Phase 2 Study of Bintrafusp Alfa in Recurrent/Metastatic Olfactory Neuroblastoma (BARON).
Phase: PHASE2
Conditions: Olfactory Neuroblastoma, Esthesioneuroblastoma, Neoplasm of the Nasal Cavity
Sponsor: National Cancer Institute (NCI)

Abbreviated Title: Bintrafusp alfa in ONB
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Abbreviated Title: Bintrafusp alfa in ONB 
NIH Protocol #: 000030
Version Date: September 27, 2022
NCT Number: NCT05012098  
Title: Phase 2 Study of Bintrafusp alfa in Recurrent/Metastatic Olfactory Neuroblastoma 
(BARON)
NCI Principal Investigator:
Charalampos Floudas, MD, DMSc, MS
Center for Immuno-Oncology
National Cancer Institute
Building 10, Rm 7N240A
9000 Rockville Pike
Bethesda, MD 20892
Phone: 240-474-1575
E-mail: charalampos.floudas@nih.gov
Drug Name:
Bintrafusp alfa (M7824, 
MSB0011359C)
IND Number:
154950
Sponsor:
CCR, NCI
Manufacturer:
EMD Serono, Inc.
Supplier:
EMD Serono, Inc.
Commercial Agents: None

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PRÉCIS
Background:
Olfactory neuroblastoma (ONB, also known as esthesioneuroblastoma), is a rare malignant 
neoplasm of the nasal cavity. At diagnosis, ONB is often locally advanced. It tends to invade 
locally and has high rates of regional spread to the neck, and distally to the lungs and bones. 
The 10-year survival rate for ONB is reported at 46%.
Standard of care treatment is surgical resection followed by adjuvant radiation. In advanced 
unresectable or metastatic cases, systemic chemotherapy is used off label, with agent selection 
based on published case series. Genomic profiling of ONB has not yet informed the utilization 
of an appropriate molecularly targeted treatment. 
High PD-L1 expression by immunohistochemistry was shown in ONB tumor samples, 
providing a rationale for immune checkpoint blockade in ONB. In addition, high expression 
of transforming growth factor beta (TGF-β) ligands has been identified in ONB, implying that 
additional benefit may be achieved by combination of checkpoint blockade with TGF-β 
inhibition.
Bintrafusp alfa is a novel bifunctional fusion protein composed of a blocking monoclonal 
antibody against PD-L1 fused with the soluble extracellular domain of the human TGF-β 
receptor II (TGF-βRII), acting as a decoy target for TGF-β. The safety profile of bintrafusp 
alfa in clinical trials to date has been shown to be manageable. 
Objective:
To assess the objective response rate (ORR) to bintrafusp alfa in participants with 
recurrent/metastatic ONB, immune checkpoint-naïve (CN)
Eligibility:
Participants must have histologically confirmed recurrent or metastatic ONB, not amenable 
to potentially curative local therapies.
Participants should have received at least one line of systemic therapy including a platinum 
agent, with evidence of disease progression clinically or radiographically.
Presence of ≥ 1 lesion measurable by RECIST 1.1 criteria
Age ≥ 18 years, men and women
Adequate organ function, and without serious comorbidity (e.g., autoimmune disease), that 
would preclude concurrent systemic treatment.
Design:
Single-institution, single-arm Phase II trial to determine ORR in participants with 
recurrent/metastatic ONB treated with bintrafusp alfa.
Participants will be treated with bintrafusp alfa 1200 mg every 2 weeks for 26 doses. 
The trial will initially enroll 12 checkpoint-naïve (CN) participants; if responses are observed 
in one or more participants, the second stage will enroll another 9 CN participants to define 
the response rate to bintrafusp alfa, for a total of 21 CN participants. 

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An additional cohort of checkpoint-resistant (CR) participants will be enrolled and evaluated 
separately. Initially 5 CR participants will be enrolled; if responses are observed in one or 
more participants, the second stage will enroll another 3 participants, for a total of up to 8 CR 
participants. Accrual for CR participants will end when the preset number of CN participants 
has been accrued. 

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TABLE OF CONTENTS 
PRÉCIS...........................................................................................................................................2
STATEMENT OF COMPLIANCE ................................................................................................7
1
INTRODUCTION ...................................................................................................................8
1.1
Study Objectives............................................................................................................8
1.2
Background and Rationale ............................................................................................8
2
ELIGIBILITY ASSESSMENT AND ENROLLMENT .......................................................18
2.1
Eligibility Criteria........................................................................................................18
2.2
Screening Evaluation...................................................................................................22
2.3
Participant Registration and Status Update Procedures ..............................................23
2.4
Baseline Evaluation.....................................................................................................24
3
STUDY IMPLEMENTATION .............................................................................................25
3.1
Study Design ...............................................................................................................25
3.2
Study Accrual Stopping Rule......................................................................................26
3.3
Drug Administration....................................................................................................26
3.4
Dose Modifications .....................................................................................................27
3.5
Assessments On Treatment .........................................................................................29
3.6
Study Intervention Compliance...................................................................................29
3.7
Study Calendar ............................................................................................................30
3.8
Cost and Compensation...............................................................................................34
3.9
Criteria for Removal from Protocol Therapy and Off Study Criteria .........................34
4
CONCOMITANT MEDICATIONS/MEASURES...............................................................36
4.1
Acceptable Medications/Measures..............................................................................36
4.2
Prohibited Medications................................................................................................37
5
CORRELATIVE STUDIES FOR RESEARCH ...................................................................37
5.1
Summary .....................................................................................................................37
5.2
Sample Collection and Processing ..............................................................................40
5.3
Sample Storage, Tracking and Disposition .................................................................42
5.4
Samples for Genetic/Genomic Analysis......................................................................44
6
DATA COLLECTION AND EVALUATION .....................................................................45
6.1
Data Collection............................................................................................................45
6.2
Data Sharing Plans ......................................................................................................46

