grade 3 events.  
 
New immune related events or exacerbation of existing events during steroid treatment or taper 
suggest the presence of ongoing immune activation and should require permanent discontinuation 
of nivolumab.  
 
A patient who is treated with steroids, evaluated, and found to not have an autoimmune or 
inflammatory event requiring steroid treatment, may be restarted if asymptomatic off steroids for 
2 weeks and other restarting criteria are met.  
 
Prior to starting corticosteroids or hormone replacement for any reason, appropriate endocrine 
testing including cortisol, ACTH, TSH and T4 must be drawn if clinically feasible to document 
baseline function and distinguish the pituitary from peripheral organ dysfunction and later from 
steroid (or thyroid) treatment associated ACTH (or TSH) suppression. Steroids should be started 
prior to obtaining results based on clinical indications.  
 
5.7 
Treatment of Nivolumab-Related Infusion Reactions 
 
Since nivolumab contains only human immunoglobulin protein sequences, it is unlikely to be 
immunogenic and induce infusion or hypersensitivity reactions. However, if such a reaction were 
to occur, it might manifest with fever, chills, rigors, headache, rash, urticaria, angioedema, 
pruritus, arthralgia, hypo- or hypertension, bronchospasm, or other symptoms.  
 
All Grade 3 or 4 infusion reactions should be reported as an SAE if criteria are met. Infusion 
reactions should be graded according to NCI CTCAE version 4.0 guidelines. 
 
Treatment recommendations are provided below and may be modified based on local treatment 
standards and guidelines as medically appropriate: 
 
For Grade 1 symptoms: 
(Mild reaction; infusion interruption not indicated; intervention not indicated) 
 
Remain at bedside and monitor subject until recovery from symptoms. Infusion rate may be 
slowed. If the infusion is interrupted, then restart the infusion at 50% of the original infusion rate 
when symptoms resolve; if no further complications ensue after 30 minutes, the rate may be 

NCI Protocol #: 9925 
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29 
 
increased to 100% of the original infusion rate. Monitor patient closely. 
 
The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) at 
least 30 minutes before additional nivolumab administrations, slowing infusion rate as above. 
 
For Grade 2 symptoms: 
(Moderate reaction requires therapy or infusion interruption but responds promptly to 
symptomatic treatment [e.g., antihistamines, non-steroidal anti-inflammatory drugs, narcotics, 
corticosteroids, bronchodilators, IV fluids]; close observation for recurrence and treatment 
medications may need to be continued for 24-48 hours). 
 
Stop the nivolumab infusion, begin an IV infusion of normal saline, and treat the subject with 
diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen); 
remain at bedside and monitor patient until resolution of symptoms. Corticosteroid or 
bronchodilator therapy may also be administered as appropriate. If the infusion is interrupted, then 
restart the infusion at 50% of the original infusion rate when symptoms resolve; if no further 
complications ensue after 30 minutes, the rate may be increased to 100% of the original infusion 
rate. Monitor patient closely. If symptoms recur, then no further nivolumab will be administered 
at that visit. Administer diphenhydramine 50 mg IV, and remain at bedside and monitor the patient 
until resolution of symptoms. The amount of study drug infused must be recorded on the electronic 
case report form (eCRF). 
 
The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and (acetaminophen) (or paracetamol) 325 to 1000 mg 
should be administered at least 30 minutes before additional nivolumab administrations. If 
necessary, corticosteroids (recommended dose: up to 25 mg of IV hydrocortisone or equivalent) 
may be used. 
 
For Grade 3 or Grade 4 symptoms: (Severe reaction) 
(Grade 3 symptoms: prolonged [i.e., not rapidly responsive to symptomatic medication and/or 
brief interruption of infusion]; recurrence of symptoms following initial improvement; 
hospitalization indicated for other clinical sequelae [e.g., renal impairment, pulmonary 
infiltrates]). 
(Grade 4 symptoms: life threatening; pressor or ventilatory support indicated.) 
 
Immediately discontinue infusion of nivolumab. Begin an IV infusion of normal saline, and treat 
the subject as follows. Recommend bronchodilators, epinephrine 0.2 to 1 mg of a 1:1,000 solution 
for subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 solution injected slowly for IV 
administration, and/or diphenhydramine 50 mg IV with methylprednisolone 100 mg IV (or 
equivalent), as needed. Patient should be monitored until the investigator is comfortable that the 
symptoms will not recur. Nivolumab will be permanently discontinued.  
 
Investigators should follow their institutional guidelines for the treatment of anaphylaxis. Remain 
at bedside and monitor patient until recovery from symptoms.  

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30 
 
 
In the case of late-occurring hypersensitivity symptoms (e.g., appearance of a localized or 
generalized pruritus within 1 week after treatment), symptomatic treatment may be given (e.g., 
oral antihistamine, or corticosteroids). 
 
Please note that late occurring events including isolated fever and fatigue may represent the 
presentation of systemic inflammation. Please evaluate accordingly. 
 
 
5.8 
Treatment Beyond Progression 
 
Patients are allowed to continue treatment for 4-6 weeks and reassessed. Treatment may continue 
up to an additional 30% total single diameter increased over baseline, if no change in performance 
status, no new serious adverse event, and no need for intervention. New measureable lesions are 
not permitted with this schema. 
 
6. DOSING DELAYS/DOSE MODIFICATIONS 
 
There will be no dose adjustments allowed. Subjects with infusion delays > 49 days (i.e., 2 missed 
doses + 7 days) should discontinue the study drugs. 
 
Please refer to Appendix E to the protocol for toxicity management algorithms which include 
specific treatment guidelines. These algorithms should be followed unless there are specific 
clinical circumstances which the treating physician indicates variations or alternative treatment is 
needed. 
 
Generally, we strongly encourage early evaluation, withholding drug, and appropriate treatment 
as indicated in the management tables and following event specific guidelines. 
 
ALL OTHER 
EVENTS* 
Management/Next Dose for Nivolumab 
*Not agent related, or agent related non-immunologically mediated 
≤ Grade 1 
No change in dose. 
Grade 2 
Hold until ≤ Grade 1 OR baseline. Resume at same dose level. 
Grade 3 
Hold until ≤ Grade 1 continue at investigator discretion.  
Grade 4 
Off protocol therapy. 
Recommended management: As clinically indicated. 
 
ALL OTHER 
EVENTS** 
Management/Next Dose for Nivolumab 
**Immunologically mediated 
≤ Grade 1 
No change in dose.  
Grade 2 
Hold until ≤ Grade 1 OR baseline. When resolved, resume at same dose level. 
Grade 3 
Off protocol therapy (exceptions noted in Section 5.3)  
Grade 4 
Off protocol therapy 
Recommended management: As clinically indicated.  
 

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31 
 
Skin Rash and 
Oral Lesions 
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose.* 
Grade 2 
No change in dose.* May continue on treatment at investigator discretion. 
Grade 3 
Hold* until ≤ Grade 1. Resume at same level at investigator discretion.  
Grade 4 
Off protocol therapy. 
*Patients with purpuric or bullous lesions must be evaluated for vasculitis, Steven-Johnson syndrome, 
TEN, and autoimmune bullous disease including oral lesions of bullous pemphigus/pemphagoid. Pruritus 
may occur with or without skin rash and should be treated symptomatically if there is no associated liver 
or GI toxicity. Note skin rash typically occurs early and may be followed by additional events particularly 
during steroids tapering. 
Recommended management: See Appendix E for Skin AE management algorithm. 
 
Liver Function 
AST, ALT, 
Bilirubin 
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose. May continue on treatment at investigator discretion. 
Grade 2 
Hold until UNL or baseline. Resume at same dose level. Consider steroid treatment > 
7 days. 
Grade 3 
Off protocol therapy.  
Grade 4 
Off protocol therapy. 
Continued treatment of active immune mediated hepatitis may exacerbate ongoing inflammation. Holding 
drug to evaluate LFT changes and early treatment are recommended. 
LFT changes may occur during steroid tapers from other events and may occur together with other GI 
events including cholecystitis/pancreatitis. 
For individuals who are hepatitis B or C positive, viral DNA or RNA load, respectively, should be 
measured to determine if worsening LFTs are due to immune-mediated hepatitis or infectious hepatitis.  
Recommended management: See Appendix E for Hepatic AE management algorithm. 
 
Diarrhea/  
Colitis 
Management/Next Dose for Nivolumab 
≤ Grade 1 
Hold until Grade 0 or baseline. When resolved, resume at same dose level. 
Grade 2 
Hold until Grade 0 or baseline. Consider steroid treatment > 7 days. 
Grade 3 
Off protocol therapy. 
Grade 4 
Off protocol therapy. 
Patients with Grade 2 symptoms but normal colonoscopy and biopsies may be retreated after resolution.  
Patients who require steroids should be taken off study treatment.  
Please evaluate pituitary function prior to starting steroids if possible without compromising acute care.  
Evaluation for all patients for additional causes includes C. diff, acute and self-limited infectious and food 
borne illness, ischemic bowel, diverticulitis, and IBD.  
Recommended management: See Appendix E for GI AE management algorithm for management of 
symptomatic colitis. 
 
Pancreatitis 
Amylase/Lipase Management/Next Dose for Nivolumab 
≤ Grade 1 
If asymptomatic without evidence of pancreatitis, liver or gallbladder disease, or new 
onset diabetes, may continue on treatment at investigator discretion. 
Grade 2 
If asymptomatic without evidence of pancreatitis, liver or gallbladder disease, or new 

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Pancreatitis 
Amylase/Lipase Management/Next Dose for Nivolumab 
onset diabetes, may continue on treatment at investigator discretion. 
Grade 3 
If symptomatic, hold until Grade 0. If asymptomatic, without clinical, radiographic, 
or ultrasound evidence of pancreatitis, and no evidence of associated liver or gall 
bladder disease or new onset diabetes, may continue on treatment at investigator’s 
discretion. Patients who develop symptomatic pancreatitis or DM should be taken off 
protocol therapy. 
Grade 4 
If symptomatic, hold until Grade 0. If asymptomatic, without clinical, radiographic, 
or ultrasound evidence of pancreatitis, and no evidence of associated liver or gall 
bladder disease or new onset diabetes, may continue on treatment at investigator’s 
discretion. Patients who develop symptomatic pancreatitis or DM should be taken off 
protocol therapy. 
Patients may develop symptomatic and radiologic evidence of pancreatitis as well as DM and DKA. 
Lipase elevation may occur during the period of steroid withdrawal and with other immune mediated 
events or associated with colitis, hepatitis, and patients who have asymptomatic lipase elevation typically 
have self-limited course and may be retreated.  
Recommended management:  See Appendix E for the Hepatic AE management algorithm for treatment 
management of symptomatic pancreatitis. 
 
Pneumonitis 
 
Management/Next Dose for Nivolumab 
≤ Grade 1 
Hold dose pending evaluation and resolution to ≤ Grade 0 or baseline including 
baseline pO2. Resume no change in dose after pulmonary and/or ID consultation.  
Grade 2 
Hold dose pending evaluation. Resume no change in dose after pulmonary and/or ID 
consultation if lymphocytic pneumonitis is excluded. Off study if steroids are 
required.  
Grade 3 
Hold dose pending evaluation. Resume no change in dose after pulmonary and/or ID 
consultation only if lymphocytic pneumonitis is excluded. Off protocol therapy.  
Grade 4 
Off protocol therapy. 
Distinguishing inflammatory pneumonitis is often a diagnosis of exclusion for patients who do not 
respond to antibiotics and have no causal organism identified including influenza. Most patients with 
respiratory failure or hypoxia will be treated with steroids. Bronchoscopy may be required and analysis 
of lavage fluid for lymphocytic predominance may be helpful. Patients with new lung nodules should be 
evaluated for sarcoid like granuloma. Please consider recommending seasonal influenza killed vaccine 
for all patients. 
Recommended management: See Appendix E for Pulmonary AE management algorithm. 
 
Other GI  
N-V 
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose.  
Grade 2 
Hold pending evaluation for gastritis duodenitis and other immune adverse events or 
other causes. Resume at same dose level after resolution to ≤ Grade 1. 
Grade 3 
Hold pending evaluation until ≤ Grade 1. Resume at same dose level. If symptoms do 
not resolve within 7 days with symptomatic treatment patients should go off protocol 
therapy. 
Grade 4 
Off protocol therapy. 
Patients with Grade 2 or 3 N-V should be evaluated for upper GI inflammation and other immune related 

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Other GI  
N-V 
Management/Next Dose for Nivolumab 
events. 
 
Fatigue 
 
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose. 
Grade 2 
No change in dose. 
Grade 3 
Hold until ≤ Grade 2. Resume at same dose level. 
Grade 4 
Off protocol therapy 
Fatigue is the most common adverse event associated with immune checkpoint therapy. Grade 2 or greater 
fatigue should be evaluated for associated or underlying organ involvement including pituitary, thyroid, 
and hepatic, or muscle (CPK) inflammation.  
 
Neurologic 
Events 
Management/Next Dose for Nivolumab 
≤ Grade 1 
Hold dose pending evaluation and observation. When resolved, resume with no 
change in dose. * 
Grade 2 
Hold dose pending evaluation and observation. Hold until ≤ Grade 1.*Off protocol 
therapy if treatment with steroids is required. When resolved, resume at same dose 
level for peripheral isolated n. VII (Bell’s palsy) 
Grade 3 
Off protocol therapy. 
Grade 4 
Off protocol therapy.  
*Patients with any CNS events including aseptic meningitis, encephalitis, symptomatic hypophysitis, or 
myopathy, peripheral demyelinating neuropathy, cranial neuropathy (other than peripheral n. VII), GB 
syndrome, myasthenia gravis should be off study. 
Recommended management: See Appendix E for Neurologic AE management algorithm. 
 
Endocrine 
Hypophysitis Adrenal 
Insufficiency 
Management/Next Dose for Nivolumab 
≤ Grade 1 
With asymptomatic TSH elevation may continue on study with appropriate 
evaluation, and endocrine consultation suggested.*  
Grade 2 
Hold until patients are on a stable replacement hormone regimen. If treated with 
steroids patients must be stable off steroids for two weeks. Resume at same dose 
level.  
Grade 3 
Off protocol therapy. 
Grade 4 
Off protocol therapy. 
Note all patients with symptomatic pituitary enlargement, exclusive of hormone deficiency, but including 
severe headache or enlarged pituitary on MRI should be considered Grade 3 events. Isolated thyroid or 
testosterone deficiency may be treated as Grade 2 if there are no other associated deficiencies and adrenal 
function is monitored.  
Please evaluate pituitary function before beginning steroid therapy or replacement therapy of any kind.  
*Note patients with thyroiditis may be retreated on replacement therapy. Patients must be evaluated to 
rule out pituitary disease prior to initiating thyroid replacement. 
Recommended management: See Appendix E for Endocrine AE management algorithm. 
 

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34 
 
Fever 
 
Management/Next Dose for Nivolumab 
≤ Grade 1 
Antipyretic therapy if no evidence of infection. 
Grade 2 
Hold until ≤ Grade 1. Resume at same dose level. 
Grade 3 
Hold until ≤ Grade 1. Resume at same dose level. 
Grade 4 
Off protocol therapy. 
Patients with fever should be evaluated as clinically appropriate. Patients may experience isolated fever 
during infusion reactions or up to several days after infusion. Evaluation over the course of 1-2 weeks 
should be done for other autoimmune events that may present as fever  
 
Renal Acute 
Toxicity 
Management/Next Dose for Nivolumab 
≤ Grade 1 
Hold for evaluation and treatment. Resume at same dose level.   
Grade 2 
Hold for evaluation and treatment until ≤ Grade 1. Resume at same dose level if an 
inflammatory response is excluded. 
Grade 3 
Hold for evaluation and treatment until ≤ Grade 1. Resume at same dose level if an 
inflammatory response is excluded. 
Grade 4 
Off protocol therapy.  Evaluation and treatment. 
 
Infusion Reaction 
 
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose. 
Grade 2 
Hold until ≤ Grade 1. Resume at same dose level. 
Grade 3 
Off protocol therapy. 
Grade 4 
Off protocol therapy.  
Patients with fever should be evaluated as clinically appropriate. Patients may experience isolated fever 
during infusion reactions or up to several days after infusion. Evaluation over the course of 1-2 weeks 
should be done for other autoimmune events that may present as fever  
Recommended management:  See Section 5.8 for treatment of infusion reactions. 
 
Cardiac *   
Management/Next Dose for BMS-936558 (Nivolumab) Cardiac Toxicities  
≤ Grade 1  
Hold dose pending evaluation and observation.**  Evaluate for signs and symptoms 
of CHF, ischemia, arrhythmia or myositis.  Obtain history EKG, CK (for 
concomitant myositis), CK-MB.  Repeat troponin, CK and EKG 2-3 days.  If 
troponin and labs normalize may resume therapy.   If labs worsen or symptoms 
develop then treat as below.  Hold pending evaluation  
Grade >2 with 
suspected 
myocarditis 
Hold dose.**  Admit to hospital.  Cardiology consult.  Rule out MI and other causes 
of cardiac disease.  Cardiac Monitoring.  Cardiac Echo.  Consider cardiac MRI and 
cardiac biopsy.  Initiate high dose methylprednisolone.  If no improvement within 
24 hours, add either infliximab, ATG or tacrolimus. Consult algorithm for more 
details.  Resume therapy if there is a return to baseline and myocarditis is excluded 
or considered unlikely. 
Grade >2 with 
confirmed 
myocarditis   
Off protocol therapy.  Admit to CCU (consider transfer to nearest Cardiac 
Transplant Unit).  Treat as above.  Consider high dose methylprednisolone   
Add ATG or tacrolimus if no improvement.   Off treatment. 
*Including CHF, LV systolic dysfunction, Myocarditis, CPK, and troponin  

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35 
 
 
If treatment is delayed > 6 weeks (> 8 weeks for patients on high dose steroids with recommended 
4 weeks taper and 2 week observation), the patient must be permanently discontinued from study 
therapy, except as specified in Section 5.7 (Criteria to Resume Treatment.) 
 
Patients requiring > 2 dose delays for the same event should go off protocol therapy. 
 
Prior to starting corticosteroids or hormone replacement for any reason, appropriate endocrine 
testing including cortisol, ACTH, TSH and T4 must be obtained to document baseline.  
 
Patients may be dose-delayed for evaluation and restarted depending on results.  
 