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6.3
Response Assessment..................................................................................................46
6.4
Toxicity Criteria ..........................................................................................................52
7
NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING PLAN...53
7.1
Definitions...................................................................................................................53
7.2
OHSRP Office of Compliance and Training / IRB Reporting....................................53
7.3
NCI Clinical Director Reporting .................................................................................53
7.4
NIH Required Data and Safety Monitoring Plan ........................................................53
8
SPONSOR PROTOCOL / SAFETY REPORTING..............................................................54
8.1
Definitions...................................................................................................................54
8.2
Assessment of Safety Events.......................................................................................56
8.3
Reporting of Serious Adverse Events .........................................................................56
8.4
Waiver of Expedited Reporting to CCR......................................................................57
8.5
Safety Reporting Criteria to the Pharmaceutical Collaborators ..................................57
8.6
Reporting Pregnancy ...................................................................................................57
8.7
Regulatory Reporting for Studies Conducted Under CCR-Sponsored IND ...............57
8.8
Sponsor Protocol Deviation Reporting........................................................................58
9
CLINICAL MONITORING..................................................................................................58
10
STATISTICAL CONSIDERATIONS ..................................................................................59
10.1
Statistical Hypothesis ..................................................................................................59
10.2
Sample Size Determination.........................................................................................59
10.3
Populations for Analyses.............................................................................................60
10.4
Statistical Analyses......................................................................................................60
11
COLLABORATIVE AGREEMENTS..................................................................................62
11.1
Cooperative Research and Development Agreement (CRADA)................................62
12
HUMAN SUBJECTS PROTECTIONS................................................................................62
12.1
Rationale For Subject Selection ..................................................................................62
12.2
Participation of Children .............................................................................................62
12.3
Participation of Subjects Unable to Give Consent ......................................................62
12.4
Evaluation of Benefits and Risks/Discomforts ...........................................................63
12.5
Risk/Benefit Assessment.............................................................................................63
12.6
Consent Process and Documentation ..........................................................................65
13
REGULATORY AND OPERATIONAL CONSIDERATIONS..........................................66

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13.1
Study Discontinuation and Closure.............................................................................66
13.2
Quality Assurance and Quality Control ......................................................................67
13.3
Conflict of Interest Policy ...........................................................................................67
13.4
Confidentiality and Privacy.........................................................................................67
14
PHARMACEUTICAL INFORMATION .............................................................................68
14.1
Bintrafusp alfa (M7824, MSB0011359C) (IND # 154950)........................................68
15
REFERENCES ......................................................................................................................72
16
LIST OF ABBREVIATIONS................................................................................................77
17
APPENDICES .......................................................................................................................81
17.1
Appendix A: Performance Status Criteria...................................................................81
17.2
Appendix B: Recommendations for management of IRRs and AEs ..........................82
17.3
Appendix C: Best Overall Response per RECIST 1.1 ................................................86

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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following: 

United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR 
Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812) 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled. Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.

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1
INTRODUCTION
1.1
STUDY OBJECTIVES
1.1.1
Primary Objective

To determine the objective response rate (ORR) to bintrafusp alfa according to 
RECIST 1.1(1) in participants with immune checkpoint-naïve, recurrent or metastatic 
Olfactory Neuroblastoma (ONB)
1.1.2
Secondary Objectives

To assess the safety and tolerability of 1200 mg bintrafusp alfa administered once 
every 2 weeks in participants with recurrent or metastatic ONB

To assess Duration of Response (DOR)

To assess Progression Free Survival (PFS).

To assess Overall Survival (OS)
1.1.3
Exploratory Objectives

To perform immune corelative studies in the peripheral blood as well as in the tumor, 
including, but not limited to immune cell subset quantitative and functional analyses, 
PD-L1 expression, evaluation of soluble factors and intra-tumoral changes before and 
after treatment with bintrafusp alfa (studies may be performed in selected participants 
where adequate samples (blood/tissue) and resources are available)

To develop in vitro organoid ONB models for evaluation of immunotherapeutic 
approaches in vitro

To evaluate antitumor efficacy per iRECIST (3)

To determine the ORR in immune checkpoint-resistant participants

To assess pharmacokinetics (PK) of bintrafusp alfa and anti-drug antibodies (ADA)
1.2
BACKGROUND AND RATIONALE
1.2.1
Introduction 
Olfactory neuroblastoma (ONB), also known as esthesioneuroblastoma, was first described by 
Berger et al in 1924. (4) It is a malignant neuroectodermal tumor of the nasal cavity developing in 
the superior portion of the nasal vault, believed to arise from the stem-cell-like basal cells of the 
olfactory neurosensory epithelium. (5-8) ONB is very rare, with a reported incidence of 0.4 per 
million(9) and accounts for 3% of all the tumors found in the nasal cavity. (6) The Surveillance 
Epidemiology and End Results (SEER) 1973-2015 database contains a total of 949 participants 
with ONB. (10) There is a slight male predilection (54.8%) in population based studies (11), while 
in terms of age distribution it has been reported as diagnosed in all decades, with a peak in the fifth 
or sixth decade, and published cases have been largely in whites. (6) A query of the database of 
the genomics corporation Foundation Medicine compiled a cohort of 75 participants from 2013-
2019 (median of 9 participants annually, range 7 – 17 participants), with 44/75 (58.6%) men and 
41.3% women, and median age 54.4 years, (range 16-8 years) (unpublished data). 
Due to the location of ONB in the sinonasal tract and anterior skull base, the presenting symptoms 
are often non-specific, including nasal obstruction and epistaxis, thus participants often present at 
advanced stages. (7, 12) ONB has a propensity for local invasion (i.e., orbit, cranium), and lymph 

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nodes are involved in up to 10% at diagnosis, while the probability of recurrence in the neck nodes 
has been reported up to 20-30%, (6, 7, 9, 13) and the reported survival at 15 years being 17% after 
recurrence of the neck. (14) Distant metastases develop in 12-39% of participants, with a median 
time-to-distant metastases of 15 months (ranging from 0.75 to 276 months)(14, 15), most 
commonly to the neck, lungs, and bones, but also drop spinal metastases and brain metastases, 
with a 2-year survival of 63% (15), and a 5-year survival of 42%. (14)
Comparative genomic hybridization has been employed to analyze the copy number variations in 
small cohorts of ONB participants. However, while these studies have demonstrated some 
chromosomal instability, the results generated by various studies have been highly heterogeneous, 
making correlation analysis and generalizations across studies challenging. (16-22) A 
comprehensive genomic profiling of 41 recurrent or refractory ONB tumors reported TP53 
mutations in 17% of these samples, followed by NF1, PIK3CA, and CDKN2C, mutated in <7% of 
samples of participants. They also reported 4.8% (2/41) with mutations in isocitrate 
dehydrogenase-2 (IDH2), both involving codon R172. (22) An expansion of this study is the 
aforementioned Foundation Medicine cohort. In this cohort, the microsatellite instability status is 
available in 64/75 participants, with only one being MSI-high 1/64 (1.56%). The tumor mutation 
burden (TMB) is 1.7 (test threshold for high: 10 mutations per mega base), with a range of 0 to 7.8 
mutations per mega base; the MSI-H sample is an outlier with a TMB of 27 mutations per mega 
base (unpublished data). The most frequently altered gene is TP53, in 24% (18/75) of participants, 
with CDKN2C following, altered in 16% (12/75) participants, while IDH2 is mutated in 4% 
participants (3/75), two involving the codon R172 and the third involving codon R149 with a 
missense mutation. A recent multi-omic analysis of 14 ONB tumor samples reported a similar rate 
of TP53 mutations (21.4%) and in addition confirmed the presence of mutations in isocitrate 
dehydrogenase-2 (IDH2) R172 codon, in a higher proportion of tumors (7/42 participants, 16.7%). 
(23) 
1.2.2
Current standard of care for ONB
The current treatment paradigm for newly diagnosed local and locoregional ONB involves 
complete surgical resection, followed by adjuvant radiation therapy, which provides the best 
overall survival (OS) and progression-free survival (PFS). (8, 24) The extend and route of surgical 
resection depend upon the location and spread of the disease and may include endoscopic unilateral 
or bilateral approaches, combined endoscopic and open approach, or craniofacial resection. (7, 25) 
Surgery is often well tolerated in these participants but post-operative complications may include 
bleeding, infection such as meningitis, cerebrospinal fluid leak, and tumor recurrence. (25) 
Adjuvant radiation administered within 6 weeks after primary surgery has shown to be superior 
than delayed irradiation (administered 6 weeks to 2 months after surgery) in terms of disease-free 
time and time to recurrence with metastasis. (24) Neoadjuvant chemotherapy with or without 
radiation therapy has also been used, resulting in decrease of disease-related mortality in 
participants that responded to it. (26)
For recurrence of ONB in the lymph nodes of the neck, surgery and radiation are used to achieve 
locoregional control, however the risk of distant metastases is high in these participants. (14, 15) 
A recent systematic review and meta-analysis of metastatic ONB reported 83 of 678 participants 
(12%) with a median time-to-distant-metastasis after primary diagnosis of 15 months (range 0.75 
– 276 months). Of the 48 studies with enough data for survival analysis, they reported a 6-month 
survival rate after distant metastasis of 63%, decreasing to 56% for those who received 
chemotherapy. Across all the studies analyzed by the authors, at total of 21 different 

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chemotherapies were used, with 66% of the studies implementing a platinum-based regimen, and 
37% also including etoposide; there is no tabulation of toxicity data. (15) The same study further 
concluded that the combination of chemotherapy with surgery and/or radiation was associated with 
improved survival in the metastatic setting. Sunitinib monotherapy and sunitinib combined with 
cetuximab have induced complete responses in case reports of two participants (27, 28) but there 
is no case series describing ONB participants treated with a molecularly targeted agent. In addition, 
there is no published case series or case report of immunotherapy in ONB. 
1.2.3
Immune checkpoint and TGF-β blockade 
Tumors evade the immune system via tolerogenic pathways. A well characterized tolerogenic 
pathway is the programmed death 1 (PD-1)/ programmed death-ligand 1 (PD-L1) checkpoint 
pathway, which involves interactions between the programmed death 1 (PD-1) molecule on T cells 
and the programmed death-ligand 1 (PD-L1) present on tumor cells. This interaction leads to 
suppression of T cell signaling and promotes immune tolerance. Consequently, blockade of the 
PD-1/ PD-L1 pathway has been exploited therapeutically, and immune checkpoint blockade 
monoclonal antibodies (ICBMs) have been successful in inducing responses in many different 
malignancies. The efficacy of PD-L1 monoclonal antibodies in particular has been shown to be 
predicted by the presence of PD-L1 in the tumor (29-31). However, the response rate is low (~15% 
objective response across indications), and strategies attempting to increase the efficacy of anti-
PD-L1 antibodies include combinations with agents targeting immunomodulatory factors of the 
tumor microenvironment, (32) such as TGF-β. 
TGF-β is a multifunctional cytokine with three isoforms, TGF-β1, TGF-β2, and TGF-β3, which 
bind to high-affinity cell-surface receptors in a cascade leading to SMAD-mediated transcriptional 
activation or repression of genes controlling cell growth, differentiation, and migration. In cancer, 
these result in promoting epithelial-to-mesenchymal transition, invasion, and metastasis (33, 34) 
but also in local suppression of both T cell and NK cell function. (35-39) In mice, the absence of 
CD4+ and regulatory T cell-derived TGFβ1 has been shown to inhibit tumor growth, (40) while 
inhibition of TGF-β in combination with checkpoint blockade has been shown previously to be 
advantageous. (41, 42)
1.2.4
Bintrafusp alfa drug product, preclinical pharmacology
Bintrafusp alfa (M7824; anti-PD-L1/TGF-RII) is a novel bifunctional fusion protein composed 
of a fully human IgG1 mAb against PD-L1 fused to the soluble extracellular domain of human 
transforming growth factor-beta receptor II (Figure 1) that binds TGF-β superfamily ligands, 
which has been co-developed by the NCI LTIB in collaboration with the CRADA partner EMD 
Serono. The anti-PD-L1 moiety of bintrafusp alfa is based on avelumab. Functionally, bintrafusp 
alfa mediates antibody-dependent cellular toxicity, increases expression of T-cell trafficking-
related molecules in the tumor cells, enhances antigen-specific and tumor necrosis factor-related 
apoptosis-inducing ligand (TRAIL)-specific CD8+ lymphocyte mediated tumor cell lysis, and 
reduces immunosuppressive activity induced by TGF-β. (43, 44)

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Figure 1: Bintrafusp alfa (PD-L1/TGF-βRII) 
molecule
Work with the in vivo preclinical murine carcinoma models has shown anti-tumor activity of 
bintrafusp alfa (Figure 2 A). In these models, bintrafusp alfa accumulates in the tumor 
microenvironment (Figure 2B), decreases TGF-β signaling, as shown by significantly decreased 
SMAD2 phosphorylation (Figure 2C), and increases CS8+ and NK cell activity (Figure 2D). (45)
Figure 2: Bintrafusp alfa decreases TGF-β signaling in the tumor microenvironment
(A) Comparison of anti-tumor activity of bintrafusp alfa, and bintrafusp alfa (mut) devoid of PD-L1 binding site in 
the EMT6 breast cancer model. (B) Accumulation of bintrafusp alfa in the TME resulting in (C) reduction of 
SMAD2 signaling and (D) increased T- and NK-cell activation.
The advantage of using the anti-PD-L1/TGF-βRII antibody-ligand fusion protein over using anti-
CTLA4 or anti-PD-1/PD-L1 as monotherapy or in combination with an anti-TGF-β monoclonal 
antibody was shown in preclinical models. (34, 46)