Any patient started on corticosteroids initially who is determined to not require steroids treatment 
for an autoimmune adverse event may resume therapy after a 2 week observation period without 
further symptoms at the discretion of the PI or investigator. 
 
For subjects who are HIV co-infected and compliant with antiviral medications, nivolumab will 
be held if viral load increases to >500 copies/ml or CD4 count falls to <100 cells/mL. CD4 and 
virus load will be repeat 2-4 weeks later, and if the above parameters are still found, then 
nivolumab will be permanently discontinued. 
 
7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The following 
list of AEs (Section 7.1) and the characteristics of an observed AE (Section 7.2) will determine 
whether the event requires expedited reporting via the CTEP Adverse Event Reporting System 
(CTEP-AERS) in addition to routine reporting. 
 
7.1 
Comprehensive Adverse Events and Potential Risks List (CAEPR) 
 
BMS-936558 (Nivolumab, MDX-1106, NSC 748726) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of 
reported and/or potential adverse events (AE) associated with an agent using a uniform 
presentation of events by body system. In addition to the comprehensive list, a subset, the 
Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column and 
is identified with bold and italicized text. This subset of AEs (SPEER) is a list of events that are 
protocol specific exceptions to expedited reporting to NCI (except as noted below). Refer to the 
'CTEP, NCI Guidelines: Adverse Event Reporting Requirements' 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf for 
further clarification. Frequency is provided based on 2069 patients. Below is the CAEPR for 
BMS-936558 (Nivolumab, MDX-1106). 
**Patients with evidence of myositis without myocarditis may be treated according as “other event”   
Note:  The optimal treatment regimen for immune mediated myocarditis has not been established.  
Since this toxicity has caused patient deaths, an aggressive approach is recommended.   

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36 
 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses 
next to the AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple 
investigational agents and has an AE listed on different SPEERs, use the lower of the grades 
to determine if expedited reporting is required. 
                                                                                                         Version 2.2, November 15, 20161 
 
 Adverse Events with Possible  
 Relationship to BMS-936558 (Nivolumab, MDX-1106) 
 (CTCAE 4.0 Term) 
[n= 2069] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia 
 
 Anemia (Gr 2) 
CARDIAC DISORDERS 
  
 
 
Cardiac disorders - Other 
(cardiomyopathy) 
  
 
 
Myocarditis 
  
 
 
Pericardial tamponade2 
  
 
 
Pericarditis 
  
ENDOCRINE DISORDERS 
  
 
Adrenal insufficiency 
 
  
 
Endocrine disorders - 
Other (hypophysitis) 
 
  
 
Hyperthyroidism 
 
  
 
Hypothyroidism 
 
  
EYE DISORDERS 
  
 
 
Eye disorders - Other 
(diplopia) 
  
 
 
Eye disorders - Other 
(Graves ophthalmopathy) 
  
 
 
Eye disorders - Other (optic 
neuritis retrobulbar) 
  
 
Uveitis 
 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
Colitis 
 
  
 
 
Colonic perforation 
  
 
Diarrhea 
 
 Diarrhea (Gr 2) 
 
Dry mouth 
 
 Dry mouth (Gr 2) 
 
 
Gastritis 
  
 
Nausea 
 
 Nausea (Gr 2) 
 
Pancreatitis3 
 
  
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
Fatigue 
 
 
 Fatigue (Gr 2) 
 
Fever 
 
 Fever (Gr 2) 
 
Infusion related reaction4 
 
  
 
Injection site reaction 
 
 Injection site reaction (Gr 2) 
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction 
  

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37 
 
 
 Adverse Events with Possible  
 Relationship to BMS-936558 (Nivolumab, MDX-1106) 
 (CTCAE 4.0 Term) 
[n= 2069] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
 
Autoimmune disorder5 
  
 
 
Cytokine release syndrome6   
 
 
Immune system disorders - 
Other (GVHD in the setting 
of allotransplant)7 
  
 
 
Immune system disorders - 
Other (sarcoid granuloma)5  
  
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased 
 
 Alanine aminotransferase 
increased (Gr 2) 
 
Aspartate 
aminotransferase 
increased 
 
 Aspartate aminotransferase 
increased (Gr 2) 
 
Blood bilirubin increased  
 Blood bilirubin increased (Gr 
2) 
 
Creatinine increased 
 
  
 
Lipase increased 
 
  
 
Lymphocyte count 
decreased 
 
 Lymphocyte count 
decreased (Gr 2) 
  
Neutrophil count 
decreased 
 
  
 
Platelet count decreased  
  
 
Serum amylase increased  
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
  
 
 
Hyperglycemia 
 Hyperglycemia (Gr 2) 
 
 
Metabolism and nutrition 
disorders - Other (diabetes 
mellitus with ketoacidosis) 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
 
 
Musculoskeletal and 
connective tissue disorder - 
Other (polymyositis) 
  
 
 
Musculoskeletal and 
connective tissue disorder - 
Other (rhabdomyolysis) 
  
 
 
Myositis 
  
NERVOUS SYSTEM DISORDERS 
  
 
 
Encephalopathy 
  
 
 
Facial nerve disorder5 
  
 
 
Nervous system disorders - 
Other (demyelination 
myasthenic syndrome) 
  
 
 
Nervous system disorders - 
Other (encephalitis) 
  

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38 
 
 
 Adverse Events with Possible  
 Relationship to BMS-936558 (Nivolumab, MDX-1106) 
 (CTCAE 4.0 Term) 
[n= 2069] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
 
Nervous system disorders - 
Other (Guillain-Barre 
syndrome)5  
  
 
 
Nervous system disorders - 
Other (meningoencephalitis) 
  
 
 
Nervous system disorders - 
Other (meningoradiculitis) 
  
 
 
Nervous system disorders - 
Other (myasthenia gravis)5  
  
 
 
Nervous system disorders - 
Other (myasthenic 
syndrome) 
  
 
 
Peripheral motor 
neuropathy 
  
 
 
Peripheral sensory 
neuropathy 
  
RENAL AND URINARY DISORDERS 
  
 
 
Acute kidney injury 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Pleural effusion 
 
  
 
Pneumonitis 
 
  
 
 
Respiratory, thoracic and 
mediastinal disorders - 
Other (bronchiolitis 
obliterans with organizing 
pneumonia) 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
 
Erythema multiforme 
  
 
Pruritus 
 
 Pruritus (Gr 2) 
 
Rash maculo-papular 
 
 Rash maculo-papular (Gr 2) 
 
Skin hypopigmentation 
 
  
 
Skin and subcutaneous 
disorders - Other (Sweet’s 
Syndrome) 
 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2Pericardial tamponade may be related to possible inflammatory reaction at tumor site. 
 
3Pancreatitis may result in increased serum amylase and/or more frequently lipase. 
 
4Infusion reactions, including high-grade hypersensitivity reactions which have been observed following 
administration of nivolumab, may manifest as fever, chills, shakes, itching, rash, hypertension or 

NCI Protocol #: 9925 
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39 
 
hypotension, or difficulty breathing during and immediately after administration of nivolumab. 
 
5BMS-936558 (Nivolumab, MDX-1106) being a member of class of agents involved in the inhibition of 
“immune checkpoints”, may result in severe and possibly fatal immune-mediated adverse events probably 
due to T-cell activation and proliferation.  This may result in autoimmune disorders that can include (but 
are not limited to) autoimmune hemolytic anemia, acquired anti-factor VIII immune response, autoimmune 
aseptic meningitis, autoimmune hepatitis, autoimmune nephritis, autoimmune neuropathy, autoimmune 
thyroiditis, bullous pemphigoid, exacerbation of Churg-Strauss Syndrome, drug rash with eosinophilia 
systemic symptoms [DRESS] syndrome, facial nerve disorder (facial nerve paralysis), limbic encephalitis, 
hepatic failure, pure red cell aplasia, pancreatitis, ulcerative and hemorrhagic colitis, endocrine disorders 
(e.g., autoimmune thyroiditis, hyperthyroidism, hypothyroidism, autoimmune hypophysitis/hypopituitarism, 
thyrotoxicosis, and adrenal insufficiency), sarcoid granuloma, myasthenia gravis, polymyositis, and 
Guillain-Barre syndrome. 
 
6Cytokine release syndrome may manifest as hemophagocytic lymphohistiocytosis with accompanying 
fever and pancytopenia. 
 
7Complications including hyperacute graft-versus-host disease (GVHD), some fatal, have occurred in 
patients receiving allo stem cell transplant (SCT) after receiving BMS-936558 (Nivolumab, MDX-1106).  
These complications may occur despite intervening therapy between receiving BMS-936558 (Nivolumab, 
MDX-1106) and allo-SCT. 
 
Adverse events reported on BMS-936558 (Nivolumab, MDX-1106) trials, but for which there is 
insufficient evidence to suggest that there was a reasonable possibility that BMS-936558 
(Nivolumab, MDX-1106) caused the adverse event: 
 
CARDIAC DISORDERS - Atrial fibrillation; Atrioventricular block complete; Heart failure; Ventricular 
arrhythmia 
EAR AND LABYRINTH DISORDERS - Vestibular disorder 
EYE DISORDERS - Eye disorders - Other (iridocyclitis); Optic nerve disorder 
GASTROINTESTINAL DISORDERS - Constipation; Duodenal ulcer; Flatulence; Gastrointestinal 
disorders - Other (mouth sores); Mucositis oral; Vomiting 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema limbs; Malaise; 
Pain 
HEPATOBILIARY DISORDERS - Bile duct stenosis 
IMMUNE SYSTEM DISORDERS - Anaphylaxis; Immune system disorders - Other (autoimmune 
thrombotic microangiopathy); Immune system disorders - Other (limbic encephalitis) 
INFECTIONS AND INFESTATIONS - Bronchial infection; Lung infection; Sepsis; Upper respiratory 
infection 
INVESTIGATIONS - GGT increased; Investigations - Other (blood LDH increased); Investigations - Other 
(protein total decreased); Investigations - Other (WBC count increased); Lymphocyte count increased; 
Weight loss  
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hyperuricemia; Hypoalbuminemia; 
Hypocalcemia; Hyponatremia; Hypophosphatemia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Back pain; Musculoskeletal and 
connective tissue disorder - Other (musculoskeletal pain); Musculoskeletal and connective tissue disorder 
- Other (polymyalgia rheumatica); Myalgia; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Neoplasms 
benign, malignant and unspecified (incl cysts and polyps) - Other (histiocytic necrotizing lymphadenitis) 
NERVOUS SYSTEM DISORDERS - Dizziness; Headache; Intracranial hemorrhage 
PSYCHIATRIC DISORDERS - Insomnia 
RENAL AND URINARY DISORDERS - Hematuria; Renal and urinary disorders - Other (tubulointerstitial 
nephritis) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchospasm; Cough; Dyspnea; 
Hypoxia 

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SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Dry skin; Hyperhidrosis; Pain of skin; 
Periorbital edema; Photosensitivity; Rash acneiform; Skin and subcutaneous tissue disorders - Other 
(rosacea); Toxic epidermal necrolysis 
VASCULAR DISORDERS - Flushing; Hypertension; Hypotension; Vasculitis 
 
Note: BMS-936558 (Nivolumab, MDX-1106) in combination with other agents could cause an 
exacerbation of any adverse event currently known to be caused by the other agent, or the combination 
may result in events never previously associated with either agent. 
 
7.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found in the 
revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will be 
utilized for AE reporting.  All appropriate treatment areas should have access to a copy of the 
CTCAE version 4.0.  A copy of the CTCAE version 4.0 can be downloaded from the CTEP 
web site: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
• AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the SPEER 
column, Section 7.1.1) should be reported through CTEP-AERS only if the grade is above 
the grade provided in the SPEER. 
• Other AEs for the protocol that do not require expedited reporting are outlined in Section 
7.3.4. 
 
• Attribution of the AE: 
o Definite – The AE is clearly related to the study treatment. 
o Probable – The AE is likely related to the study treatment. 
o Possible – The AE may be related to the study treatment. 
o Unlikely – The AE is doubtfully related to the study treatment. 
o Unrelated – The AE is clearly NOT related to the study treatment. 
 
7.3 
Expedited Adverse Event Reporting 
 
Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event Reporting 
System), accessed via the CTEP Web site (https://eapps-ctep.nci.nih.gov/ctepaers).  The reporting 
procedures to be followed are presented in the “NCI Guidelines for Investigators: Adverse Event 
Reporting Requirements for DCTD (CTEP and CIP) and DCP INDs and IDEs” which can be 
downloaded from the CTEP Web site: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm. 
 
These requirements are briefly outlined in the tables below (Section 7.3.3). 
 
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be made to 
CTEP by telephone at 301-897-7497.  Once Internet connectivity is restored, the 24-hour 
notification phoned in must be entered electronically into CTEP-AERS by the original submitter 

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41 
 
at the site. 
 
7.3.1 Distribution of Adverse Event Reports 
 
CTEP-AERS is programmed for automatic electronic distribution of reports to the following 
individuals:  Principal Investigator and Adverse Event Coordinator(s) (if applicable) of the 
Corresponding Organization or Lead Organization, the local treating physician, and the Reporter 
and Submitter.  CTEP-AERS provides a copy feature for other e-mail recipients.  
The Coordinating Center of the Corresponding Organization is responsible for submitting to the 
CTSU documentation of AEs that they deem reportable for posting on the CTSU protocol web 
page and inclusion on the CTSU bi-monthly broadcast. 
 
7.3.2 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial registration 
on all reports. 
 
Note:  A death on study requires both routine and expedited reporting, regardless of 
causality.  Attribution to treatment or other cause must be provided. 
 
Death due to progressive disease should be reported as Grade 5 “Neoplasms benign, malignant 
and unspecified (incl cysts and polyps) - Other (Progressive Disease)” under the system organ 
class (SOC) of the same name.  Evidence that the death was a manifestation of underlying disease 
(e.g., radiological changes suggesting tumor growth or progression: clinical deterioration 
associated with a disease process) should be submitted.  
 
Late Phase 2 and Phase 3 Studies: Expedited Reporting Requirements for Adverse Events 
that Occur on Studies under an IND/IDE within 30 Days of the Last Administration of the 
Investigational Agent/Intervention1, 2 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) 
NOTE:  Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not 
they are considered related to the investigational agent(s)/intervention (21 CFR 312.64) 
An adverse event is considered serious if it results in ANY of the following outcomes:   
• 
Death 
• 
A life-threatening adverse event  
• 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 
hours  
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
• 
A congenital anomaly/birth defect.  
• 
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or 
subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. (FDA, 21 CFR 312.32; ICH E2A and ICH E6). 
 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via electronic 
submission within the timeframes detailed in the table below. 
Hospitalization 
Grade 1 
Timeframes 
Grade 2 
Timeframes 
Grade 3 Timeframes 
Grade 4 & 5 
Timeframes 

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42 
 
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 
Calendar Days 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 
10 Calendar Days 
NOTE:  Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be submitted electronically within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted electronically within 10 
calendar days of learning of the AE. 
1Serious adverse events that occur more than 30 days after the last administration of investigational 
agent/intervention and have an attribution of possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for: 
• 
All Grade 4, and Grade 5 AEs 
Expedited 10 calendar day reports for: 
a) 
Grade 2 adverse events resulting in hospitalization or prolongation of hospitalization  
a) 
Grade 3 adverse events 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above 
applies after this reporting period. 
Effective Date:  May 5, 2011 
 
7.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data submissions. 
 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents.  AEs are reported in a routine manner at scheduled times during 
the trial using Medidata Rave.  For this trial the Adverse Event CRF is used for routine AE 
reporting in Rave. 
 
7.5 
Secondary Malignancy 
 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., treatment 
with investigational agent/intervention, radiation or chemotherapy). A secondary malignancy is 
not considered a metastasis of the initial neoplasm. 
 
CTEP requires all secondary malignancies that occur following treatment with an agent under an 
NCI IND/IDE be reported expeditiously via CTEP-AERS.  Three options are available to describe 
the event:  
 
• Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia [AML])  
• Myelodysplastic syndrome (MDS)  

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43 
 
• Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also be 
reported via the routine reporting mechanisms outlined in each protocol.  
 
7.6 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is NOT a 
metastasis from the initial malignancy).  Second malignancies require ONLY routine AE reporting 
unless otherwise specified. 
 
7.7 
Adverse Event Monitoring 
 
Safety and tolerability will be monitored by AEs determined every 2 weeks while on treatment. It 
is expect that about 10% of subjects will have intolerable toxicity, requiring discontinuation of 
therapy. If the number of subjects discontinuing therapy is greater than 10% (p<0.05), this therapy 
will be considered intolerable in this population. 
 
Participating sites will enter data every two weeks at a minimum. Participating sites will also  
notify the coordinating center of Grade 3 and higher adverse events and serious adverse events 
within 24 hours of occurrence or notification. The study chair (PI) will be notified of such events 
by the coordinating center team at Washington University, the Lead Protocol Organization (LPO) 
and Duke University, the Lead Academic Organization (LAO). The coordinating center team and 
LAO and LPO investigators will have a weekly conference call to review subject enrollment, study 
progress, and available safety data including those generated from the study database. In addition, 
there will be monthly conference calls with the coordinating center, study chair, and participating 
sites (study nurses/ coordinators/ investigators) to review study progress and safety data. 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agent 
administered in this study can be found in Section 7.1. 
 
8.1 
Nivolumab (NSC 748726) 
 
Amino Acid Sequence:  4 polypeptide chains, which include 2 identical heavy chains with 440 
amino acids and 2 identical light chains. 
 
Other Names: 
BMS-936558, MDX1106 
 
Classification: 
Anti-PD-1MAb 
 
M.W.:  146,221 daltons 
 
Mode of Action:  Nivolumab targets the programmed death–1 (PD-1, cluster of differentiation 279 

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44 
 
[CD279]) cell surface membrane receptor. PD-1 is a negative regulatory receptor expressed by 
activated T and B lymphocytes. Binding of PD-1 to its ligands, programmed death–ligand 1 (PD-
L1) and 2 (PD-L2), results in the down-regulation of lymphocyte activation. Nivolumab inhibits 
the binding of PD-1 to PD-L1 and PD-L2.  Inhibition of the interaction between PD-1 and its 
ligands promotes immune responses and antigen-specific T-cell responses to both foreign antigens 
as well as self-antigens. 
 