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1.2.5
Bintrafusp alfa clinical efficacy and safety
The first-in-human Phase I dose escalation study of bintrafusp alfa in participants with advanced 
solid tumors was conducted at the CCR (47). This work demonstrated on-target PD-L1 saturation, 
sequestration of circulating TGF-β, and early evidence of clinical efficacy (Figure 3) across all 
dose-levels, in a cohort of heavily pretreated participants. 
Figure 3: First-in-human Phase 1 trial of bintrafusp alfa. Objective responses in solid 
tumors.
Further clinical testing in 43 participants with HPV-associated, pre-treated, checkpoint-naive 
metastatic cancers reported a 38.9% total clinical response rate (complete response, partial 
response and delayed partial response – the latter being partial response after an initial progression 
of disease), regardless of PD-L1 expression (Figure 4). (48) The reported response rate is notably 
higher than the 12-24% response rate seen with blockade of PD-1 or PD-L1 alone for HPV-
associated malignancies (e.g., cervical, anal, P16+ oropharyngeal) in the literature. (49-54) 
Figure 4: Bintrafusp alfa in participants with metastatic HPV-associated cancers.

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Waterfall plot of confirmed best overall responses in participants with immune checkpoint inhibitor-naïve, 
recurrent/metastatic HPV-positive OPSCC (orange).
In the context of non-HPV-associated malignancies, such as in a population of 80 pretreated (no 
prior immunotherapy) participants with advanced non-small cell lung cancer, the overall response 
rate to bintrafusp alfa was 25% in the overall (PD-L1 unselected) population (20/80 participants), 
31% (18/58) in the PD-L1+ (≥1%) population and 53.8% (7/13) in the PD-L1 high (≥80%) 
population. (55) In comparison, in a single-arm trial of 184 pretreated NSCLC participants (no 
prior immunotherapy), the objective response rate was 12% in the overall population (56), while 
in a randomized, open-label comparison of avelumab vs. docetaxel in pretreated NSCLC 
participants reported an objective response rate of 15% (59/396 participants) in the PD-L1 
unselected population, 19% in the PD-L1 >=1% population, 25% in the PD-L1 >=50% population, 
and 31% in the PD-L1 >=80% population. (57) 
For data on the safety of bintrafusp alfa, please refer to Section 14.1.2
1.2.6
Rationale for immune checkpoint blockade and combination with TGF-β blockade in 
ONB
As discussed in Section 1.2.1, while the existing data on ONB are retrospective and therefore quite 
heterogeneous, there is a consensus that the natural history of ONB involves a high rate of 
locoregional recurrences and distant metastases, which portend a poor prognosis. 
Consequently, there is an unmet need for improved systemic treatments, especially for the 
participants with recurrent and metastatic disease. Chemotherapy in ONB has been reported in 
case reports, case series, and systematic reviews to result in responses, even complete ones, but 
there has been no prospective trial of a single regimen or a comparison of different regimens 
leading to the establishment of a standard of care regimen. Furthermore, there has been no 
published report of any cytotoxic agent or combination of agents tested in a preclinical model, 
which might provide data to inform further development of a therapeutic regimen with cytotoxic 
chemotherapy. In addition, the existing genomic analyses of ONB have revealed a low frequency 
(16.7%) of a druggable mutation, IDH2 in particular (Section 1.2.1), which leaves the remaining 
83.3% without an option for a targeted agent. We have therefore studied the tumor 
microenvironment to examine the potential for immunotherapy in ONB. 
A recent study of 10 ONB samples reported negative results from immunohistochemistry (ICH) 
for PD-L1(60), but a subsequent study of ONB examined 36 primary ONB samples with 
immunohistochemistry for PD-L1 expression on tumor and immune cells and reported 14 samples 
(39%) having a positive score of ≥1% for expression on both tumor cells and immune cells. (23) 
The presence of PD-L1 was confirmed by immunohistochemistry studies from the London lab: 
samples from 10 participants were available, six primary lesion samples (non-paired) and four 
pairs of primary – metastatic lesion samples. In the non-paired group 4 primary ONB lesion 
samples demonstrated positive PD-L1 staining (Figure 5). (61) In the paired group, all primary 
lesion samples were negative, but three of the metastatic lesion samples were positive for PD-L1; 
summarily, for the primary lesions 4 of 10 were positive (40%), and for the metastatic lesions 3 of 
4 (75%) where positive; if pooled together, 7 out of 14 (50%) were positive. All PD-L1 positive 
samples were found to contain PD-1+ tumor cells (Figure 6).An explanation for the negative initial 
study for PD-L1 may be randomness due to the small sample size and underlying stratification 
(primary vs. metastatic).

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Figure 5 Primary olfactory neuroblastoma.
In 
a 
primary 
olfactory 
neuroblastoma 
(A, 
H&E), 
immunohistochemistry demonstrates PD-L1 expression in a 
subset of tumor cells (B, brown chromagen), PD-1 expression in 
scattered tumor cells as well as lymphocytes in the tumor and 
stroma (C, brown chromagen), and CD8 expression in 
lymphocytes in the tumor and stroma (D, brown chromagen) (All 
40x).
The percentage of tumor cells staining positive for PD-L1, which has been described as the tumor 
positive score and is a predictive biomarker for response to immune checkpoint blockade in some 
tumors, is presented in Table 1.
Furthermore, PD-L1+ primary and metastatic tumors demonstrated increased PD-1+ infiltrating 
lymphocytes in the tumor and CD8+ lymphocytes in the tumor and stroma compared to PD-L1 
negative tumors (P<0.05; Table 2). 
Tumor infiltrating CD8 and CD4 lymphocytes were also examined in the multi-omic study of 
ONB by Classe et al, which reported their presence ranging from 0-350 cells per mm2. In addition, 
the group of ONB samples with the higher CD8 counts had higher mRNA levels of cytotoxic cell 
markers, T cell invasion chemokines, immune checkpoints and ligands, as well as suppressive 
factors, including TGFB, Figure 7) (23).
PD-L1+ tumor cells (%)
Primary
0
0
1
5
10
20
0
0
0
0
Metastatic
N/A
N/A
N/A
N/A
N/A
N/A
0
1
2
5
Table 1. PD-L1 positive tumor cells (%).
Figure 6 Metastatic olfactory neuroblastoma.
In 
a 
metastatic 
olfactory 
neuroblastoma 
(A, 
H&E), 
immunohistochemistry demonstrates PD-L1 expression in rare 
tumor cells (B, brown chromagen), PD-1 expression in 
occasional tumor cells as well as lymphocytes in the tumor and 
stroma (C, brown chromagen), and CD8 expression in 
lymphocytes in the tumor and stroma (D, brown chromagen) (All 
40x).