Description:  Nivolumab Injection is a clear to opalescent, colorless to pale yellow liquid; light 
(few) particulates may be present. The drug product is a sterile, nonpyrogenic, single-use, isotonic 
aqueous solution formulated in sodium citrate, sodium chloride, mannitol, diethylenetriamine 
pentacetic acid (pentetic acid) and polysorbate 80 (Tween® 80), pH 6.0. 
 
How Supplied:  Nivolumab is supplied by Bristol-Myers Squibb and distributed by the 
Pharmaceutical Management Branch, CTEP/DCTD/NCI as 100 mg vials (10 mg/mL) with a 0.7mL 
overfill.  It is supplied in 10 mL type I flint glass vials, with butyl rubber stoppers and aluminum seals. 
 
Preparation:  Nivolumab injection can be infused undiluted (10 mg/mL) or diluted with 0.9% 
Sodium Chloride Injection, USP or 5% Dextrose, USP to concentrations no less than 1 mg/mL. 
 
Storage: Vials of Nivolumab injection must be stored at 2°-8°C (36°-46°F) and protected from 
light, freezing and shaking.  
 
Stability:  Shelf-life surveillance of the intact vials is ongoing. 
 
The administration of undiluted and diluted solutions of Nivolumab must be completed within 24 
hours of preparation.  If not used immediately, the infusion solution may be stored up to 24 hours 
in a refrigerator at 2°-8°C (36°-46°F) and a maximum of 4 hours of the total 24 hours can be at 
room temperature (20°-25°C, 68°-77°F) and room light.  The maximum 4-hour period under room 
temperature and room light conditions includes the product administration period. 
 
CAUTION:  The single-use dosage form contains no antibacterial preservative 
or bacteriostatic agent.  Therefore, it is advised that the product be discarded 8 
hours after initial entry.  
 
Route of Administration: Intravenous infusion.  Do not administer as an IV push or bolus injection. 
 
Method of Administration: Administer through a 0.2 micron to 1.2 micron pore size, in-line filter.  
 
Potential Drug Interactions: No incompatibilities between Nivolumab injection and polyvinyl 
chloride (PVC), non-PVC/non-DEHP (di(2-ethylhexyl)phthalate) IV components, or glass bottles 
have been observed. 
 
Availability: Nivolumab is an investigational agent supplied to investigators by the Division of 
Cancer Treatment and Diagnosis (DCTD), NCI. 

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45 
 
 
Nivolumab is provided to the NCI under a Collaborative Agreement between the Pharmaceutical 
Collaborator and the DCTD, NCI (see Section 12.2). 
 
8.2 
Agent Ordering and Agent Accountability 
 
NCI-supplied agents may be requested by the Principal Investigator (or their authorized designee) 
at each participating institution. Pharmaceutical Management Branch (PMB) policy requires that 
agent be shipped directly to the institution where the patient is to be treated. PMB does not permit 
the transfer of agents between institutions (unless prior approval from PMB is obtained). The 
CTEP-assigned protocol number must be used for ordering all CTEP-supplied investigational 
agents. The responsible investigator at each participating institution must be registered with CTEP, 
DCTD through an annual submission of FDA Form 1572 (Statement of Investigator), Curriculum 
Vitae, Supplemental Investigator Data Form (IDF), and Financial Disclosure Form (FDF). If there 
are several participating investigators at one institution, CTEP-supplied investigational agents for 
the study should be ordered under the name of one lead investigator at that institution. 
 
Active CTEP-registered investigators and investigator-designated shipping designees and ordering 
designees can submit agent requests through the PMB Online Agent Order Processing (OAOP) 
application (https://eapps-ctep.nci.nih.gov/OAOP/pages/login.jspx). Access to OAOP requires the 
establishment of a CTEP Identity and Access Management (IAM) account (https://eapps-
ctep.nci.nih.gov/iam/) and the maintenance of an “active” account status and a “current” password. 
For questions about drug orders, transfers, returns, or accountability, call (240) 276-6575 Monday 
through Friday between 8:30 am and 4:30 pm (ET) or email PMBAfterHours@mail.nih.gov 
anytime. 
 
8.2.1 Agent Inventory Records 
 
The Investigator, or a responsible party designated by the Investigator, must maintain a careful 
record of the inventory and disposition of all drugs received using the NCI Drug Accountability 
Record Form (DARF) (available on the CTEP home page (http://ctep.cancer.gov) or by calling 
the Pharmaceutical Management Branch at 301-496-5725). The DARFs document the drug 
delivery date to the site, inventory at the site, use by each study participant, and disposal of the 
drug (if applicable). A site-specific accountability record, either manual or electronic, may be used 
if it includes all the information required on the NCI Investigational Drug Accountability Record 
and if the paper printout is identical to the NCI accountability record. A separate DARF is required 
for each protocol using the same agent. The investigator will ensure that the drugs are used only 
in accordance with this protocol. 
 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Integral Laboratory or Imaging Studies 
 
N/A 

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46 
 
 
9.2 
Investigational Device Information 
 
N/A 
 
9.3 
Integrated Correlative Studies 
 
N/A 
 
9.4 
Exploratory/Ancillary Correlative Studies 
 
9.4.1 HTLV-1 Studies - Biological Markers of Anti-Tumor Response 
 
A.  HTLV-1 DNA Proviral Load 
 
Hypothesis: Nivolumab will enhance anti-ATLL immune responses and result in a decrease 
in HTLV-1 proviral load. 
 
Rationale: An effective immune response against HTLV-1 should decrease the number of 
HTLV-1 infected cells. 
 
Preclinical and Clinical Results: See Section 2.1 for HTLV-1 Proviral DNA and Cell-
Associated and Virion RNA Load and Protein Expression (2.1.2).   
 
Assay Methodology: Genomic DNA will be extracted from PBMCs isolated from whole 
blood obtained at baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, every 12 weeks thereafter, 
and at the end of study time point, and tumor tissue at baseline and end of study time point (if 
available). The HTLV-1 DNA assay is performed with PBMCs, prepared in a BSL3 facility, 
measuring the number of copies of integrated or unintegrated viral genome with a Biorad 
digital drop PCR assay [53]. PCR is performed with tax primers that amplify a 154 bp region, 
and a FAM/MGB probe. Additionally, in a duplex PCR, a cellular housekeeping gene, 
ribonuclease P protein subunit P30 is amplified and detected with VIC/MGB probe. DNA will 
be digested with BamHI, mixed with the primers and probes and Bio-Rad 2× Supermix, and 
then emulsified using a QX-200 droplet generator, and PCR performed in a 96 well plate, and 
analyzed on the QX200 droplet reader. QuantaSoftware version 1.3.2.0 is used to quantify the 
copies/μl. Thresholds are determined manually for each experiment, according to the negative 
controls, which include a no template control and DNA from a healthy volunteer. Droplet 
positivity is determined by fluorescence intensity; only droplets above a minimum amplitude 
threshold are counted as positive. The PVL is calculated as the percentage of infected cells  
Data normalization is accomplished by applying the log (base 2) transformation, calculating 
the mean and standard deviation (SD), and defining the lower (mean-2SD) and upper 
(mean+2SD) values of the expected range for each assay type. These values are used to 
convert the log transformed values to a percentage of the expected range for each assay type, 
by subtracting the lower range value for the assay first then dividing by the difference of the 
upper and lower values of the expected range for the assay. Linear relationship of the post-

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47 
 
normalized values is assessed using Pearson correlation.  
 
Investigator’s Experience and Competence with the Assay: Dr. Lee Ratner, the Principal 
Investigator, used this assay in previous publications [29, 54, 55], and has funding for these 
studies PO1 100730, R01 CA63417, and P50 CA094056 
 
Justification for Number of Patients and Specimens: Blood samples will be obtained at 
baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, and every 12 weeks thereafter, and at the end 
of study treatment, in order to examine the correlation between proviral load, clinical 
response, and other correlative studies. Tumor tissue sample is obtained at baseline and off-
study time point (if available) to determine proviral load in the tumor. 
 
B.  HTLV-1 RNA Levels 
 
Hypothesis: Nivolumab will enhance anti-ATLL immune responses and result in a decrease 
in HTLV-1 RNA levels in PBMCs and tumors. 
 
Rationale: Nivolumab will enhance anti-ATLL immune responses and result in a more 
dramatic decrease in HTLV-1 RNA levels than HTLV-1 DNA levels, since not all infected 
cells will be expressing viral antigens. 
 
Preclinical and Clinical Results: See Section 2.1 for HTLV-1 Proviral DNA and Cell-
Associated and Virion RNA Load and Protein Expression (2.1.2).   
 
Assay Methodology: RNA will be extracted from PBMCs isolated from whole blood obtained 
at baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, every 12 weeks thereafter, and at the end of 
study, and tumor tissue at baseline and end of study time point (if available). The HTLV-1 
RNA assay is performed with PBMCs. RNA extraction, complementary DNA (cDNA) 
synthesis, and then digital drop PCR is performed. The extracted RNA is converted to cDNA 
using High Capacity cDNA Reverse Transcription Kit (Applied Biosystems, Foster City, CA) 
according to the manufacturer’s instructions.  The conversion is performed using a GeneAmp 
9700 thermocycler (Applied Biosystems, Grand Island, NY) with the following parameters: 
10 min at 25°C, 120 min at 37°C, 5 min at 85°C, and a hold at 4°C. HTLV-1 tax and HBZ 
primers and FAM/MGB probes were designed for ddPCR using NCBI Primer Blast and 
Primer3Plus.  Additionally, we amplify a housekeeping gene, Hypoxanthine-guanine 
phosphoribosyltransferase (HPRT), using a commercially available mix (Life Technologies, 
Frederick, MD).  The final concentrations in the ddPCR reaction are 900 nM of each primer 
and 250 nM of each probe. 
 
Digital droplet PCR is performed as described in assay methodology noted above for HTLV-
1 DNA proviral load. Briefly, the cDNA is mixed with the HTLV-1 tax (or HBZ) and HPRT1 
primers and probes and Bio-Rad 2x Supermix, which is then emulsified with droplet generator 
oil (Bio-Rad, Hercules, CA) using a QX-200 droplet generator according to the 
manufactuter’s instructions.  The droplets are transferred to a 96-well reaction plate 
(Eppendorf, Hauppage, NY) and heat-sealed with pierceable sealing foil sheets (Thermo 

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48 
 
Fisher Scientific, West Palm Beach, FL.).  PCR amplification is performed using a GeneAmp 
9700 thermocycler (Applied Biosystems, Grand Island, NY) with the following cycling 
parameters: 10 min at 95°C, 40 cycles consisting of a 30-s denaturation at 94°C and a 60-s 
extension at 59°C, followed by 10 min at 98°C and a hold at 12°C. Following PCR 
amplification, the 96-well plate was transferred to a QX100 droplet reader (Bio-Rad, 
Hercules, CA).  Each well was queried for fluorescence to determine the quantity of positive 
events. 
 
QuantaSoft software version # 1.7.4.0917 (Bio-Rad, Hercules, CA) is used to quantify the 
copies/μl of each queried target per well. Droplet positivity was determined by fluorescence 
intensity.  Thresholds are determined manually for each experiment, according to negative 
controls, which included a no template control and cDNA from a HTLV-I seronegative 
healthy volunteer.  All samples are run in duplicate and the gene expression is the average of 
the two measurements.  The gene expression was normalized to the housekeeping gene 
expression using the following formula: Gene expression = ((quantity of HTLV-1 tax or HBZ) 
/ (quantity of housekeeping gene))*100.  
 
 
 
 
Primers and Probe Sequences: 
 
 
 
Investigator’s Experience and Competence with the Assay: Dr. Lee Ratner, the Principal 
Investigator, used this assay in previous publications [29, 54, 55], and has funding for these 
studies PO1 100730, R01 CA63417, and P50 CA094056. 
 
Justification for Number of Patients and Specimens: Blood samples will be obtained at 
baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, and every 12 weeks thereafter, and at the end 
of study treatment, in order to examine the correlation between viral RNA levels, clinical 
response, and other correlative studies. Tumor tissue sample is obtained at baseline and off-
study time point (if available) to determine viral RNA levels in the tumor. 
 
C.  HTLV-1 Clonality Analysis 
 
Hypothesis: Nivolumab will enhance anti-ATLL immune responses and result in a decrease 
in the clonality index of integrated HTLV-1 proviruses. 
 
Rationale: Nivolumab will enhance anti-ATLL immune responses and result in a decrease in 
the clonally expanded population of infected cells, as quantified by integration site analyses. 
Gene 
Name 
Forward Primer (5’-3’) 
Reverse Primer (5’-3’) 
Probe Sequence (5’-3’) 
Tax  
cDNA 
ATCCCGTGGAGACTCC
TCAA 
CCAAACACGTAGACTGGGT
ATCC 
6FAM 
CCCCGCCGATCCCAAA 
MGBNFQ 
HBZ 
cDNA 
AGAACGCGACTCAACC
GG 
TGACACAGGCAAGCATCG
A 
6FAM 
ATGGCGGCCTCAGGGCT 
MGBNFQ 

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49 
 
 
Preclinical and Clinical Results: See Section 2.1 for HTLV-1 Clonality (2.1.3). 
 
Assay Methodology: Genomic DNA will be extracted from PBMCs isolated from whole 
blood obtained at baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, every 12 weeks thereafter, 
and at the end of study time point and with tumor tissue at baseline and end of study time 
point (if available). Clonality is determined from deep sequencing of integration sites [56]. 
Ten micrograms of DNA from uncultured PBMCs or tumor cells is sheared by sonication. 
DNA ends are then end-repaired using T4 DNA polymerase, DNA polymerase I Klenow 
fragment, T4 polynucleotide kinase. Addition of an adenosine at the 3’ ends of the DNA is 
performed with Klenow Fragment 3’ to 5’ exo. One hundred pmol of a partially double 
stranded DNA linker is ligated to the DNA ends. Twenty six different linkers are constructed, 
each one with a specific 6bp tag to allow multiplexing of DNA samples during the sequencing. 
The ligated product is then split into 3 aliquots and each aliquot used in a separate PCR 
reaction. For each PCR reaction, ligated product is 50 pmol of B3 primer (binds HTLV-1 
LTR), 10 pmol of B4 primer (which anneals to the strand of the linker generated by the 
amplification from Bio3), Phusion DNA polymerase. The 3 PCR1 products, derived from the 
same sample are then pooled, and PCR2 performed with PCR1 product using 25pmol of P5B5 
primer (binds HTLV-1 LTR), 25 pmol of P7 primer (binds the linker), Phusion DNA 
polymerase. A library is constructed by pooling the different PCR2 products (each one 
possessing a specific tag). Quantification of the libraries is made by QPCR using primers P5 
and P7 libraries are diluted to 0.5 pM and clustered on the Illumina flow cell. Paired-end reads 
(read1 and read2 each 50bp) plus a 6 bp tag read (read 3) are acquired on a GA II. The library 
construction pipeline is split into four steps: 1. DNA isolation and shearing; 2. Pre-PCR 
manipulations (ends repair and ligation); 3. PCR1 and PCR2 and library QPCR; 4. Library 
sequencing. Each step is carried out in a specific room and the sample flow is unidirectional, 
to minimize the risk of PCR contamination.  
 
Read 1 and read 2 are mapped against the HTLV-1 and the human genome. First, overlapping 
clusters are exclude and then the following quality control filters: i) the single-read alignment 
scores of read 1 and read 2 must be higher than 10, ii) the strand orientation of the 2 reads 
must be opposite; iii) the length of the amplicons must be smaller than 1kb. Because the PCR 
is not specific to the 3’LTR, we discard the amplicons generated from the 5’LTR that 
contained only HTLV-1 sequences. We identify read 1 sequences that start with ACACA (the 
five bases at the 3’ terminus of the HTLV-1 LTR). Read 1 and read 2 sequences are used to 
map the insertion site and the shear site. Read 3 is used to allocate the insertion site to a 
particular sample. Together with the mapping of a large number of UISs, the goal of our 
approach is to quantify the abundance of each unique integration site (UIS). Because PCR 
preferentially amplifies short products, the number of amplicons cannot be used to quantify 
the abundance of a given UIS. Random DNA fragmentation by sonication is a key feature to 
allow the quantification of the UIS abundance because, it is not biased to particular nucleotide 
sequences. For each UIS, we count the number of amplicons of different length. Additionally, 
misreading of the tag index during the sequencing could lead to the attribution of a particular 
insertion site to different samples. We solve this issue by taking into account not only the 6bp 
tag information but also the total number of distinct shear sites and the total number of reads 

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50 
 
for a given insertion site to attribute the insertion site to the correct sample. Finally, control 
DNA (from a human T-cell line (Jurkat) uninfected by HTLV-1) is run on every lane of each 
flow cell to assess the effectiveness of our quality control procedures. Clonality is then 
determined from the oligoclonality index.  
 
Investigator’s Experience and Competence with the Assay: Dr. Lee Ratner, the Principal 
Investigator, used this assay in a previous report [55], and has funding for these studies PO1 
100730, R01 CA63417, and P50 CA094056. 
 
Justification for Number of Patients and Specimens: Blood samples will be obtained at 
baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, and every 12 weeks thereafter, and at the end 
of study treatment, in order to examine the correlation between clonality, clinical response, 
and other correlative studies. Tumor tissue samples are obtained at baseline and off-study time 
point (if available) to determine clonality in the tumor. 
 
D.  HTLV-1 Specific CTL Analysis 
 
Hypothesis: Nivolumab will enhance anti-ATLL immune responses, including Tax-specific 
CTL numbers. 
 
Rationale: Nivolumab will enhance anti-ATLL immune responses, as measured by HTLV-1 
specific CTL numbers. 
 
Preclinical and Clinical Results: See Section 2.1 for HTLV-1 Immune Responses (2.1.7).   
 
Assay Methodology: Tax-specific CTLs are determined with PBMCs obtained at baseline, 
Day 1 of Cycle 3, and end of study endpoint. To stimulate IFN-γ+ HTLV-1 Tax-specific CD8+ 
T cells, we use two pools of overlapping 20 mer peptides (offset by 6 amino acids) spanning 
the full length of the Tax protein. One hundred thousand CD4-depleted PBMCs are incubated 
at 37°C for 6 h in the presence a range of concentrations (0, 0.01, 0.1, 1, 5 and 10 μM) of the 
Tax peptide pools in duplicate wells. IFN-γ production by Tax-specific CTLs is quantified by 
ELISpot. Spot-forming cells (SFCs) were counted using an automated ELISpot reader. For 
each peptide pool concentration, the frequency of IFN-γ+Tax-specific CTLs is calculated as 
follows: (SFCpoolA + SFCpoolB − 2 · SFCno peptide)/(total number of CD8+ T cells). Log10[peptide] 
is then plotted against the number of IFN-γ+ Tax-specific CTLs. Using Graphpad Prism 
software, the following equation was fitted to the data: y = (max)/(1 + 10((LogEC50-x) · Hillslope)); 
where x = log10 (peptide concentration); y = % CD8+ cells producing IFN-γ at a given peptide 
concentration; Hillslope = gradient of fitted curve; and max = predicted maximum SFC (i.e., 
where peptide concentration is not a limiting factor in IFN-γ production by Ag specific cells). 
The effective concentration of peptide that induced IFN-γ production by half the maximum 
number of Tax-specific cells (EC50) is estimated using this equation, and CD8+ T cell avidity 
was defined as the reciprocal of this value (1/EC50). Avidity is expressed in units of 106 M−1.  
 
Investigator’s Experience and Competence with the Assay: Dr. Lee Ratner, the Principal 
Investigator, has unpublished experience in this assay. 

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51 
 
 
Justification for Number of Patients and Specimens: Blood samples will be obtained at 
baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, and every 12 weeks thereafter, and at the end 
of study treatment, in order to examine the correlation between viral RNA levels, clinical 
response, and other correlative studies. Tumor tissue sample is obtained at baseline and off-
study time point (if available) to determine viral RNA levels in the tumor. 
 
9.4.1.1 Collection of Specimens 
 
The risks of obtaining the blood samples are that of venipuncture and are minimal. No additional 
tumor tissue will be obtained beyond that initially obtained for clinical purposes, but no longer 
needed for those purposes. 
 
Blood for PBMC 
For each subject: 
• Collect five 10mL green-top (sodium heparin) tubes (BD Vacutainer, Catalog no. 
366480) OR five 8.5ml yellow-top (acid citrate dextrose or ACD) tubes (BD Vacutainer, 
Catalog no. 364606) of peripheral blood for the following time point: 
a) Baseline 
• Collect three 10mL green-top (sodium heparin) tubes (BD Vacutainer, Catalog no. 
366480) OR three 8.5ml yellow-top (ACD) tubes (BD Vacutainer, Catalog no. 364606) 
for the following time points: 
a) Day 1 of Cycle 3 
b) Day 1 of Cycle 5 
c) Every 12 weeks (after Day 1 of Cycle 5) 
d) End of study treatment 
 
Tumor Tissue 
For each subject: 
• Obtain tumor tissue sample (block or core) for the following time points: 
a) Baseline 
b) End of study treatment (if available)  
 
9.4.1.2 Handling of Specimens 
 
Blood for PBMC 
• If collected Monday through Thursday, ship tubes on day of collection at room 
temperature. 
• If not shipped on day of collection, isolate and store PBMCs using the PBMC Isolation 
Procedure (see Table 9.4.1.2 below).   
• Label each sample (tube or cryovial) with:    

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52 
 
- 
Study Number NCI9925 
- 
Sample Type PBMC 
- 
Subject ID Number  
- 
Collection Date 
- 
Collection Time 
- 
WBC Volume in mL (for cryovials only) 
 
      Table 9.4.1.2 PBMC Isolation Procedure 
 
A. Collection  
1. Collect blood in specified tube(s). 
2. Prepare an ice bucket with dry ice.  Chill one 2mL cryovial for each tube to collect the 
white blood cells isolated in the procedure.  
  
B. Blood Separation  
1. Fractionate the whole blood by centrifuging at 1500-2000 X g for 10-15 min at room 
temperature. This will separate the blood into an upper plasma layer, a lower red blood 
cell (RBC) layer, and a thin interface containing the white blood cells (WBCs) / buffy 
coat.  Fractionate the blood as soon as possible after collection.  
NOTE: In a typical clinical centrifuge 1500-2000 X g is ~3000-3400 rpm. Check the 
appropriate settings for your centrifuge using the nomogram in your user’s manual.  
2. Use a disposable, plastic transfer pipet or Pasteur pipet to slowly and carefully aspirate off 
the plasma (upper layer) down to about 1 mm above the buffy coat.  Do not disturb the 
buffy coat.  Discard the plasma into a 250 mL flask containing bleach.  
3. Gently recover the buffy coat (WBCs) with a fresh disposable pipet, Pasteur pipet, or 
1000 ul micropipettor with a sterile tip.  Try not to uptake the RBC layer below the buffy 
coat.  
4. Place the recovered buffy coat into the WBC labeled cryovial cooled on ice from step 2. 
5. Screw on the cryovial cap tightly to prevent isopentane from seeping into the vial.  
6. Visually estimate the volume of WBCs recovered using the volume lines on the cryovial 
and write the information on the cryovial label.  Buffy coat volume is greater in samples 
with high WBC counts.  Usually you can expect < 0.5 mL total. 
7. Proceed to section C, “Freezing Collected Cells”. 
  
C. Freezing Collected Cells 
1. Set Up Freezing Station  
• 
Do not perform snap freezing with bare hands.  Wear gloves at all times and heavy 
duty gloves when working with liquid nitrogen or cooled isopentane. 
• 
Use extreme caution when dispensing liquid nitrogen. 
• 
Fill a small 100 ml metal beaker about 1/4 full with isopentane  
• 
Fill the Dewar thermo-flask about 1/3 full with liquid nitrogen.  
  
2. Freezing Blood Cells in Cryovial  
1. Lower the 100 ml metal beaker containing isopentane half-way into the liquid 
nitrogen for cooling. The liquid nitrogen will boil as the beaker is lowered, when the 
isopentane is reaching its freezing point the tone of the boiling will increase for 2-3 
seconds.  

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2. Lift the beaker out of the liquid nitrogen once more than you see beads of solid 
isopentane at the bottom of the beaker (about 2 minutes).  
3. Use long forceps to hold the cryovial down into the cooled isopentane. Hold for at 
least 1 minute.  
4. Use the long forceps to take out the cryovial(s).  
5. Store vial(s) in -80ºC freezer.  
 
 
Tumor Tissue 
• Formalin fixed tumor biopsy - prepare as 3x3mm core. 
• Fresh tumor tissue (flash frozen in liquid nitrogen within 2 hours of collection) - prepare 
excised tissue or cores measuring at least 10x2x2mm in aggregate.   
• Site may opt to send tumor tissue block.  Blocks will be handled by the Ratner 
Laboratory per study specifications (not to exhaust the tissue sample) and the remaining 
tissue will be returned to the site. 
• Label each tissue sample with: 
- 
Study Number NCI9925 
- 
Subject ID Number 
- 
Sample Type Block or Core  
- 
Date of Specimen 
- 
Corresponding Accession Number  
 
9.4.1.3 Shipping of Specimens 
 
Blood for PBMC 
• On Monday through Thursday, overnight ship tubes on day of collection at room 
temperature OR batch ship cryovials at the end of the study on dry ice to the Ratner 
Laboratory at the following address: 
 
Dr. Lee Ratner / John Harding 
Washington University 
McDonnell Science Research Building Room 562 
4523 Clayton Avenue 
St Louis, MO 63110 
Telephone: 314-362-8836 
 
• Please notify the Ratner Laboratory (LRATNER@DOM.WUSTL.EDU) of any incoming 
blood specimen shipments by providing notification two days prior to shipment via the 
9925 Study Portal. The shipment notification will include upload of the PBMC Shipment 
Log (see Appendix F).  The 9925 Study Portal may be accessed through the following 
link: http://j.mp/2g4kpUG 
 
 
 

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54 
 
Tumor Tissue 
• On Monday through Thursday, batch ship tissue samples at the end of study at room 
temperature to the Ratner Laboratory at the following address: 
 
Dr. Lee Ratner / John Harding 
Washington University 
McDonnell Science Research Building Room 562 
4523 Clayton Avenue St Louis, MO 63110 
Telephone: 314-362-8836 
 
• Please notify the Ratner Laboratory (LRATNER@DOM.WUSTL.EDU) of any incoming 
tissue specimen shipments by providing notification two days prior to shipment via the 
9925 Study Portal. The shipment notification will include upload of the Tissue Shipment 
Log (see Appendix G).  The 9925 Study Portal may be accessed through the following 
link: http://j.mp/2g4kpUG 
 
 
9.4.1.4 Site Performing Correlative Study 
 
Studies will be performed at the Ratner Laboratory at Washington University. 
 
9.4.2 Immune Cell Numbers - Biomarker of Anti-Tumor Activity 
 
Hypothesis: Nivolumab will enhance anti-ATLL immune responses and will decrease the 
number of CD3+CD4+CD25+ cells carrying HTLV-1 provirus, while increasing the number 
of CD3+CD8+ cells without affecting CD56+ or CD19+ cell numbers 
 
Rationale: Nivolumab will enhance anti-ATLL immune responses and decrease infected 
immune responses and increase anti-ATLL immune effectors, which are likely primarily 
CD8+ cells 
 
Preclinical and Clinical Results: See Section 2.1 for HTLV-1 Immune Responses (2.1.7).   
 
Assay Methodology: Fluorescence Activated Cell Sorting (FACS) assay to be run at each 
institution.   
 
Investigator’s Experience and Competence with the Assay: N/A 
 
Justification for Number of Patients and Specimens: Blood samples will be obtained at 
baseline, Day 1 of Cycle 3, Day 1 of Cycle 5, and every 12 weeks thereafter, and at the end 
of study treatment, in order to examine the correlation between immune cell numbers, clinical 
response, and other correlative studies. Tumor tissue sample is obtained at baseline and off-
study time point (if available) to determine immune cell numbers in the tumor. 
 

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55 
 
9.4.2.1 Collection of Specimens 
 
The risks of obtaining the blood samples are that of venipuncture and are minimal. No additional 
tumor tissue will be obtained beyond that initially obtained for clinical purposes, but no longer 
needed for those purposes. 
 
Blood for FACS 
For each subject: 
• Collect peripheral blood per standard institutional procedure at the following time points: 
a) Baseline 
b) Day 1 of Cycle 3 
c) Day 1 of Cycle 5 
d) Every 12 weeks (after Day 1 of Cycle 5) 
e) End of study treatment 
 
Tumor Tissue 
For each subject: 
• Obtain tumor tissue sample per standard institutional procedure at the following time 
points: 
a) Baseline (not required if fresh tissue is not available) 
b) End of study treatment (if available)  
 
9.4.2.2 Handling of Specimens 
 
FACS assay of blood and tumor tissue will be completed per standard institutional procedure.  
Assay results should include the following: CD3, CD4, CD8, CD19, CD56, and CD25. 
 
9.4.2.3 Shipping of Specimens 
 
N/A 
 
9.4.2.4 Site Performing Correlative Study 
 
FACS assay will be performed at the institution where the patient was enrolled. 
 
9.4.3 PD-1, PD-L1, PD-L2 Expression - Biomarker of Anti-Tumor Activity 
 
Hypothesis: Nivolumab responses will be greater in tumors will high levels of PD-L1 or PD-
L2 as compared to tumors with low levels of expression of these checkpoint proteins. 
 
Rationale: Nivolumab responses for solid tumors have been shown to correlate with levels of 
PD-L1 or PD-L2 expression. 
 

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56 
 
Preclinical and Clinical Results: See Section 2.2 on Pharmacodynamics/Biomarkers (2.2.6).    
 
Assay Methodology: IHC assay. 
 
Investigator’s Experience and Competence with the Assay: Dr Ratner, PI of the study, has 
significant experience with IHC assays.  
 
9.4.3.1 Collection of Specimens 
 
No additional tumor tissue will be obtained beyond that initially obtained for clinical purposes, 
but no longer needed for those purposes. 
 
Tumor Tissue 
For each subject: 
• Obtain 10 tumor tissue sample (slides) for the following time points: 
a) Baseline 
b) End of study treatment (if available)  
 
9.4.3.2 Handling of Specimens 
 
Tumor Tissue 
• Sections should be freshly cut for IHC staining. 
• Use positively charged microscope slides, such as Superfrost Plus Fisher Catalog #22-
034-979 or #12-550-15. 
• Cut 10 unstained slides with section thickness of 5 microns.  
• Slide drying should be performed at 37°C overnight.  
• Storage of cut slides at room temperature should ideally not exceed more than 7 days.  
• Longer-term storage should be at 4°C, with slide boxes carefully parafilmed to prevent 
moisture entering the slide box.  
• Mark each slide with: 
- 
Study Number NCI9925 
- 
Subject ID Number  
- 
Sample Type PDL  
- 
Date of Specimen 
- 
Corresponding Accession Number  
- 
Serial Number of Slide (1, 2, 3…) 
 
9.4.3.3 Shipping of Specimens 
 
Tumor Tissue 
• On Monday through Thursday, batch ship tissue samples at the end of study at room 
temperature to the Ratner Laboratory at the following address: 
 

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57 
 
Dr. Lee Ratner / John Harding 
Washington University 
McDonnell Science Research Building Room 562 
4566 Scott Ave4523 Clayton Avenue 
St Louis, MO 63110 
Telephone: 314-362-8836 
 
• Please notify the Ratner Laboratory (LRATNER@DOM.WUSTL.EDU) of any incoming 
tissue specimen shipments  by providing notification two days prior to shipment via the 
9925 Study Portal. The shipment notification will include upload of the Tissue Shipment 
Log (see Appendix G).  The 9925 Study Portal may be accessed through the following 
link: http://j.mp/2g4kpUG 
 
9.4.3.3 Site Performing Correlative Study 
 
IHC study will be performed in the Ratner Laboratory at Washington University.   
 
9.4.4 Tumor Antigen Analysis - Biomarker for Correlation with Responses 
 
Hypothesis: Nivolumab will enhance anti-ATLL immune responses directed against tumor 
antigens. 
 
Rationale: Responses to nivolumab in solid tumors correlate with the level of mutant tumor 
antigens. 
 
Preclinical and Clinical Results: See Section 2.2 for Pharmacodynamics/Biomarkers (2.2.6).   
 
Assay Methodology: Primary tumor or leukemic blood samples and matched normal 
specimens (skin or CD19+ peripheral blood B cells) are obtained. Only specimens with high 
tumor cellularity (>75%) will be used. Tumor and skin specimens are snap frozen in liquid 
nitrogen after surgical resection or biopsy and stored at −80 °C. Sections of tumor are stained 
with hematoxylin and eosin. DNA is extracted and exon capture is performed using a human 
All Exon 50MB kit (Agilent) with the addition of capture probes corresponding to the entire 
HTLV-1 genome. Enriched exome libraries will be sequenced on the HiSeq 2500 platform 
(llumina) to >100X coverage. Alignment, base-quality score recalibration and duplicate-read 
removal are performed, germline variants excluded, mutations annotated and indels evaluated. 
Samples with tumor coverage ≤10X were excluded. Medium-confidence reads (11-34X) are 
manually reviewed using the Integrated Genomics Viewer for sequencing of candidate 
mutations. Mutations between clinical groups were compared using the Mann-Whitney test.  
 
HLA typing is performed by either low to intermediate resolution polymerase chain reaction-
sequence-specific primer (PCR-SSP) method or by high–resolution SeCore HLA sequence-
based 
typing 
method 
(HLA-SBT) 
(Invitrogen). 
ATHLATES 
(http://www.broadinstitute.org/scientificcommunity/science/projects/viral-
genomics/athlates)3 is also used for HLA typing and confirmation. 

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58 
 
 
The bioinformatic tool NAseek is used which performs two functions: translation of stretches 
surrounding each mutation, and comparison between the resulting peptides for homology. 
First, NASeek translates all mutations in exomes so strings of 17 amino acids are generated 
for the predicted wild type and mutant, with the amino acid resulting from the mutation is 
situated centrally. Next, to evaluate MHC Class I binding, wild type and mutant nonamers 
containing the tetrapeptides common to the complete responders are input into NetMHC v3.4 
(http://www.cbs.dtu.dk/services/NetMHC/) 
or 
RANKPEP 
(http://imed.med.ucm.es/Tools/rankpep.html) for patient-specific HLA types, using a sliding 
window method. These programs generate a predicted MHC Class I binding strength. Finally, 
NAseek assesses for similarity between nonamers that are predicted to be presented by 
patient-specific MHC Class I. The logo plot of the amino acid frequencies is executed using 
Weblogo (http://weblogo.berkeley.edu/logo.cgi) with default parameters. In order to further 
narrow down the predicted nonamers for testing in vitro, nonamers were also evaluated for 
putative binding to the T cell receptor using the IEDB immunogenicity predictor with patient-
specific HLA types (http://tools.immuneepitope.org/immunogenicity/) and CTLPred 
(http://www.imtech.res.in/raghava/ctlpred/). To evaluate homology to known pathogens’ 
antigens, conserved tetrapeptides are analyzed using Immune Epitope Database 
(www.iedb.org) and assessed as substrings of immunogens in the database for a positive T 
cell response in Homo sapiens host. The “neoantigen signature” is generated from the 
nonamers containing the peptides common to patients with long-term benefit. Standard 
methods for signature derivation using unsupervised hierarchical clustering followed by 
logistic regression are used to determine predictive models based solely on the discovery set 
data. We will perform simulation/permutation testing to demonstrate that the neoantigen 
signature is highly unlikely to result from chance. To assess the null hypothesis that the 
signature is due to chance, 5 distinct simulation models are evaluated, three with new datasets 
and two using permutations of our dataset. The simulations are executed using (a) nonamers 
drawn from the SwissProt database (b) mutations from the TCGA T-cell lymphoma dataset 
(c) randomly generated nonamers (d) redistribution of the mutations found in our data and (e) 
reordering of the 9 amino acids within each nonamer predicted to be presented in our dataset. 
In each simulation, the nonamers are distributed randomly, and in proportion to our data (for 
example, if an actual sample harbored 150 nonamers predicted to bind MHC Class I, then the 
“virtual” sample is assigned 150 nonamers). Simulation testing is then conducted by applying 
the same iterative model used on the actual data applied to this virtual dataset, and repeating 
this process 1,000 times, recording the frequency of signatures greater than the actual 
signature to determine the p value. P value was calculated as the proportion of iterations with 
a signature greater that correctly classified segregation of the clinical cohorts, divided by the 
1,000 iterations. 
  