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Average PD-1+ 
lymphocytes in 
tumor ± S.E.M.
Average PD-1+ 
lymphocytes in 
stroma ± S.E.M.
Average CD8+ 
lymphocytes in 
tumor ± S.E.M.
Average CD8+ 
lymphocytes in 
stroma ± S.E.M.
PD-L1+  ONB 
8.29 ± 2.97
13.86 ± 5.38
13.86 ± 4.73
15.29 ± 2.66
PD-L1- ONB 
0.71 ± 0.29
3.0 ± 0.62
1.86 ± 0.4
7.14 ± 0.63
Fold increase 
11.6 (P<0.05)
4.62 (P=0.068)
7.46 (P<0.05)
2.14 (P<0.05)
Table 2. Correlation between PD-L1 expression and ONB lymphocyte infiltration.
Figure 7 Immune gene expression heatmap and CD8+ TILs in ONB.
Using whole-transcriptome RNA-Seq data from the study by Classe et al, we can compare the 
levels of mRNA for CD274, TGFB1, TGFB2, and TGFB3 in ONB with those in some of the 
tumors included in TCGA (Figure 8). We can observe that the CD274 mRNA levels in ONB are 
quite comparable to those in cutaneous melanoma, cervical squamous carcinoma, and head and 
neck squamous carcinoma, tumors where ICBMs have been approved by the FDA. We can also 
observe that mRNA levels for the genes of the TGF-β ligands (TGFB1, TGFB2, TGFB3) are 

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higher than in cutaneous melanoma, cervical squamous carcinoma, and head and neck squamous 
carcinoma, tracking those of breast cancer, a tumor which has resisted immunotherapy thus far. 
Figure 8 CD274 and TGFB ligands mRNA in ONB and other types of tumors
Gene-level transcription estimates (log2(x+1) transformed RSEM normalized counts). ONB: Olfactory 
neuroblastoma, HNSC: head and neck squamous cancer, CESC: cervical squamous cancer, SKCM: cutaneous 
melanoma, COAD: colon adenocarcinoma, BRCA: breast cancer. Results in part based upon data generated by the 
TCGA Research Network: https://www.cancer.gov/tcga.
Thus, a proportion of ONB primary and metastatic tumors express PD-L1 and possesses an 
associated infiltrate of PD-1+ and CD8+ lymphocytes, which may render them susceptible to 
immune checkpoint blockade, while at the same time they also have high levels of mRNA for 
TGF-β ligands, which may drive immunosuppression in the microenvironment. Taken together, 
these data suggest that choosing bintrafusp alfa, which combines blockade of PD-L1 and TGF-β 
signaling, rather than a-PD-L1, is a rational therapeutic strategy for ONB.
1.2.7
Bintrafusp alfa dose and schedule rationale
The dose of bintrafusp alfa is derived from previous experience using this drug in multiple studies 
here at the National Institutes of Health. Thus, 1200mg will be administered intravenously once 
every 2 weeks.
1.2.8
Rationale for performing exploratory studies
Due in part to the rare nature of ONB and to the lack of development of in vitro or in vivo models 
to study this disease, few exploratory studies have been reported in the literature. This underscores 

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the importance for the development of models to study this disease as described in this proposal. 
These exploratory studies will provide critical insight into the biology of this disease and help to 
guide the development and refinement of subsequent clinical trial protocols in the future.

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2
ELIGIBILITY ASSESSMENT AND ENROLLMENT 
2.1
ELIGIBILITY CRITERIA
2.1.1
Inclusion Criteria
2.1.1.1
Histologically or cytologically confirmed recurrent or metastatic ONB not amenable to 
potentially curative local therapies. Review of tissue samples by Pathology at the NIH 
is preferred.
2.1.1.2
Participants must have measurable disease, per RECIST 1.1. See Section 6.3 for the 
evaluation of measurable disease. A previously treated lesion by radiotherapy can be 
chosen as the target lesion only if progression in the respective lesion has been 
demonstrated during or following radiotherapy.
2.1.1.3
Participants should have received at least one line of systemic therapy including a 
platinum agent, with evidence of disease progression clinically or radiographically. 
2.1.1.4
Men or Women >18 years of age on day of signing informed consent. Because no dosing 
or adverse event data are currently available on the use of bintrafusp alfa in participants 
<18 years of age, children are excluded from this study.
2.1.1.5
ECOG performance status (PS) <2 (see Appendix A).
2.1.1.6
Participants must have adequate organ and marrow function as defined below: 
Absolute neutrophil count (ANC)
≥1,500/mcL
Hemoglobin
≥ 9 g/dL 
(transfusions allowed)
Platelets
≥ 100,000/mcL
Serum Creatinine
OR
Measured CrCl or eGFR by CKD-
EPI formula may be used to 
estimate CrCl/eGFR
≤ 1.5 × ULN
OR
≥ 30 mL/min/1.73m2 for participant with creatinine 
levels > 1.5 × institutional ULN 
Serum total bilirubin
OR
Direct bilirubin 
≤ 1.5 × upper limit of normal (ULN) 
OR
≤ ULN for participants with total bilirubin levels > 
1.5 × ULN
AST(SGOT) and ALT(SGPT)
≤ 2.5 × ULN

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2.1.1.7
The effects of immunotherapy on the developing human fetus are unknown. Therefore, 
participants must use effective methods of contraception (such as implants, injectables, 
combined oral contraceptives, IUDs, sexual abstinence or vasectomized partner). 

Women of child-bearing potential (WOCBP: any woman who has experienced 
menarche and has not had hysterectomy or bilateral oophorectomy or is not 
postmenopausal (amenorrheic 12 months or more following cessation of exogenous 
hormonal treatments; if <50 years old need follicle stimulating hormone FSH in the 
post-menopausal range)) must agree to use highly effective contraception prior to 
study entry and for up to 65 days following the last dose of study treatment.