Mann-Whitney test is used to compare non-synonymous exonic mutational burden between 
clinical groups. Log-Rank test was used to compare the Kaplan-Meier curves for overall 
survival in the discovery and validation sets. As described above, simulation testing was used 
with the null hypothesis that all tetrapeptides contribute equally to clinical benefit to determine 
if a signature of the size we found happened by chance. 
 

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59 
 
Investigator’s Experience and Competence with the Assay: Dr. Lee Ratner, the Principal 
Investigator, has used this assay in a previous report [55], and has funding for these studies 
PO1 100730, R01 CA63417, and P50 CA094056 
 
Justification for Number of Patients and Specimens: Tumor samples will be obtained at 
baseline and end of study time point. A skin biopsy is obtained at baseline, at the same time 
as the bone marrow biopsy to provide germline DNA not contaminated with PBMCs. 
 
9.4.4.1 Collection of Specimens 
 
No additional tumor tissue will be obtained beyond that initially obtained for clinical purposes, 
but no longer needed for those purposes. 
 
Tumor Tissue 
• The same tumor tissue samples obtained for HTLV-1 studies will be used for this 
analysis. 
Skin 
For each subject: 
• Obtain a 3 or 4 mm punch biopsy of skin per standard institutional procedure at the 
following time point: 
a) Baseline (at the same time as bone marrow biopsy) 
 
9.4.4.2 Handling of Specimens 
 
Tumor Tissue  
• The same tumor tissue samples obtained for HTLV-1 studies will be used for this 
analysis. 
 
Skin 
• Skin punch biopsy should be flash frozen in liquid nitrogen within 2 hours of collection.   
• Label each skin sample with: 
- 
Study Number NCI9925 
- 
Subject ID Number  
- 
Sample Type Skin 
- 
Collection Date 
- 
Collection Time 
 
9.4.4.3 Shipping of Specimens 
 
Tumor Tissue 
• The same tumor tissue samples obtained for HTLV-1 studies will be used for this 
analysis. 

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60 
 
 
Skin 
• On Monday - Thursday, batch ship tissue samples at the end of study at room temperature 
to the Ratner Laboratory at the following address: 
 
Dr. Lee Ratner/ John Harding 
Washington University 
McDonnell Science Research Building Room 562 
4566 Scott Ave4523 Clayton Avenue 
St Louis, MO 63110 
Telephone: 314-362-8836 
 
• Please notify the Ratner Laboratory (LRATNER@DOM.WUSTL.EDU) of any incoming 
tissue specimen shipments by providing notification two days prior to shipment via the 
9925 Study Portal. The shipment notification will include upload of the Tissue Shipment 
Log (see Appendix G).  The 9925 Study Portal may be accessed through the following 
link: http://j.mp/2g4kpUG 
 
9.4.4.4 Site Performing Correlative Study 
 
Studies will be performed at the Ratner Laboratory at Washington University. 
 
9.4.5 Protein Markers Associated with Sensitivity or Resistance to Nivolumab  
 
Multiplex ELISA assays have been developed to analyze over 25 angiogenic, inflammatory 
and immune-related markers in less than 0.5 ml of plasma.  Coefficients of variation for 
most analytes are <10%.  This platform has been successfully applied to several in-house 
phase I and II studies, as well as several phase III, Alliance-conducted studies with 
bevacizumab in colorectal and other cancers at Duke University. Markers of inflammation 
will be analyzed in the Duke Phase I Biomarker Lab, which serves as a core lab for these 
analyses for the US Cooperative Group, the Alliance.  
 
Analyses will be performed on pre-treatment and on-treatment plasma samples. Analyte 
levels, and changes in analyte levels, will be correlated with clinical outcome (PFS, OS).  
Plasma will also be evaluated for protein markers that may be associated with sensitivity or 
resistance to ibrutinib. These may include CRP and other markers of inflammation, 
including but not limited to IFNγ, IL1β, IL6, sILR6R, sGP130, IL4, IL7, IL10, IL12, IL17A, 
IL17E, and IL23. Additional markers of proteins regulated by the PD-1/PD-L1 interaction 
and the IL6/JAK-STAT axis will also be assessed, including but not limited to VEGF, HER 
and TGFβ family members. 
 
9.4.5.1 
Collection of Specimens 
 
Plasma Collection and Processing: 
• Draw one 10ml lavender top (K2EDTA) tube (BD Vacutainer, Catalog no. 366643) at the 

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61 
 
following time points: 
a) Baseline; 
b) Every restaging;   
c) End of study treatment. 
• Invert tubes 10 times to mix blood. 
• Centrifuge at 4°C at 2500 x g for 15 minutes (or in accordance with centrifuge 
manufacturer’s instructions). 
• Remove plasma from each tube and transfer equally into two separate clean 15ml 
polypropylene tubes (or institutional equivalent). 
• Repeat centrifuge at 4°C at 2500 x g for 15 minutes (or in accordance with centrifuge 
manufacturer’s instructions). 
• Aliquot approximately 1.0ml of plasma from each tube evenly into four 2.0ml cryovials.   
• Label each cryovial with:    
- 
Study Number NCI9925 
- 
Subject ID Number  
- 
Sample Type Plasma 
- 
Collection Date 
- 
Collection Time 
- 
Frozen Time 
 
9.4.5.1       Handling of Specimens 
 
Plasma samples will be stored at -70C until further use.  
 
9.4.5.2 
Shipping of Specimens 
 
In the end of trial accrual, all protein marker (plasma) and pharmacogenomics (whole blood) 
specimens will be batched (approximately 2 batches per institution) and shipped on dry ice by 
courier guaranteeing overnight delivery (Monday-Thursday) to the following address:    
 
 
 
Phase I Biomarker Laboratory 
 
 
ATTN:  Andrew Nixon, PhD 
 
 
Duke University Medical Center 
 
 
395 MSRB, Research Drive 
 
 
Durham, NC 27710 
 
• Please notify the Phase I Biomarker Laboratory (andrew.nixon@duke.edu) of any 
incoming blood specimen shipments by providing notification two days prior to shipment 
via the 9925 Study Portal. The shipment notification will include upload of the 
Biomarker Shipment Log (see Appendix H).  The 9925 Study Portal may be accessed 
through the following link: http://j.mp/2g4kpUG 
 
9.4.5.4 
Site Performing Correlative Studies 
 
Protein marker analysis will be performed at the Duke Phase I Biomarker Laboratory. 

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62 
 
 
9.4.6 Pharmacogenomics Assessment 
 
A one-time, blood sample will be drawn prior to initiation of therapy for assessment of variants 
in genes anticipated to be involved in the pharmacokinetics or pharmacodynamics of nivolumab.  
 
9.4.6.1 
 Collection of Specimens 
 
Whole Blood Collection and Processing: 
• Draw one 6ml pink top (K2EDTA) tube (BD Vacutainer, Catalog no. 367899) at the 
following time point: 
a) pre-study (i.e., baseline) only. 
• Invert tube 10 times to mix blood. 
• Label the tube with:    
- 
Study Number NCI9925 
- 
Sample Type Whole Blood 
- 
Subject ID Number  
- 
Collection Date 
- 
Collection Time 
- 
Frozen Time 
 
9.4.6.2 
Handling of Specimens 
 
Whole blood samples will be stored at -70C until further use.  
 
9.4.6.3 
 Shipping of Specimens 
 
In the end of trial accrual, all protein marker (plasma) and pharmacogenomics (whole blood) 
specimens will be batched (approximately 2 batches per institution) and shipped on dry ice by 
courier guaranteeing overnight delivery (Monday-Thursday) to the following address:    
 
 
 
Phase I Biomarker Laboratory 
 
 
ATTN:  Andrew Nixon, PhD 
 
 
Duke University Medical Center 
 
 
395 MSRB, Research Drive 
 
 
Durham, NC 27710 
 
• Please notify the Phase I Biomarker Laboratory (andrew.nixon@duke.edu ) of any 
incoming blood specimen shipments by providing notification two days prior to shipment 
via the 9925 Study Portal. The shipment notification will include upload of the 
Biomarker Shipment Log (see Appendix H).  The 9925 Study Portal may be accessed 
through the following link: http://j.mp/2g4kpUG 
 
9.4.6.4 
 Site Performing Correlative Studies 
 

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63 
 
Pharmacogenomic analysis will be performed at the Duke Phase I Biomarker Laboratory. 
 
10. STUDY CALENDAR 
Baseline evaluations are to be conducted within 2 weeks prior to start of protocol therapy. Scans and 
x-rays must be done <4 weeks prior to the start of therapy.  
PROCEDURE/TEST* 
 
Week* 
Cycle* 
 
Pre-study 
1 
2 
3 
4 
5 
6 
7 
8 
5 - 46 
Off-study5 
Nivolumab 
 
A 
 
A 
 
A 
 
A 
 
A 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
Concurrent Medications 
X 
X-------------------------------------------------------------X 
 
Physical Exam 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
Neurological Exam 1 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
Vital Signs 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
Height 
X 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
Performance Status 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
HTLV Antibody Assay 
X 
 
 
 
 
 
 
 
 
 
 
CBC w/diff and Platelets 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Serum Chemistry 2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Hormone Levels 3 
X 
 
 
 
 
 
 
 
 
 
 
B-HCG 4 
X 
 
 
 
 
 
 
 
 
 
 
EKG  
X 
 
 
 
 
 
 
 
 
 
 
Echocardiogram14 
X14 
 
 
 
 
 
 
 
 
 
 
Cardiac Evaluations15 
 
X------------------------------------------------------------X 
X 
Adverse Event Evaluation 
 
X------------------------------------------------------------X 
X 
Radiologic Evaluation 
X 
Radiologic evaluations should be performed every 12 weeks. 
X 
Tumor Measurements 
X 
Tumor measurements are repeated every 12 weeks.  
Documentation (radiologic) must be provided for patients 
removed from study for progressive disease. 
X 
Bone Marrow and Skin 
Biopsy 
X 
Bone marrow biopsy is repeated if positive at baseline and 
complete response (CR) is obtained by all other criteria. 
 
CORRELATIVE STUDIES 
HTLV-1 Studies 6   
- PBMC  
X6 
 
 
 
 
X6 
 
 
 
X6 
X6 
HTLV-1 Studies 7   
- Tumor Tissue (block/core) 
X7 
 
 
 
 
 
 
 
 
 
X7 
Immune Cell Numbers 8  
- Blood  
X8 
 
 
 
 
X8 
 
 
 
X8 
X8 
Immune Cell Numbers 9  
- Tumor Tissue 
X9 
 
 
 
 
 
 
 
 
 
X9 
PD-1,-L1,-L2 Expression 10   
 - Tumor tissue (slides) 
X10 
 
 
 
 
 
 
 
 
 
X10 
Tumor Antigen Analysis 11 
- Skin 
X11 
 
 
 
 
 
 
 
 
 
 

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64 
 
PROCEDURE/TEST* 
 
Week* 
Cycle* 
 
Pre-study 
1 
2 
3 
4 
5 
6 
7 
8 
5 - 46 
Off-study5 
Protein Markers 12   
- Plasma  
X12 
 
 
 
 
 
 
 
 
X12 
X12 
Pharmacogenomic 13  
- Whole Blood  
X13 
 
 
 
 
 
 
 
 
 
 
*: +/- 1 day permissible for procedures, labs, and study drug administration  
A:  Nivolumab, 240 mg every 2 weeks 
1:   See Appendix H 
2:   Albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH,  
      phosphorus, potassium, total protein, SGOT [AST], SGPT [ALT], sodium. 
3:   TSH and am (i.e., before midday) cortisol are drawn at baseline. 
4:   Serum pregnancy test for women of childbearing potential only. 
5:   Off-study evaluation.  Follow up assessments will be every 3 months (+/- 2 weeks) if patient is < 1 year from study    
      completion. However, patients with ongoing toxicities should be seen more often as clinically indicated. Patients who   
      develop recurrent disease will be followed for survival and for information on salvage patterns. The schedule of clinical  
      follow up for these patients will be at the discretion of the treating physician and according to established Standard of Care. 
      Adverse events assessment on the study will continue for all patients until 90 days after the last study drug administration.  
6:   Blood for PBMCs will be obtained at the following time points (+/- 2 days) for HTLV-1 DNA proviral load, RNA levels, 
clonality analysis, and specific CTL analysis:  at baseline (50mL), Day 1 of Cycle 3 (30mL), Day 1 of Cycle 5 (30mL), and 
then every 12 weeks thereafter (30mL) and at the end of study treatment (30mL).  Refer to Section 9.4.1 for sample collection,  
handling, and shipping.   
7:   Tumor tissue will be obtained at the following time points (+/- 2 days) for HTLV-1 DNA proviral load, RNA levels, 
clonality analysis,  and specific CTL analysis:  at baseline and end of study treatment (if available).  Refer to Section 9.4.1 for 
sample collection, handling, and shipping.   
8:   Blood will be obtained at the following time points for immune cell numbers: at baseline, Day 1 of Cycle 3, Day 1 of  
      Cycle 5, and then every 12 weeks thereafter and at the end of study treatment.  FACS to assay to be performed per   
      institutional standard procedure.   
9:   Tumor tissue will be obtained at the following time points for immune cell numbers: at baseline and at the end of study  
      treatment (if available).  FACS to assay to be performed per institutional standard procedure.  This is not required at 
baseline if not done prior to study and fresh tissue is not available. 
10:  Slides from tumor tissue will be obtained at the following time points for PD-1, PD-L1, PD-L2 Expression: at baseline and   
       at the end of study treatment (if available).  Refer to Section 9.4.3 for sample collection, handling, and shipping. 
11:  Skin from punch biopsy collected at the same time as baseline bone marrow biopsy will be obtained for tumor antigen  
       analysis.  Refer to Section 9.4.4 for collection, handling, and shipping.   
12:  Blood for plasma will be obtained at the following time points for protein markers at baseline (10mL), at every restaging  
       (10mL), and at the end of study treatment (10mL).  Refer to Section 9.4.5 for sample collection, handling, and shipping. 
13:  Whole blood will be obtained at baseline (6mL) for pharmacogenomics.  Refer to Section 9.4.6 for sample collection,     
       handling, and shipping. 
14:  Only for patients with a history of congestive heart failure or at risk because of underlying cardiovascular disease or              
       exposure to cardiotoxic drugs as clinically indicated. 
15:  As clinically indicated for patients with evidence of congestive heart failure, myocardial infarction, cardiomyopathy or     
       myositis.  To include EKG, CPK, troponin and echocardiogram as indicated. 
 
 
11. MEASUREMENT OF EFFECT 
 
11.1 
Antitumor Effect  
 
For the purposes of this study, patients should be re-evaluated for response every 12 weeks.  In 

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65 
 
addition to a baseline scan, confirmatory scans should also be obtained 12 weeks following initial 
documentation of objective response. 
 
Response and progression will be evaluated in this study using criteria suggested by Tsukasaki et 
al [19].   
 
 
11.1.1 Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of their first 
treatment with nivolumab. 
 
Evaluable for objective response.  Only those patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-evaluated will 
be considered evaluable for response.  These patients will have their response classified according 
to the definitions stated below.  (Note:  Patients who exhibit objective disease progression prior to 
the end of cycle 1 will also be considered evaluable.) 
 
Evaluable Non-Target Disease Response.  Patients who have lesions present at baseline that are 
evaluable but do not meet the definitions of measurable disease, have received at least one cycle 
of therapy, and have had their disease re-evaluated will be considered evaluable for non-target 
disease.  The response assessment is based on the presence, absence, or unequivocal progression 
of the lesions.  
 
11.1.2 Disease Parameters 
 
Measurable disease.  Measurable lesions are defined as those that can be accurately measured in 
at least one dimension (longest diameter to be recorded) as ≥20 mm (≥2 cm) by chest x-ray or as 
≥10 mm (≥1 cm) with CT scan, MRI, or calipers by clinical exam.  All tumor measurements must 
be recorded in millimeters (or decimal fractions of centimeters). 
 
Note:  Tumor lesions that are situated in a previously irradiated area might or might not be 
considered measurable. 
 
Malignant lymph nodes.  To be considered pathologically enlarged and measurable, a lymph node 
must be ≥15 mm (≥1.5 cm) in short axis when assessed by CT scan (CT scan slice thickness 
recommended to be no greater than 5 mm [0.5 cm]).  At baseline and in follow-up, only the short 
axis will be measured and followed. 
 
Non-measurable disease.  All other lesions (or sites of disease), including small lesions (longest 
diameter <10 mm [<1 cm] or pathological lymph nodes with ≥10 to <15 mm [≥1 to <1.5 cm] short 
axis), are considered non-measurable disease.  Bone lesions, leptomeningeal disease, ascites, 
pleural/pericardial effusions, lymphangitis cutis/pulmonitis, inflammatory breast disease, and 
abdominal masses (not followed by CT or MRI), are considered as non-measurable. 
 

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66 
 
Note:  Cystic lesions that meet the criteria for radiographically defined simple cysts should not be 
considered as malignant lesions (neither measurable nor non-measurable) since they are, by 
definition, simple cysts. 
 
‘Cystic lesions’ thought to represent cystic metastases can be considered as measurable lesions, if 
they meet the definition of measurability described above. However, if non-cystic lesions are 
present in the same patient, these are preferred for selection as target lesions. 
 
Target lesions.  All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in 
total, representative of all involved organs, should be identified as target lesions and recorded and 
measured at baseline.  Target lesions should be selected on the basis of their size (lesions with the 
longest diameter), be representative of all involved organs, but in addition should be those that 
lend themselves to reproducible repeated measurements.  It may be the case that, on occasion, the 
largest lesion does not lend itself to reproducible measurement in which circumstance the next 
largest lesion which can be measured reproducibly should be selected.  A sum of the diameters 
(longest for non-nodal lesions, short axis for nodal lesions) for all target lesions will be calculated 
and reported as the baseline sum diameters.  If lymph nodes are to be included in the sum, then 
only the short axis is added into the sum.  The baseline sum diameters will be used as reference to 
further characterize any objective tumor regression in the measurable dimension of the disease. 
 
Non-target lesions.  All other lesions (or sites of disease) including any measurable lesions over 
and above the 5 target lesions should be identified as non-target lesions and should also be 
recorded at baseline.  Measurements of these lesions are not required, but the presence, absence, 
or in rare cases unequivocal progression of each should be noted throughout follow-up.  
 