Men must agree to use highly effective contraception prior to study entry and up to 
125 days following the last dose of study treatment. 

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. 
2.1.1.8
Participants with bone metastases or hypercalcemia on intravenous bisphosphonate 
treatment, zolendronic acid, denosumab, or similar agents are eligible to participate and 
may continue this treatment.
2.1.1.9
Participants with treated CNS ONB lesions are eligible if follow-up brain imaging after 
at least a month following central nervous system (CNS)-directed therapy shows no 
evidence of progression. 
2.1.1.10
Participants with new or progressive non-intraparenchymal CNS ONB lesions are 
eligible if the treating physician determines that immediate CNS specific treatment is 
not required and is unlikely to be required during the first cycle of therapy.
2.1.1.11
Human immunodeficiency virus (HIV)-positive participants must have CD4 count ≥ 
200 cells per cubic millimeter at enrollment, be on stable antiretroviral therapy for at 
least 4 weeks and have no reported opportunistic infections or Castleman’s disease 
within 12 months prior to enrollment.
2.1.1.12
For participants with serological evidence of chronic hepatitis B virus (HBV) infection, 
the HBV DNA viral load must be undetectable on suppressive therapy, if indicated.
2.1.1.13
For participants with serological evidence of HCV infection, the HCV RNA viral load 
must be negative to be eligible for study participation.
2.1.1.14
Ability of participant to understand and the willingness to sign a written informed 
consent document.
2.1.1.15
Must co-enroll in the following two studies. A separate inform consent will be obtained 
from participant for these studies.

21-C-0009: “A Natural History Study of Children and Adults with Olfactory 
Neuroblastoma,” and 

18-DC-0051: “Biospecimen procurement for NIDCD clinical protocols”
2.1.2
Exclusion Criteria
2.1.2.1
Anticancer treatment, concurrent or prior (chemotherapy, monoclonal antibody, 
cytokine therapy, immune therapy, targeted small molecule therapy) or any 

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investigational drug, within 4 weeks or 5 half-lives (whichever shorter) prior to the first 
drug administration. All residual treatment-related toxicities must have resolved or be 
minimal and not constitute a safety risk. Note: Palliative radiotherapy is permitted 
concurrently or within the pretreatment period. Subjects receiving bisphosphonates or 
denosumab are eligible provided treatment was initiated at least 14 days before 
treatment. 
2.1.2.2
Participants who received prior checkpoint blockade therapy and were taken off 
treatment for serious adverse events related to immuno-therapy are excluded. 
2.1.2.3
Major surgery within 4 weeks prior to the first drug administration (minimally invasive 
procedures such as diagnostic biopsies are permitted).
2.1.2.4
Active or prior documented autoimmune or inflammatory diseases that might deteriorate 
on immunostimulatory agent (including colitis or Crohn’s disease, systemic lupus 
erythematosus, sarcoidosis, vasculitis, Grave’s disease, hypophysitis, uveitis, 
rheumatoid arthritis etc.), except the following:

Type I diabetes mellitus

Chronic skin conditions that do not require systemic therapy (including eczema, 
vitiligo, alopecia, psoriasis)

Hypothyroidism (e.g., post-Hashimoto thyroiditis) stable, on hormone replacement

Mild autoimmune disease not active in the last 5 years may be eligible after 
consultation with the principal investigator. 
2.1.2.5
Current use of immunosuppressive medication within 14 days before the first dose of 
the study medication, except the following: 

Intranasal, inhaled, topical glucocorticoids; locally injected glucocorticoids (i.e. 
intra-articular, intra-ocular)

Systemic glucocorticoids at physiologic doses (generally ≤ 10 mg prednisone or 
equivalent per day)

Glucocorticoids as premedication for contrast-enhanced studies is allowed prior to 
enrollment and on study.
2.1.2.6
Uncontrolled intercurrent chronic or acute illness including, but not limited to the 
following, that may limit interpretation of results or increase risk to the participant in 
the judgment of the investigator:

Bleeding diathesis or recent (<3 months) clinically significant bleeding event. 

Prior organ transplantation including allogenic stem-cell transplantation

Impaired cardiovascular function or clinically significant cardiovascular disease, 
including, but not limited to, any of the following: 
o cerebral vascular accident/stroke (< 3 months prior to enrollment), 
o acute coronary syndromes (including myocardial infarction < 6 months prior to 
enrollment, unstable angina), 

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o Congestive Heart Failure (≥ New York Heart Association Classification Class 
III); CHF Class II must have been stable for 3 months prior to enrollment
o history or presence of clinically significant cardiac arrhythmia including resting 
bradycardia, uncontrolled atrial fibrillation or paroxysmal supraventricular 
tachycardia (controlled arrhythmias, e.g. stable atrial fibrillation, may be allowed 
at the discretion of the investigator),
o history of myocarditis
History of idiopathic pulmonary fibrosis, drug-induced or idiopathic pneumonitis, 
active interstitial lung disease, blood oxygen saturation <90% at rest (on ambient 
air).
Clinically significant hepatic disease.
Active infection requiring systemic therapy (minor infections may be allowed at the 
discretion of the investigator).
2.1.2.7
Subjects unwilling to accept blood products as medically indicated.
2.1.2.8
Vaccination with live vaccines within 4 weeks of the first dose of treatment and while 
on study is prohibited. Inactivated vaccines may be administered. 
2.1.2.9
History of allergic reactions or hypersensitivity attributed to compounds of similar 
chemical or biologic composition to bintrafusp alfa. Participants with history of severe 
hypersensitivity reaction to monoclonal antibodies (grade ≥ 3 NCI-CTCAE v5) will be 
evaluated by the allergy/immunology team prior to enrollment.
2.1.2.10
History of second malignancy within 3 years of enrollment except for the following: 
adequately treated localized basal cell or squamous skin cancer, cervical carcinoma in 
situ, superficial bladder cancer, other localized malignancy which has been adequately 
treated or malignancy which does not require active systemic treatment (e.g. low risk 
CLL). 
2.1.2.11
Pregnant or breastfeeding women are excluded from this study because the study 
medications have not been tested in pregnant women and there is 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 the study 
medications, breastfeeding should be discontinued if the mother is treated on this 
protocol.
2.1.3
Recruitment Strategies
The study may be abstracted to a plain language announcement posted on NIH website, on NIH 
social media forums, and on www.clinicaltrials.gov. A link to the clinical trial from 
www.clinicaltrials.gov will be placed on the investigators’ NIH research websites. Following IRB 
approval of the recruitment materials, this study may be posted at national conferences including 
AACR, ASCO, North America Skull Base Society (NASBS) meeting, American Rhinologic 
Society (ARS) meeting, American Academy of Otolaryngology-Head and Neck Surgery (AAO-
HNS) meeting, American Head and Neck Society (AHNS) meeting, local sinonasal/skull base 
CME courses and/or symposia, and may also be shared with the organizations including Rare as 
One, NASBS, ARS, AAO-HNS, AHNS, National Organization for Rare Disorders (NORD), 
Genetic Alliance, Global Genes, TRAIN, and HRA who may advertise it further. the Office for 
Participant Recruitment services will be utilized to and the study will be added to the Research 
Match site (www.researchmatch.org). 

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Outside physicians may directly refer participants for screening to the study and participants may 
be self-referred. Study participants may also be recruited from the population of participants 
screened for or participating in the ONB natural history protocol. 
2.2
SCREENING EVALUATION
2.2.1
Screening activities performed prior to obtaining informed consent
Minimal risk activities that may be performed before the subject has signed a consent include the 
following: 

Email, written, in person or telephone communications with prospective subjects 

Review of existing medical records to include H&P, laboratory studies, etc. 

Review of existing MRI, x-ray, or CT images

Review of existing photographs or videos

Review of existing pathology specimens/reports from a specimen obtained for diagnostic 
purposes.
2.2.2
Screening activities performed after a consent for screening has been signed
The following activities will be performed after the subject has signed the study consent or the 
consent for study 01-C-0129 (provided the procedure is permitted on that study) on which 
screening activities may also be performed. 
Assessments performed at outside facilities or on another NIH protocol within the timeframes 
below may also be used to determine eligibility once a participant has signed the consent.
Any time prior to initiation of study therapy:
Histologic confirmation by the NCI Laboratory of Pathology: archival tumor samples will be 
requested from each participant; if there is no available tumor sample or pathology report, a 
biopsy may be performed to confirm the diagnosis. 
NOTE: Pathology report of histologic confirmation by Johns Hopkins Pathology (Dr. Lisa 
Rooper) may be accepted as evidence of histologic confirmation at the discretion of the PI.
Within 3 months prior to initiation of study therapy: 
HBV, HCV, HIV serologies: may include viral load for HCV, HBV and HIV if clinically 
indicated. CD4 testing may also be required for HIV+ participants.
Within 28 days prior to initiation of study therapy:
Clinical evaluations:
o
Medical history, complete review of concomitant medications and symptoms/side effects; 
assessment of performance status per ECOG.
o
Physical examination, including height (at screening only), weight, vital signs (i.e., 
temperature, blood pressure, heart rate, respiratory rate, oxygen saturation by pulse 
oximetry).
Laboratory evaluations 

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o
Complete blood count (CBC) with differential.
o
Serum biochemical profile: 

Acute care panel (Na+, K+, Cl-, CO2, creatinine, glucose, urea nitrogen)

Mineral panel (albumin, calcium total, magnesium total, phosphorus)

Hepatic panel (AST/GOT, ALT/GPT, total bilirubin, direct bilirubin, alkaline 
phosphatase)
o
Troponin I
o
Amylase, lipase
o
Creatine kinase (CK/CPK)
o
Thyroid function tests: thyroid stimulating hormone (TSH) and free thyroxine (FT4)
o
Lymphocyte phenotype TBNK (T, B, and natural killer cells)
o
Urinalysis
o
24-hour urine collection for creatinine clearance (if needed to measure CrCl in cases where 
serum creatinine > 1.5 X ULN)
Imaging tests: (NOTE: external imaging may be used for screening; however, NIH reading will 
be used to determine eligibility, and baseline imaging performed at NIH will be required):
o
CT of skull base, neck, chest, abdomen and pelvis, or MRI.
o
Brain MRI or CT, if clinically indicated. 
o
PET/CT (FDG or Dotatate)
o
Nuclear bone scan for individuals with known/suspected bone lesions 
Cardiac evaluation: 
o
12-lead EKG
Within 1 week prior to enrollment: 
Urine or serum pregnancy test (β-HCG) for WOCBP (see Inclusion Criteria 2.1.1.7 for 
definition of WOCBP).
2.3
PARTICIPANT REGISTRATION AND STATUS UPDATE PROCEDURES
Registration and status updates (e.g., when a participant is taken off protocol therapy and when a 
participant is taken off-study) will take place per CCR SOP ADCR-2, CCR Participant 
Registration & Status Updates found at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825.
2.3.1
Screen Failures
Screen failures are defined as participants who consent to participate in the clinical trial but are 
not subsequently assigned to the study intervention or entered in the study. A minimal set of screen 
failure information is required to ensure transparent reporting of screen failure participants, to meet 
the Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to 
respond to queries from regulatory authorities. Minimal information includes demography, screen 
failure details, eligibility criteria, and any serious adverse event (SAE).
Individuals who do not meet the criteria for participation in this trial (screen failure) because of a 
laboratory test abnormalities or non-measurable disease may be rescreened.

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2.3.2
Treatment Assignment 
Cohorts
Number
Name
Description
1
Cohort 1
Participants with recurrent or metastatic ONB, checkpoint-
naïve
2
Cohort 2
Participants with recurrent or metastatic ONB, checkpoint-
resistant
Arms
Number
Name
Description
1
Arm 1
Treatment with Bintrafusp alfa
Arm Assignment
Participants in Cohorts 1 and 2 will be assigned to Arm 1.
2.4
BASELINE EVALUATION
All participants are required to complete baseline evaluations within the below designated intervals 
prior to the first planned dosing of the study drug. 
Tests performed during screening or on another NIH protocol within the designated time frame before 
first dose of the study drug do not need to be repeated for the baseline evaluation, unless otherwise 
indicated: 
Within 28 days prior to first dose:
Baseline research tumor biopsy (optional; does not need to be repeated if biopsy was done 
during screening or if performed on another NIH protocol)
o
If intranasal disease is present and amenable, endoscopic endonasal tumor biopsy will be 
performed in an out-participant clinic setting. 
o
Core needle biopsy of metastatic disease will be performed, if present and amenable (see 
Section 5.2.2).
Within 14 days prior to the first dose:
Clinical evaluations:
o
Medical history (interim, signs and symptoms); review of concomitant medications and 
symptoms/side effects; assessment of performance status
o
Physical examination, including weight, vital signs (i.e., temperature, blood pressure, heart 
rate, respiratory rate, oxygen saturation with pulse oximetry), and skin assessment 
Laboratory evaluations:
o
Urine or serum pregnancy test (β-HCG) for WOCBP (see Inclusion Criteria 2.1.1.7 for 
definition of WOCBP)