11.1.3 Methods for Evaluation of Measurable Disease 
 
All measurements should be taken and recorded 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 4 weeks before the beginning of the treatment. 
 
The same method of assessment and the same technique should be used to characterize each 
identified and reported lesion at baseline and 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. 
 
Clinical lesions will only be considered measurable when they are superficial (e.g., skin nodules 
and palpable lymph nodes) and ≥10 mm (≥1 cm) diameter as assessed using calipers (e.g., skin 
nodules).  In the case of skin lesions, documentation by color photography, including a ruler to 
estimate the size of the lesion, is recommended.  
 
All subjects with skin disease and/or erythema using the SWAT and will have photographs taken 
using a digital camera. Special care should be taken to shield the patient’s identity 
 
Photos must be provided labeled with patient’s protocol number and initials and date.  

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67 
 
The body is divided into 12 regions with preassigned percentage total body surface area (%TBSA) 
based on methodology used to assess burns: head is 7% BSA, neck 2%, ant trunk 13%, post trunk 
13%, buttocks 5%, genitals 1%, upper arms 8%, forearms 6%, hands 5%, thighs 19%, lower leg 
14%, feet 7%.  
 
Biopsies at baselines and subsequent times can be performed to confirm a CR at the discretion of 
the investigator.  
 
Chest x-ray:  Lesions on chest x-ray are acceptable as measurable lesions when they are clearly 
defined and surrounded by aerated lung.  However, CT is preferable.  
 
Conventional CT and MRI:  This guideline has defined measurability of lesions on CT scan based 
on the assumption that CT slice thickness is 5 mm (0.5 cm) or less.  If CT scans have slice thickness 
greater than 5 mm (0.5 cm), the minimum size for a measurable lesion should be twice the slice 
thickness.  MRI is also acceptable in certain situations (e.g. for body scans).   
 
Use of MRI remains a complex issue.  MRI has excellent contrast, spatial, and temporal resolution; 
however, there 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 technical specifications of the scanning 
sequences used should be optimized for the evaluation of the type and site of disease.  Furthermore, 
as with CT, the modality used at follow-up should be the same as was used at baseline and the 
lesions should be measured/assessed on the same pulse sequence.  It is beyond the scope of the 
RECIST guidelines to prescribe specific MRI pulse sequence parameters 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. 
 
PET-CT: At present, the low dose or attenuation correction CT portion of a combined PET-CT is 
not always of optimal diagnostic CT quality for use with RECIST measurements.  However, if the 
site can document that the CT performed as part of a PET-CT is of identical diagnostic quality to 
a diagnostic CT (with IV and oral contrast), then the CT portion of the PET-CT can be used for 
RECIST measurements and can be used interchangeably with conventional CT in accurately 
measuring cancer lesions over time.  Note, however, that the PET portion of the CT introduces 
additional data which may bias an investigator if it is not routinely or serially performed.   
 
Ultrasound is not useful in assessment of lesion size and should not be used as a method of 
measurement.  Ultrasound examinations cannot be reproduced in their entirety for independent 
review at a later date and, because they are operator dependent, it cannot be guaranteed that the 
same technique and measurements will be taken from one assessment to the next.  If new lesions 
are identified by ultrasound in the course of the study, confirmation by CT or MRI is advised.  If 
there is concern about radiation exposure at CT, MRI may be used instead of CT in selected 
instances. 
 
Endoscopy, Laparoscopy: The utilization of these techniques for objective tumor evaluation is not 

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68 
 
advised.  However, such techniques may be useful to confirm complete pathological response 
when biopsies are obtained or to determine relapse in trials where recurrence following complete 
response (CR) or surgical resection is an endpoint. 
 
Tumor markers alone cannot be used to assess response.  If markers are initially above the upper 
normal limit, they must normalize for a patient to be considered in complete clinical response.   
 
Cytology, Histology: These techniques can be used to differentiate between partial responses (PR) 
and complete responses (CR) in rare cases (e.g., residual lesions in tumor types, such as lymphoma, 
where known residual benign tumors can remain). 
 
The cytological confirmation of the neoplastic origin of any effusion that appears or worsens 
during treatment when the measurable tumor has met criteria for response or stable disease is 
mandatory to differentiate between response or stable disease (an effusion may be a side effect of 
the treatment) and progressive disease. 
 
FDG-PET  While FDG-PET response assessments need additional study, it is sometimes 
reasonable to incorporate the use of FDG-PET scanning to complement CT scanning in assessment 
of progression (particularly possible 'new' disease).  New lesions on the basis of FDG-PET imaging 
can be identified according to the following algorithm:  
a. Negative FDG-PET at baseline, with a positive FDG-PET at follow-up is a sign of PD 
based on a new lesion. 
b. No FDG-PET at baseline and a positive FDG-PET at follow-up:  If the positive FDG-PET 
at follow-up corresponds to a new site of disease confirmed by CT, this is PD.  If the 
positive FDG-PET at follow-up is not confirmed as a new site of disease on CT, additional 
follow-up CT  scans are needed to determine if there is truly progression occurring at that 
site (if so, the date of PD will be the date of the initial abnormal FDG-PET scan).  If the 
positive FDG-PET at follow-up corresponds to a pre-existing site of disease on CT that is 
not progressing on the basis of the anatomic images, this is not PD. 
c. FDG-PET may be used to upgrade a response to a CR in a manner similar to a biopsy in 
cases where a residual radiographic abnormality is thought to represent fibrosis or scarring.  
The use of FDG-PET in this circumstance should be prospectively described in the protocol 
and supported by disease-specific medical literature for the indication.  However, it must 
be acknowledged that both approaches may lead to false positive CR due to limitations of 
FDG-PET and biopsy resolution/sensitivity. 
 
Note:  A ‘positive’ FDG-PET scan lesion means one which is FDG avid with an uptake greater 
than twice that of the surrounding tissue on the attenuation corrected image. 
 
 

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69 
 
11.1.4 Response Criteria 
 
Response Criteria for Adult T-Cell Leukemia-Lymphoma 
Response 
Definition 
Lymph 
Nodes 
Extranodal 
Masses 
Spleen, 
Liver 
Skin 
Peripheral 
Blood 
Bone 
Marrow 
Complete 
Remission1 
Disappearance 
of all disease 
Normal 
Normal 
Normal 
Normal 
Normal2 
Normal 
Uncertified 
Complete 
Remission1 
Stable residual 
mass in bulky 
lesion 
>75% 
decrease3 
>75% 
decrease3 
No 
increase 
>50% 
decrease 
> 50% 
decrease 
Normal 
Partial 
Remission1 
Regression of 
disease 
>50% 
decrease3 
>50% 
decrease3 
No 
increase 
>50% 
decrease 
>50% 
decrease 
Irrelevant 
Stable 
Disease1 
Failure to attain 
complete/partial 
remission and 
no progressive 
disease 
No change 
in size 
No change 
in size 
No 
change 
in size 
No 
chance 
in size 
No  
change 
No change 
Relapse 
Disease or 
Progressive 
Disease 
New or 
increased 
lesions 
New or 
>50% 
increase 4 
New or 
>50% 
increase 4 
New or 
>50% 
increase  
New or 
>50% 
increase  
New or 
>50% 
increase 5 
Re-
appearance 
Not 
Assessable 
 
1 Require each criterion to be present for a period of at least 4 weeks 
2 Provided that <5% of flower cells remained, complete remission was judged to have been attained if the absolute 
lymphocyte count, including flower cells, was <4x109/L 
3 Calculate by the sum of the products of the greatest diameters of measurable disease 
4 Defined by >50% increase from nadir in the sum of the products of measurable disease 
5 Defined by >50% increase from nadir in the count of flower cells and an absolute lymphocyte count, including 
flower cells, of >4x109/L 
  
 
11.1.4.1 
Evaluation of Best Overall Response 
 
The best overall response is the best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest measurements 
recorded since the treatment started).  The patient's best response assignment will depend on the 
achievement of both measurement and confirmation criteria. 
 
11.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
measurement criteria are met for CR or PR (whichever is first recorded) until the first date that 
recurrent or progressive disease is objectively documented (taking as reference for progressive 
disease the smallest measurements recorded since the treatment started). 
 
The duration of overall CR is measured from the time measurement criteria are first met for CR 
until the first date that progressive disease is objectively documented. 
 
 

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70 
 
Duration of stable disease:  Stable disease is measured from the start of the treatment until the 
criteria for progression are met, taking as reference the smallest measurements recorded since the 
treatment started, including the baseline measurements.  
 
11.1.6 Progression-Free Survival 
 
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first. 
 
11.1.7 Response Review 
 
Simultaneous review of the patients’ files and radiological images will be reviewed by an 
independent expert.  
 
11.2 
Other Response Parameters 
 
Skin involvement will be assessed by the severity-weighted assessment tool (SWAT) scores 
obtained for patients at each tumor assessment visit. This score represents the product of the 
percentage total surface area (%TBSA) involvement of each lesions type (patch, plaque, and tumor 
or ulceration), multipled by a weight factor: SWAT = (patch%TBSA x1) + (plaque %TBSA x 2) 
+ (tumor or ulcer %TBSA x 3). In addition, the standard measurements of TBSA involvement and 
physician global assessments are recorded for comparison. 
 
12. DATA REPORTING / REGULATORY REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Study Oversight 
 
This protocol is monitored at several levels, as described in this section. The Protocol Principal 
Investigator is responsible for monitoring the conduct and progress of the clinical trial, including 
the ongoing review of accrual, patient-specific clinical and laboratory data, and routine and 
serious adverse events; reporting of expedited adverse events; and accumulation of reported 
adverse events from other trials testing the same drug(s). The Protocol Principal Investigator and 
statistician have access to the data at all times through the CTMS web-based reporting portal.  
The Protocol Principal Investigator will have, at a minimum, quarterly conference calls with the 
Study Investigators to review accrual, progress, and pharmacovigilance. 
All Study Investigators at participating sites who register/enroll patients on a given protocol are 
responsible for timely submission of data via Medidata Rave and timely reporting of adverse 
events for that particular study. This includes timely review of data collected on the electronic 
CRFs submitted via Medidata Rave. 
All studies are also reviewed in accordance with the enrolling institution’s data safety monitoring 
plan. 

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71 
 
 
12.2 
Data Reporting 
 
Data collection for this study will be done exclusively through Medidata Rave.  Access to the trial 
in Rave is granted through the iMedidata application to all persons with the appropriate roles 
assigned in the Regulatory Support System (RSS).  To access Rave via iMedidata, the site user 
must have an active CTEP IAM account (https://eapps-ctep.nci.nih.gov/iam) and the appropriate 
Rave role (Rave CRA, Read-Only, or Site Investigator) on either the Corresponding Organization 
or Participating Organization roster at the enrolling site.   
 
Upon initial site registration approval for the study in RSS, all persons with Rave roles assigned 
on the appropriate roster will be sent a study invitation e-mail from iMedidata.  To accept the 
invitation, site users must log into the Select Login (https://login.imedidata.com/selectlogin) using 
their CTEP-IAM user name and password, and click on the “accept” link in the upper right-corner 
of the iMedidata page.  Please note, site users will not be able to access the study in Rave until all 
required Medidata and study specific trainings are completed.  Trainings will be in the form of 
electronic learnings (eLearnings), and can be accessed by clicking on the link in the upper right pane 
of the iMedidata screen.   
 
Users that have not previously activated their iMedidata/Rave account at the time of initial site 
registration approval for the study in RSS will also receive a separate invitation from iMedidata to 
activate their account. Account activation instructions are located on the CTSU website, Rave tab 
under the Rave resource materials (Medidata Account Activation and Study Invitation 
Acceptance).  Additional information on iMedidata/Rave is available on the CTSU members’ 
website under the Rave tab or by contacting the CTSU Help Desk at 1-888-823-5923 or by e-mail 
at ctsucontact@westat.com. 
 
12.2.1 Method 
 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  Data will be 
submitted to CTMS at least once every two weeks via Medidata Rave (or other modality if 
approved 
by 
CTEP). 
 
Information 
on 
CTMS 
reporting 
is 
available 
at:  
http://www.theradex.com/CTMS.  On-site audits will be conducted on an 18-36 month basis as 
part of routine cancer center site visits. More frequent audits may be conducted if warranted by 
accrual or due to concerns regarding data quality or timely submission.  For CTMS monitored 
studies, after users have activated their accounts, please contact the Theradex Help Desk at (609) 
799-7580 or by email at ctms@theradex.com for additional support with Rave and completion of 
CRFs. 
 
12.2.2 Responsibility for Data Submission 
 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all investigators at 
the ETCTN Sites understand the procedures for data submission for each ETCTN protocol and 
that protocol specified data are submitted accurately and in a timely manner to the CTMS via the 
electronic data capture system, Medidata Rave.   

NCI Protocol #: 9925 
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72 
 
 
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less than once 
every 2 weeks.  The timeliness of data submissions and timeliness in resolving data queries will 
be tracked by CTMS.  Metrics for timeliness will be followed and assessed on a quarterly basis.  
For the purpose of Institutional Performance Monitoring, data will be considered delinquent if it 
is greater than 4 weeks past due. 
 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing basis as data 
is received.  Queries will be issued by CTMS directly within Rave.  The queries will appear on the 
Task Summary Tab within Rave for the CRA at the ETCTN to resolve.  Monthly web-based 
reports are posted for review by the Drug Monitors in the IDB, CTEP.  Onsite audits will be 
conducted by the CTMS to ensure compliance with regulatory requirements, GCP, and NCI 
policies and procedures with the overarching goal of ensuring the integrity of data generated from 
NCI-sponsored clinical trials, as described in the ETCTN Program Guidelines, which may be 
found on the CTEP website: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm 
and CTSU websites. 
 
An End of Study CRF is to be completed by the PI, and is to include the recommended phase 2 
dose (RP2D), and a description of any dose-limiting toxicities (DLTs).  CTMS will utilize a core 
set of eCRFs that are Cancer Data Standards Registry and Repository (caDSR) compliant 
(http://cbiit.nci.nih.gov/ncip/biomedical-informatics-resources/interoperability-and-
semantics/metadata-and-models).  Customized eCRFs will be included when appropriate to meet 
unique study requirements.  The PI is encouraged to review the eCRFs, working closely with 
CTMS to ensure prospectively that all required items are appropriately captured in the eCRFs prior 
to study activation.  CTMS will prepare the eCRFs with built-in edit checks to the extent possible 
to promote data integrity. 
 
Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm). 
 
12.3 
Collaborative Agreements Language 
 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the NCI under 
a Collaborative Agreement (CRADA, CTA, CSA) between the Pharmaceutical Company(ies) 
(hereinafter referred to as “Collaborator(s)”) and the NCI Division of Cancer Treatment and 
Diagnosis.  Therefore, the following obligations/guidelines, in addition to the provisions in the 
“Intellectual Property Option to Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained within the 
terms of award, apply to the use of the Agent(s) in this study: 
 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor can Agent(s) 
be transferred or licensed to any party not participating in the clinical study.  Collaborator(s) 
data for Agent(s) are confidential and proprietary to Collaborator(s) and shall be maintained 

NCI Protocol #: 9925 
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73 
 
as such by the investigators.  The protocol documents for studies utilizing Agents contain 
confidential information and should not be shared or distributed without the permission of the 
NCI.  If a copy of this protocol is requested by a patient or patient’s family member 
participating on the study, the individual should sign a confidentiality agreement.  A suitable 
model agreement can be downloaded from: http://ctep.cancer.gov. 
 
2. For a clinical protocol where there is an investigational Agent used in combination with 
(an)other Agent(s), each the subject of different Collaborative Agreements, the access to and 
use of data by each Collaborator shall be as follows (data pertaining to such combination use 
shall hereinafter be referred to as "Multi-Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator to 
develop, obtain regulatory approval or commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must agree 
in writing prior to the commencement of the trials that it will use the Multi-Party Data 
solely for development, regulatory approval, and commercialization of its own Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement will 
be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator 
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and disclosed 
consistent with all applicable federal statutes and regulations for the protection of human 
subjects, including, if applicable, the Standards for Privacy of Individually Identifiable Health 
Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and 
comment prior to submission for publication.  Collaborator(s) will have 30 days from the date 

NCI Protocol #: 9925 
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74 
 
of receipt for review.  Collaborator shall have the right to request that publication be delayed 
for up to an additional 30 days in order to ensure that Collaborator’s confidential and 
proprietary data, in addition to Collaborator(s)’s intellectual property rights, are protected.  
Copies of abstracts must be provided to CTEP for forwarding to Collaborator(s) for courtesy 
review as soon as possible and preferably at least three (3) days prior to submission, but in any 
case, prior to presentation at the meeting or publication in the proceedings.  Press releases and 
other media presentations must also be forwarded to CTEP prior to release.  Copies of any 
manuscript, abstract and/or press release/ media presentation should be sent to: 
 
Email: ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No publication, 
manuscript or other form of public disclosure shall contain any of Collaborator’s confidential/ 
proprietary information. 
 
 
13. STATISTICAL CONSIDERATIONS 
 
13.1 
Study Objectives and Endpoints 
 
The primary objective of this study is to determine safety, tolerability, and efficacy of nivolumab 
for patients with HTLV-associated ATLL. The safety and tolerability will be measured by the 
frequency of adverse events (AEs) and the number of patients who discontinue therapy due to 
intolerable toxicity, while the efficacy will be measured as overall response (Complete 
Response/CR+Partial Response/PR) rate. 
 
The secondary objectives include 
• To determine effects of nivolumab on HTLV-1 proviral DNA and RNA loads; 
• To determine the effects of nivolumab on anti-HTLV-1 and anti-ATLL immune responses; 
• To determine effects of nivolumab on HTLV-1 integration site clonality. 
 
13.2 
Study Design 
 
At least 20 evaluable patients will be enrolled for this study. Evaluable patients will be those 
patients who received study medication. The sample size of 20 patients is based on Simon’s 
Optimal 2-stage design, with the assumption that an overall response rate of 40% is the minimum 
response rate that would be considered for further analysis of this approach, compared to a rate of 
10% under null hypothesis. Thus, 20 subjects are required to with a one-side type 1 error rate of 
5% and a power of 90%. If 1 or fewer responses are seen among the first 9 subjects enrolled, the 
trial is stopped early for futility. In contrast, if 2 or more responders are observed out of the 9 
patients in the first stage, additional 11 patients will be enrolled in the 2nd stage. In a multicenter 
study such as this, however, it is difficult for a trial to reach the planned sample exactly.  The 
investigators would not turn away patients who have already been approached for participation 
just because the number of patients needed has been met.  Therefore, we adopted a flexible Phase 
II design (Chen and Ng 1998) to allow the actual number at final stage to deviate slightly from 

NCI Protocol #: 9925 
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75 
 
what is planned. Due to the expected relatively low accrual rate, we expect that the interim analysis 
could be performed at the designed sample size. Only the decision boundaries at the 2nd-stage are 
determined following Chen and Ng’s flexible design and programed by the study statistician [57].  
That is, if 5 or more responders are observed out of 20-23 patients, or 6 or more responders are 
observed out of 24-25 patients, we would conclude that preliminary evidence for efficacy exists 
and that further investigation of the treatment is warranted.   
 
The interim analysis will be based upon independent review of response, with a minimum time 
frame of 2 months for the interim analysis. Accrual will not be halted during the interim analysis. 
 
13.3 
Data Analysis 
 
Data analysis of the study will be descriptive in nature. Demographic and clinical characteristics 
of the sample, toxicity by grade, as well as tumor response, duration of response, and length of 
follow-up will be summarized using descriptive statistics. Binomial proportions and their 90% 
confidence intervals will be used to estimate the response rates of therapy. Binomial proportions 
and their 90% confidence intervals will also be calculated for the efficacy based on immune 
response criteria (Appendix D). The Kaplan-Meier method will be used to evaluate the response 
duration. Analysis of variance methods will be used to evaluate the effects of treatment and time 
on the viral load measurements, as well as measurements of viral transcripts. The incidence of 
toxicities will be estimated using the binomial proportion and its 90% confidence interval. A 
proportional hazards analysis with viral load measures as time dependent covariates will be used 
to evaluate the effects of these measures on duration of response. Detailed analysis of correlative 
studies and biomarkers are listed in Section 9.  
 
The safety and tolerability will be monitored every 2 weeks. All patients who receive treatment 
with nivolumab will be eligible for safety and tolerability analysis. A Bayesian sequential 
monitoring method [58] will be used for safety analysis and the stopping rule is defined as 
Pr(θ>0.10 |data)>0.90, where θ denotes the proportion of patients who discontinue therapy due to 
intolerable toxicity. That is, enrollment will be stopped early whenever, given the accumulated 
observed data, there is >90% probability that the discontinuation of therapy is greater than 10%. 
Specifically, enrollment will be stopped early if 3 patients discontinue therapy in the first 12 
patients, or 4 patients discontinue therapy in the first 19 patients, or 5 patients discontinue therapy 
before the last patient enrolled. These boundaries were obtained using the free-download software 
Multc99 (version 2.1) from M.D. Anderson Cancer Center. We assume that the parameter θ 
follows a prior distribution of beta (α, β), with α and β representing the number of patients 
discontinuing and continuing therapy respectively. 
 
PLANNED ENROLLMENT REPORT 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
 
Female 
Male 
Female 
Male 
 
American Indian/ Alaska 
Native 
0 
0 
0 
0 
0 

NCI Protocol #: 9925 
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76 
 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
 
Female 
Male 
Female 
Male 
 
Asian 
1 
1 
0 
0 
2 
Native Hawaiian or Other 
Pacific Islander 
1 
1 
0 
0 
2 
Black or African 
American 
6 
6 
0 
0 
12 
White 
1 
1 
1 
1 
4 
More Than One Race 
0 
0 
0 
0   
0 
Total 
9 
9 
1 
1 
20 
PHS 398 / PHS 2590 (Rev. 08/12 Approved Through 8/31/2015)  
OMB No. 0925-0001/0002 
 
13.4 
Reporting and Exclusions 
 
13.4.1 Evaluation of Toxicity 
 
All patients will be evaluable for toxicity from the time of their first treatment with nivolumab. 
 
 
13.4.2 Evaluation of Response 
 
All patients included in the study must be assessed for response to treatment, even if there are 
major protocol treatment deviations or if they are ineligible.  Each patient will be assigned one of 
the following categories:  1) complete response, 2) partial response, 3) stable disease, 4) 
progressive disease, 5) early death from malignant disease, 6) early death from toxicity, 7) early 
death because of other cause, or 8) unknown (not assessable, insufficient data).  [Note:  By 
arbitrary convention, category 8 usually designates the “unknown” status of any type of data in a 
clinical database.] 
 
All of the patients who met the eligibility criteria (with the possible exception of those who 
received no study medication) should be included in the main analysis of the response rate.  
Patients in response categories 4-9 should be considered to have a treatment failure (disease 
progression).  Thus, an incorrect treatment schedule or drug administration does not result in 
exclusion from the analysis of the response rate.  Precise definitions for categories 4-9 will be 
protocol specific.  
 
All conclusions should be based on all eligible patients.  Subgroup analyses may then be performed 
on the basis of a subset of patients, excluding those for whom major protocol deviations have been 
identified (e.g., early death due to other reasons, early discontinuation of treatment, major protocol 
violations, etc.).  However, these subgroup analyses may not serve as the basis for drawing 
conclusions concerning treatment efficacy, and the reasons for excluding patients from the analysis 
should be clearly reported.  The 95% confidence intervals should also be provided.  
 
 

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77 
 
14. REFERENCES 
 
 
1. 
Takatsuki, K., Adult T-cell leukemia. Internal Medicine, 1995. 34: p. 947-952. 
2. 
Gessain, A., R. Mahieux, and G. deThe, Genetic variability and moleuclar epidemiology 
of human and simian T cell leukemia/lymphoma virus tyep I. Journal of AIDS, 1996. 
13(Supplement 1): p. S132-145. 
3. 
Manns, A., M. Hisada, and L. LaGrenade, Human T-lymphotropic virus type I infection. 
Lancet 1999. 353: p. 1951-1958. 
4. 
Franchini, G., Molecular mechanisms of human T-cell leukemia/lymphomtropic virus type 
I infection. Blood, 1995. 86: p. 3619-3639. 
5. 
Hollsberg, P., Mechanisms of T-cell activation by human T-cell lymphotropic virus type 1. 
Microbial Molecular Biology Reviews, 1999. 63: p. 308-333. 
6. 
Mesnard, J.M. and C. Devaux, Multiple control levels of cell proliferation by human T-cell 
leukemia virus type 1 Tax protein. Virology, 1999. 257: p. 277-284. 
7. 
Matsuoka, M. and J.-I. Yasunaga, Human T-cell leukemia virus type 1: replication, 
proliferation, and propagation by Tax and HTLV -1 bZIP factor. Current Opinion in 
Virology, 2013. 3: p. 684-691. 
8. 
Tattermnuysch, S. and C.R.M. Bangham, HTLV-1 infection: what determines the risk of 
inflammatory disease? Trends in Microbiology, 2012. 20: p. 494-500. 
9. 
Shimoyama, M., Diagnostic criteria and classification of clinical subtypes of adult T-cell 
leukemia-lymphoma: a report from the Lymphoma Study Group. British Journal of 
Hematology, 1991. 79: p. 426-437. 
10. 
Nagai, M., et al., Analysis of HTLV-I proviral load in 202 HAM/TSP patients and 243 
asymptomatic HTLV-I carriers: high proviral load strongly predisposes to HAM/TSP. J 
Neurovirology, 1998. 4: p. 586-593. 
11. 
Ohshima, K., et al., Detection of human T-lymphotropic virus type I-DNA and mRNA in 
the lymph nodes; using polymerase chain reaction, in situ hybridization (PCR/ISH) and 
reverse transxription (RT-PCR/ISH). International Journal of Cnaceer, 1996. 66: p. 18-23. 
12. 
Yoshida, M., et al., Monoclonal integration of human T-cell leukemia provirus in all 
primary tumors of adulty T-cell leukemia suggests causative role of human T-cell leukemia 
virus in the disease. Proceedings of the National Academy of Sciences, U.S.A. , 1984. 81: 
p. 2534-2538. 
13. 
Wattel, E., et al., Clonal expansion of infected cells: a way of life for HTLV-1. Journal of 
AIDS, 1996. 13(Supplement 1): p. S92-99. 
14. 
Cook, L.B., et al., The role of HTLV-1 clonality, proviral structure, and genomic 
integration site in adult T-cell leukemia/lymphoma. Blood, 2014. 123: p. 3925-3931. 
15. 
Kataoka, K., et al. Landscape of genetic alterations in adult T-cell leukemia/lymphoma. in 
American Society for Hematology. 2014. San Francisco. 
16. 
Melamed, A., et al., Genome-wide determinants of proviral targeting, clonal abundance 
and expression in natural HTLV-1 infection. PLOS Pathogens, 2013. 9: p. e1003271. 
17. 
Bazarbachi, A., et al., Arsenic trioxide and interferon-alpha synergize to induce cell cycle 
arrest and apoptosis in human T-cell lymphotropic virus type I-transformed cells. Blood, 
1999. 93: p. 278-283. 
18. 
Bunn, P.A., et al., Clinical course of retrovirus-associated adult T-cell lymphoma in the 

NCI Protocol #: 9925 
Version Date:  October 27, 2017 
 
 
78 
 
United States. New England Journal of Medicine, 1983. 309: p. 257-264. 
19. 
Tsukasaki, K., et al., Definition, prognostic factors, treatment, and reponse criteria of adult 
T-cell leukemia-lymphoma: a proposal from an international consensus meeting. Journal 
of Clinical Oncology, 2009. 27: p. 453-459. 
20. 
Lofters, W., et al., 2'Deoxycoformycin therapy in adult T-cell leukemia/lymphoma. Cancer, 
1987. 60: p. 2605-2608. 
21. 
Hermine, O., et al., Treatment of adult T-cell leukemia-lymphoma with zidovudine and 
interferon alfa. N Engl J Med, 1995. 332: p. 1749-1751. 
22. 
Gill, P.S., et al., Treatment of adult T-cell leukemia-lymphoma with a combination of 
interferon alfa and zidovudine. N Engl J Med, 1995. 332: p. 1744-1748. 
23. 
Dega, H., et al., Unsuccessful association of zidovuine and interferon alpha for acult adult 
T-cell leukemia lymphoma. Dermatology, 1999. 198: p. 103-105. 
24. 
Hodson, A., et al., Use of zidovudine and interferon alfa with chemotherapy improves 
survival in both acute and lymphoma subtypes of adult T-cell leukemia/lymphoma. Journal 
of Clinical Oncology, 2011. 29: p. 4696-4701. 
25. 
Waldmann, T.A., et al., Therapy of patients with human T-cell lymphotropic virus I-
induced adult T-cell leukmeia with anti-Tac, a monoclonal antibody to the receptor for 
interleukin-2. Blood, 1988. 72: p. 1805-1816. 
26. 
Ishida, T., et al., Defucosylated anti-CCR4 monoclonal antibody (KW-0761) for relapsed 
adult T-cell leukemia-lymphoma: a multicenter phase II study. Journal of Clinical 
Oncology, 2012. 30: p. 837-842. 
27. 
Tatsuro, J., et al. Randomized phase II study of mogamulizumab (KW-0761) plus VCAP-
AMP-VECP (mLSG15) versus mLSG15 alone for newly diagnosed aggressive adult T-cell 
leukemia-lymphoma (ATL). in ASCO. 2013. Chicago. 
28. 
Taguchi, H., et al., An intensive chemotherapy of adult T-cell leukemia/lymphoma: CHOP 
followed by etoposide, vindesine, ranimustine, and mitoxantrone with granulocyte colony-
stimulating factor support. J AIDS, 1996. 12: p. 182-186. 
29. 
Ratner, L., et al., Human T cell leukemia virus reactivation with progression of adult T-cell 
leukemia-lymphoma. AIDS Malignancy Consortium PLoS One, 2009. 4: p. e4420 PMCID: 
PMC2636875. 
30. 
Taylor, G.P., et al., Effect of lamivudine on human T-cell leukemia virus type 1 (HTLV-1) 
DNA copy number, T cell phenotype, and anti-Tax cytotoxic T-cell frequency in patients 
with HTLV-1-associated myelopathy. J Virol, 1999. 73: p. 10289-10295. 
31. 
Kchour, G., et al., Zidovudine and interferon-alpha treatment induces a high response rate 
and reduces HTLV-1 proviral load and VEGF plasma levels in patients with adult T-cell 
leukemia in North East Iran. Leukemia Lymphoma, 2007. 48: p. 330-336. 
32. 
Seegulam, M.E. and L. Ratner, Integrase inhibitors effective against human T-cell 
leukemia virus type 1. Antimicrobial Agents Chemotherapy, 2011. 55: p. 2011-2017 
PMCID: PMC3088187. 
33. 
Cook, L.B., et al., HTLV-1: persistence and pathogenesis. Virology, 2013. 435: p. 131-
140. 
34. 
Jo, T., K. Horio, and K. Shigematsu. Cytotoxic T-lymphocyte analysis of aggressive types 
of adult T-cell leukemia/lymphoma patients with complete remission after intensive 
combination chemotherapy in American Society for Hematology. 2014. San Francisco, CA. 
35. 
Swann, J.B. and M.J. Smyth, Immune surveillance of tumors. Journal of Clinical 

NCI Protocol #: 9925 
Version Date:  October 27, 2017 
 
 
79 
 
Investigation, 2007. 117: p. 1137-1146. 
36. 
Drake, C.G., E. Jaffee, and D.M. Pardoll, Mechanisms of immune evasion by tumors. 
Advances in Immunology, 2006. 90: p. 51-81. 
37. 
Taube, J.M., et al., Association of PD-1, PD-1 ligands, and other features of the tumor 
immune microenviornment with response to anti-PD-1 therapy. Clinical Cancer Research, 
2014. 20: p. 5064-5074. 
38. 
Ohigashi, Y., et al., Clinical significance of programmed death-1 ligand-1 and 
programmed death-1 ligand-2 expression in human esophageal cancer. Clinical Cancer 
Research, 2005. 11: p. 2947-2953. 
39. 
Wu, Y.Y., et al., Expression of CD25(high) regulatory T cells and PD-1 in gastric 
infiltrating CD4(+) T lymphocytes in patients with Helicobacter pylori infection. Clincial 
Vaccine Immunology, 2011. 18(7):1198-201): p. 1198-1201. 
40. 
Dong, H. and L. Chen, B7-H1 pathway and its role in the evasion of tumor immunity. 
Journal of Molecular Medicine, 2003. 81: p. 281-287. 
41. 
Nomi, T., et al., Clinical significance and therapeutic potential of the programmed death-
1 ligand/programmed death-1 pathway in human pancreatic cancer. Clinical Cancer 
Research, 2007. 13: p. 2151-2157. 
42. 
Zitvogel, L. and G. Kroemer, Targeting PD-1/PD-L1 interactions for cancer 
immunotherapy. Oncoimmunology, 2012. 1: p. 1223-1225. 
43. 
Chibueze, C.E., M. Yoshimitsu, and N. Arima, CD160 expression defines a uniquely 
exhausted subset of T lymphocytes in HTLV-1 infection. Biochemical and Biophysical 
Research Communications, 2014. 453: p. 379-384. 
44. 
Sznol, M. and L. Chen, Antagonist antibodies to PD-1 and B7-H1 (PD-L1) in the treatment 
of advanced human cancer--response. Clinical Cancer Research, 2013. 19: p. 5542. 
45. 
Brahmer, R. and D.M. Pardoll, Immune checkpoint inhibitors: making immunotherapy a 
reality for the treatment of lung cancer. Cancer Immunology Research, 2013. 1: p. 85-91. 
46. 
Ramalingam, S.S., et al., Phase II study of nivolumab (anti-PD-1, BMS-936558, ONO-
4538) in patients with advanced, refractory squamous non-small cell lung cancer: 
metastatic non-small cell lung cancer. International Journal of Radiation Oncology 
Biology Physics, 2014. 90: p. 1266-1270. 
47. 
Ansell, S.M., et al., PD-1 blockade with nivolumab in relapsed or refractory Hodgkin's 
lymphoma. New England Journal of Medicine, 2015. 372: p. 311-319. 
48. 
Lesokhin, A.M., et al. Preliminary results of a phase I study of nivolumab (MS-936558) in 
patients with relapsed or refractory lymphoid malignancies. in American Society for 
Hematology. 2014. San Francisco. 
49. 
Armand, P., et al., Disabling immune tolerance by programmed death-1 blockade with 
pidilizumab after autologous hematopoietic stem-cell trnasplantation for diffuse large B-
cell lymphoma: results of an international phase II trial. Journal of Clinical Oncology, 
2013. 31: p. 4199-4206. 
50. 
Westin, J.R., et al., Safety and activity of PD-1 blockade by pidilzumab in combination with 
rituximab in patients with relapsed follicular lymphoma: a single group, open-label, phase 
2 trial. Lancet Oncology, 2014. 15: p. 69-77. 
51. 
Topalian, S.L., et al., Safety, activity, and immune correlates of anti-PD-1 antibody in 
cancer. New England Journal of Medicine, 2012. 366: p. 2443-2454. 
52. 
Schumacher, T.N., C. Kesmir, and M.M. vanBuuren, Biomarkers in cancer 

NCI Protocol #: 9925 
Version Date:  October 27, 2017 
 
 
80 
 
immunotherapy. Cancer Cell, 2015. 27: p. 12-14. 
53. 
Brunetto, G.S., et al., Digital droplet PCR (ddPCR) for the precise quantification of human 
T-lymphotropic virus 1 proviral loads in peripheral blood and cerebrospinal fluid of 
HAM/TSP patients and identification of viral mutations. Journal of Neurovirology, 2014. 
20: p. 341-351. 
54. 
Ratner, L., et al., Effect of treatment of Strongyloides infection on HTLV-1 expression in a patient 
with  adult T-cell leukemia. American Journal of Hematology, 2007. 82: p. 929-931. 
PMCID:PMC2652703. 
55. 
Ratner, L., et al., Phase I / II Trial of Dose Adjusted EPOCH Chemotherapy with 
Bortezomib Combined with Integrase Inhibitor Therapy for HTLV-1 Associated T-Cell 
Leukemia Lymphoma in 17th International HTLV Meeting. . 2015: Martinique. 
56. 
Gillet, N.A., et al., The host genomic environment of the provirus determines the 
abundance of HTLV-1-infected T-cell clones. Blood, 2011. 117: p. 3113-3122. 
57. 
Chen TT, and  Ng TH. Optimal flexible designs in phase II clinical trials. Statistics in 
Medicine. 1998;17(20):2301-12. 
58.       Thall PF, Simon RM, Estey EH. Bayesian sequential monitoring designs for single-arm  
            clinical trials with multiple outcomes. Statistics in Medicine. 1995;14:357-79. 
 
 
 
 
 

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APPENDIX A 
PERFORMANCE STATUS CRITERIA 
 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity.  Fully active, able 
to 
carry 
on 
all 
pre-disease 
performance without restriction. 
100 
Normal, no complaints, no evidence 
of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease. 
1 
Symptoms, 
but 
ambulatory.  
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary 
nature 
(e.g., 
light 
housework, office work). 
80 
Normal activity with effort; some 
signs or symptoms of disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active work. 
2 
In 
bed 
<50% 
of 
the 
time.  
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities.  Up and about more 
than 50% of waking hours. 
60 
Requires occasional assistance, but is 
able to care for most of his/her needs. 
50 
Requires considerable assistance and 
frequent medical care. 
3 
In bed >50% of the time.  Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care and 
assistance. 
30 
Severely disabled, hospitalization 
indicated.  Death not imminent. 
4 
100% bedridden.  Completely 
disabled.  Cannot carry on any self-
care.  Totally confined to bed or 
chair. 
20 
Very sick, hospitalization indicated. 
Death not imminent. 
10 
Moribund, 
fatal 
processes 
progressing rapidly. 
5 
Dead. 
0 
Dead. 
 
 
 

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APPENDIX B 
LIST OF PROHIBITED MEDICATIONS  
 
The following medications may not be taken while participating on this study through 6 weeks 
after the last dose of protocol treatment: 
 
• Any non-study anti-cancer agent (investigational or non-investigational) 
• Any other investigational agents 
• Any other CTLA-4 inhibitors or agonists 
• CD137 agonists, PD-1 inhibitors 
• Immunosuppressive agents, unless indicated to manage study therapy induced irAEs 
• Chronic systemic corticosteroids, unless indicated to manage study therapy induced irAEs 
or chronic GVHD at a stable dose prior to study entry 
• Any non-oncology vaccine therapies used for the prevention of infectious diseases (for up 
to 30 days prior to or after any dose of study drug, however it is suggested that routine 
vaccinations, including seasonal influenza, be given at least 2 weeks prior to study 
treatment) 
 
 
 

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APPENDIX C 
IMAGING METHODOLOGIES   
 
Contrast enhanced CT or enhanced MRI are the preferred imaging modalities to be used. Chest x-
rays performed during the screening phase (and repeated at anytime during the study if clinically 
indicated) may be used as supportive data, as an accessory to the CT chest scans. 
 
The same imaging techniques used at screening MUST be used at all subsequent time points to 
permit accurate, comparable measurement of lesions. All imaging data are to be collected on film 
or in digital format. 
 
CT/MRI of the Chest/Abdomen/Pelvis 
 
CT/MRI imaging of the chest, abdomen and pelvis is required at Screening and at each tumor 
assessment visit as indicated in Table 1, Table 2, and Table 3, regardless of the location of known 
metastases. In addition, CT/MRI scans must be obtained of anatomic regions not covered by the 
chest, abdomen and pelvic scans, in subjects where there is clinical suspicion of deep soft tissue 
metastases (eg, lesions in the thigh). Such additional CT/MRIs will be required at Screening only 
when deep soft tissue disease is known/suspected and must be consistently repeated at all 
subsequent tumor assessment visits. 
 
 
Non-radiographic Assessments/Digital Photography 
 
These should be made at the sites and recorded in the source documents. Visible skin lesions 
should be measured clinically and documented digitally using standardized photographic images, 
including a ruler for scale as part of the image. 
 
Image Acquisition Guidelines 
 
Similar methods of tumor assessment and similar techniques must be used to characterize each 
identified and reported lesion at Screening and during the Induction and Maintenance Phases. All 
measurable and non-measurable lesions should be assessed at Screening and at the defined tumor 
assessment time points (see Table 1, Table 2, and Table 3). Additional assessments may be 
performed, as clinically indicated, if there is a suspicion of progression or for confirmation of 
response. The Investigator will base response to treatment on the irRC (see Appendix D). Imaging-
based evaluation is preferred to physical examination. Helical (spiral) CT scans of chest, abdomen 
and pelvis are preferred. If not available, conventional (non-helical, non-spiral CT) should be used. 
 
IV contrast should be used for all CT scans. If i.v. contrast is contraindicated, CT may be 
performed without contrast. Alternatively, MRI can be used to assess lesions in the subject. 
Subjects who develop contrast allergy after study enrollment may be followed by MRI for 
subsequent tumor measurements. Sections should be contiguous, similarly sized and consistent 
from visit-to-visit. Section thickness must be based on institutional standards (eg, from 5 to 8 mm; 
10 mm cuts are not recommended). Chest x-ray, ultrasound, and PET scans are not acceptable 
methods to measure disease for the purposes of this study. 
 

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APPENDIX D 
IMMUNE-RELATED RESPONSE CRITERIA  
 
Immune-related Response Criteria (irRC) are derived from modified World Health Organization 
(mWHO) conventions. Assessments of lymph nodes are derived from current RECIST 
guidelines.1 
 
1.1.1.1.1 Definitions of Measurable/non-Measurable Lesions 
All measurable and non-measurable lesions should be assessed at Screening and at the defined 
tumor assessment time points (see Table 1). Additional assessments may be performed, as 
clinically indicated for suspicion of progression. The Investigator will base response to treatment 
using the irRC. 
 
1.1.1.1.2 Measurable Lesions 
Measurable lesions are lesions that can be accurately measured in 2 perpendicular diameters, 
with at least 1 diameter ≥ 20 mm and the other dimension ≥ 10 mm (10 mm x 10 mm for 
spiral CT with cuts of 5 mm). The area will be defined as the product of the largest diameter with 
its perpendicular. 
 
Lymph nodes may also be considered measurable. To be considered pathologically enlarged and 
measurable, a lymph node must be at least 15 mm in short axis when assessed by CT scan (CT 
scan slice thickness recommended to be no greater than 5 mm). 
 
1.1.1.1.3 Non-Measurable Lesions 
Non-measurable (evaluable) lesions are all other lesions, including unidimensional measurable 
disease and small lesions (lesions without at least 1 diameter ≥ 20 mm, or pathological lymph 
nodes with short axis ≤ 15 mm), and any of the following: lesions occurring in a previously 
irradiated area (unless they are documented as new lesions since the completion of radiation 
therapy), bone lesions, leptomeningeal disease, ascites, pleural or pericardial effusion, 
lymphangitis cutis/pulmonis, abdominal masses that are not pathologically/cytologically 
confirmed and followed by imaging techniques and cystic lesions. Lymph nodes that have a 
short axis < 10 mm are considered non-pathological and should not be recorded or followed. 
 
1.1.1.1.4 Definitions of Index/non-Index Lesions 
Measurable lesions, up to a maximum of 5 lesions per organ and ten lesions in total, must be 
identified as index lesions to be measured at Screening. The index lesions should be 
representative of all involved organs. In addition, index lesions must be selected based on their 
size (eg, lesions with the longest diameters), their suitability for accurate repeat assessment by 
imaging techniques, and how representative they are of the subject’s tumor burden. At 
Screening, a Sum of the Product Diameters (SPD) for all index lesions will be calculated and 
considered the baseline SPD. The baseline sum will be used as the reference point to determine 
                                                 
1 Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. New response 
evaluation criteria in solid tumors: Revised RECIST guideline (version 1.1). Eur J Can. 2009;45: 
228 247. 

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the objective tumor response of the index lesions at tumor assessment. 
 
1.1.1.1.5 Non Index Lesions 
Measurable lesions, other than index lesions, and all sites of non-measurable disease, will be 
identified as non-index lesions. Non-index lesions will be evaluated at the same assessment time 
points as the index lesions. In subsequent assessments, changes in non-index lesions will 
contribute only in the assessment of complete response. 
 
1.1.1.1.6 Calculation of Sum of Product of Diameters (SPD) 
Sum of Product of Diameters is an estimate of tumor burden. The 2 greatest perpendicular 
diameters are used to estimate the size of each tumor lesion. The SPD is calculated as the sum of 
the product of the diameters for index tumor lesions. Several variations of the SPD are identified 
for the purpose of classification of tumor responses. 
 
SPD at Baseline: The sum of the product of the diameters for all index lesions identified at 
baseline prior to treatment on Day 1. 
 
SPD at tumor assessment: For every on-study tumor assessment collected per protocol or as 
clinically indicated, the SPD at tumor assessment will be calculated using tumor imaging scans. 
All index lesions and all new measurable lesions that have emerged after baseline will contribute 
to the SPD at tumor assessment (irSPD). 
 
SPD at NADIR: For tumors that are assessed more than 1 time after baseline, the lowest value 
of the SPD (SPD Baseline or SPD at tumor assessment) is used to classify subsequent tumor 
assessments for each subject. The SPD at tumor assessment using the irRC for progressive 
disease incorporates the contribution of new measurable lesions. Each net percentage change in 
tumor burden per assessment using irRC accounts for the size and growth kinetics of both old 
and new lesions as they appear. In this study the irRC as defined by the Investigator will serve as 
the basis of key endpoints for efficacy analyses and guide clinical care. 
 
1.1.1.1.7 Definition of Index Lesion Response 
Immune-related Complete Response (irCR), which is defined as complete disappearance of all 
index lesions. Lymph nodes that shrink to < 10 mm short axis are considered normal. 
 
Immune-related Partial Response (irPR), which is defined as a decrease, relative to baseline, 
of 50% or greater in the sum of the products of the 2 largest perpendicular diameters of all index 
and all new measurable lesions (ie, Percentage Change in Tumor Burden), in the absence of 
irCR. 
 
Note: the appearance of new measurable lesions is factored into the overall tumor burden, but 
does not automatically qualify as progressive disease until the SPD increases by ≥ 25% when 
compared to SPD at nadir 
 
Immune-related Stable Disease (irSD), which is defined as not meeting the criteria for irCR or 

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irPR, in the absence of immune-related progressive disease (irPD) 
 
Immune-related Progressive Disease (irPD), which is defined as at least a 25% increase in 
Tumor Burden (ie, taking sum of the products of all index lesions and any new measurable 
lesions) when compared to SPD at nadir. 
 
1.1.1.1.8 Definition of Non-Index Lesion Response 
Immune-related Complete Response (irCR), which is defined as complete disappearance of all 
non-index lesions. Lymph nodes that shrink to < 10 mm short axis are considered normal. 
 
Immune-related Partial Response (irPR), non-index lesion(s) are not considered in the 
definition of PR, this term does not apply. 
 
Immune-related Stable Disease (irSD), non-index lesion(s) are not considered in the definition 
of SD, this term does not apply. 
 
Immune-related Progressive Disease (irPD), increases in number or size of non-index lesion(s) 
does not constitute progressive disease unless/until Tumor Burden increases by 25% (ie, the SPD 
at nadir of index lesions and any new measurable lesions increases by the required amount). 
 
1.1.1.1.9 Impact of New Lesions on irRC 
New lesions alone do not qualify as progressive disease. However their contribution to total 
tumor burden is included in the SPD which in turn feeds into the irRC for tumor response. 
Therefore, new non-measurable lesions will not discontinue any subject from the study. 
 
1.1.1.1.10 Definition of Overall Response Using irRC Will Be Based on the Following Criteria: 
• Immune-related Complete Response (irCR): Complete disappearance of all tumor 
lesions (index and non-index), together with no new measurable or unmeasurable lesions, 
for at least 4 weeks from the date of documentation of irCR. All lymph nodes short axes 
must be < 10 mm. 
• Immune-related Partial Response (irPR): The sum of the products of the 2 largest 
perpendicular diameters of all index lesions is measured and captured as the SPD baseline. 
At  each subsequent tumor assessment, the sum of the products of the 2 largest 
perpendicular diameters of all index lesions and of new measurable lesions are added 
together to provide the Immune Response Sum of the Product of the Diameters (irSPD). 
A decrease, relative to baseline of the irSPD of 50% or greater is considered an irPR, in 
the absence of irCR. Must be confirmed no less than 4 weeks from the first irPR. 
• Immune-related Stable Disease (irSD): irSD is defined as the failure to meet criteria 
for immune complete response or immune partial response, in the absence of 
progressive disease. 
• Immune-related Progressive Disease (irPD): It is recommended in difficult cases (eg, 
increase in SPD or irSPD accompanied with significant individual lesion regression, 
“mixed response”, or in presence of stable or improving performance status/clinical 
condition) to confirm PD at the following tumor assessment. Any of the following will 

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constitute progressive disease: 
• 
At least 25% increase in the SPD of all index lesions over nadir SPD calculated 
for these lesions. 
• 
At least a 25% increase in the SPD of all index lesions and new measurable 
lesions (irSPD) over the nadir SPD calculated for the index lesions. 
 
irRC Definitions 
Index 
Lesion 
Definition 
Non Index 
Lesion 
Definition 
New 
Measurable 
Lesions 
New 
Unmeasurable 
Lesions 
% Change in 
irSPD Tumor 
Burdon 
(including 
measurable 
new lesions 
when present) 
Overall 
irRC 
Response 
Complete 
Response 
Complete 
Response 
No 
No 
-100% 
irCR 
Partial 
Response 
Any 
Any 
Any 
≤-50% 
>-50% 
to 
<+25% 
≥ +25% 
irPR 
irSD 
irPD 
Stable 
Disease 
Any 
Any 
Any 
>-50% 
to 
<+25% 
≥ +25% 
irSD 
irPD 
Progressive 
Disease 
Any 
Any 
Any 
≥ +25% 
irPD 
 
Best Overall Response and Date of Progression Using irRC (irBOR) 
 
The Investigator will be asked to provide all responses on study and date(s) of progression, 
if applicable, and the best overall response will be calculated by the Sponsor or designee based 
on the time point responses and tumor measurements provided by the Investigators. 

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APPENDIX E 
ADVERSE EVENT MANAGEMENT ALGORITHMS  
 
Management algorithms for the above-mentioned adverse events are provided on the following pages. 
 

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APPENDIX F 
PBMC SHIPMENT LOG  
 
              Duke-UNC-Washington University (DUNCWU) 
                          An Early Therapeutics Clinical Trials Network (ETCTN) Partnership 
 
                                                                                NCI9925 PBMC Shipment Log  
Site Name: ___________________________________________  
Date of Shipment:  ______________________  FedEx _  ⃞ UPS     ⃞ 
Shipment Tracking Number: ____________________________ 
Insert copy of this log with shipment and email to lratner@dom.wustl.edu.  
Subject 
ID# 
Collection Date 
(mm/dd/yyyy) 
Study Visit 
(Baseline, Cycle# Day#, 
or End of Treatment) 
Tube Type 
(sodium heparin or 
ACD) 
 
Number of 
Tubes/Cryovials 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page __ of __ 

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APPENDIX G  
TISSUE SHIPMENT LOG  
 
               Duke-UNC-Washington University (DUNCWU) 
                          An Early Therapeutics Clinical Trials Network (ETCTN) Partnership 
 
                                                                                NCI9925 Tissue Shipment Log  
Site Name: ___________________________________________  
Date of Shipment:  ______________________  FedEx _  ⃞ UPS     ⃞ 
Shipment Tracking Number: ____________________________ 
Insert copy of this log with shipment and email to lratner@dom.wustl.edu. 
Subject 
ID# 
Tissue Specimen 
Date 
(mm/dd/yyyy) 
Study Visit 
(Baseline or  
End of Treatment) 
Sample Type 
(block, core, or 
slides) 
 
Corresponding 
Accession Number 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page __ of __ 

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APPENDIX H 
BIOMARKER SHIPMENT LOG  
 
               Duke-UNC-Washington University (DUNCWU) 
                          An Early Therapeutics Clinical Trials Network (ETCTN) Partnership 
 
                                                                         NCI9925 Biomarker Shipment Log  
Site Name: ___________________________________________  
Date of Shipment:  ______________________  FedEx _  ⃞ UPS     ⃞ 
Shipment Tracking Number: ____________________________ 
Insert copy of this log with shipment and email to andrew.nixon@duke.edu.  
Subject 
ID# 
Collection Date 
(mm/dd/yyyy) 
Study Visit 
(Baseline, Cycle# Day#, 
or End of Treatment) 
Sample Type 
(plasma or whole 
blood) 
 
Number of 
Tube/Cryovials 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Page __ of __ 
 

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APPENDIX I – NEUROLOGICAL EXAMINATION 
 
Are there mental status defects? (yes or no) 
  If yes, elaborate 
 
Are there cranial nerve defects? (yes or no) 
  If yes, elaborate 
 
Sensory Exam (elaborate for pos answers) 
  Are there symptoms of tingling, pins and needles, or burning in the extremities? (yes or no) 
  Is examination of vibratory sense impaired? (yes or no) 
  Is examination of proprioception impaired? (yes or no) 
 
Motor Exam  
  Is there a complaint on of lower extremity weakness? (yes or no) 
  Rate strength on exam as follows (for left and right side): 
• 
0 = no contraction 
• 
1 = visible muscle twitch but no movement of the joint 
• 
2 = weak contraction insufficient to overcome gravity 
• 
3 = weak contraction able to overcome gravity but no additional resistance 
• 
4 = weak contraction able to overcome some resistance but not full resistance 
• 
5 = normal; able to overcome full resistance 
  Strength of foot flexors:  
  Strength of foot extensors: 
  Strength of lower leg flexors: 
  Strength of lower leg extensors: 
  Strength of upper leg flexors: 
  Strength of upper leg extensors: 
 
Deep tendon reflexes (for left and right side), graded as follows:  
• 
0 = absent 
• 
1 = reduced (hypoactive) 
• 
2 = normal 
• 
3 = increased (hyperactive) 
• 
4 = clonus 
  Ankle jerk: 
  Knee jerk: 
  Biceps: 
  Triceps: 
  
Is there a disturbance of bladder function? (yes or no) 

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APPENDIX J – PARTICIPANT INFORMATION AND ALERT CARD 
 
Refer to separate protocol attachment titled ‘9925 Appendix J - Participant Information and Alert 
Card’ for full size card.