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o
CBC with differential 
o
Coagulation panel: PT, INR, PTT/aPTT 
o
Serum biochemical profile: 
o
Acute care panel (Na+, K+, Cl-, CO2, creatinine, glucose, urea nitrogen)
o
Mineral panel (albumin, calcium total, magnesium total, phosphorus)
o
Hepatic panel (AST/GOT, ALT/GPT, total bilirubin, direct bilirubin, alkaline 
phosphatase)
o
CRP
o
LDH 
o
Amylase, lipase
o
Urinalysis
o
Thyroid function tests: thyroid stimulating hormone (TSH) and free thyroxine (FT4)
o
Research blood samples for correlative studies. Please refer to Section 5 for details. 
3
STUDY IMPLEMENTATION
3.1
STUDY DESIGN
This is a single-site, open-label Phase 2 study of bintrafusp alfa in up to 21 checkpoint-naïve (CN) 
participants with recurrent or metastatic ONB (see Schema 1). Up to 8 checkpoint-resistant (CR) 
participants will be enrolled as an additional cohort in parallel with CN participants and evaluated 
separately; accrual for CR participants will end when the preset number of CN participants has 
been accrued.
Schema 1: Treatment and response assessment schedule. 
3.1.1
Treatment period
Participants will be treated with bintrafusp alfa 1200 mg intravenous (IV) every two weeks, for a 
total of 26 doses, at which point the drug will be withheld. Treatment will continue until 
completion of 26 doses, disease progression, unacceptable toxicity, or other stopping criterion per 
Section 3.4.1.
The primary endpoint of ORR per RECIST 1.1. criteria will be augmented with secondary 
endpoints including safety, tolerability and PFS, and with exploratory correlative studies.
All ongoing testing and procedures will take place per the Study Calendar (Section 3.7). 
Participants who complete 26 doses of bintrafusp alfa will have the drug withheld and will be 
followed with surveillance imaging per Section 3.1.3. However, participants who achieve 

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complete response, partial response, stable disease without significant toxicity may continue 
treatment beyond 26 doses of bintrafusp alfa at the discretion of the investigator.
3.1.2
Retreatment 
Participants with evidence of disease progression following treatment discontinuation after 26 
doses will be allowed re-treatment with bintrafusp alfa using the same dosing regimen, while the 
trial is ongoing. Retreatment will start after repeat of baseline evaluation and clinical assessment. 
The second course of treatment will follow the same principles of up to 26 doses, with post-
completion imaging surveillance per Section 3.1.3. 
3.1.3
End-of-Treatment
An End-of-Treatment visit should take place as soon as possible within 14 days of the decision to 
discontinue treatment prematurely before completion of 26 doses (See Study Calendar for further 
details and assessments). 
3.1.4
Post-Treatment Follow-Up: Safety and Long-term
A safety follow-up visit will be scheduled within 28 days (+/- 7 days) following last treatment (See 
Study Calendar for further details and assessments).
Subsequent post-treatment follow-up will occur every 3 months (+/- 2 weeks) starting after the 
safety visit, for the first year, then every 6 months (+/- 4 weeks) for years 2 – 5, and then annually 
(+/- 6 weeks) thereafter, at the discretion of the investigator (See Study Calendar for further 
details and assessments).
3.2
STUDY ACCRUAL STOPPING RULE
Once the 6th participant had reached the 6 months follow up period (or potentially would have 
reached the 6 months follow-up if the participant died prior to the 6 months follow-up), the study 
will be halted for a DSMB review of the available data if more than 85% of participants have PD 
≤ 6 months following the first dosage. In the absence of literature information on response rates 
with other treatments in the second-line, his threshold comes from the considerations of 
acceptable response rates used for sample size determination in Section 10.2.
3.3
DRUG ADMINISTRATION
3.3.1
Dosage of bintrafusp alfa
Participants will receive bintrafusp alfa 1,200mg IV over 60 minutes (+/- 20 minutes) once every 
2 weeks. Bintrafusp alfa will be administered as a flat dose of 1,200 mg independent of body 
weight (starting dose and all subsequent dose administrations).
3.3.2
Preparation of bintrafusp alfa
Visually inspect the vial for particulate matter and discoloration. Bintrafusp alfa is a clear, 
colorless to slightly yellow solution. Discard the vial if the solution is cloudy, discolored, or 
contains particulate matter. Further dilute the bintrafusp alfa in 0.9% sodium chloride to a final 
concentration between 0.16 mg/mL to 9.6 mg/mL. Gently invert the bag to mix the diluted solution 
and avoid foaming or excessive shearing. Inspect the solution to ensure it is clear, colorless, and 
free of visible particles. Discard any partially used or empty vials.

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3.3.3
Administration of bintrafusp alfa
Infusion: Administer the diluted solution via IV infusion with a mandatory 0.2 micron in-line filter 
over 60 minutes. Infusions may be done peripherally or via central venous access device (not 
required by study). Prior to infusion via port, the primary port material must be an approved 
material as indicated in “PowerPort Material Analysis for M7824 Administration,” a CCR 
pharmacy document. Do not co-administer other drugs through the same intravenous line. After 
administration, a flush of the line with 0.9% NaCl is recommended but not mandatory. 
Please refer to Appendix B for administration rates following an infusion-related reaction. 
Premedication: To mitigate potential infusion-related reactions, premedication with an 
antihistamine and with acetaminophen (for example, 25-50 mg diphenhydramine and/or 500-650 
mg acetaminophen) within approximately 30 to 60 minutes prior to the infusion of bintrafusp alfa 
is optional and at the discretion of the investigator. The premedication regimen may be modified 
per local site procedures and based on participant-specific factors.
For prophylaxis of flu-like symptoms, a NSAID, for example, ibuprofen 400 mg or comparable 
NSAID dose, may be administered 2 hours before and 8 hours after the start of each dose of 
bintrafusp alfa IV infusion, in participants without contraindications to NSAIDs (including allergy 
to class, renal function impairment, concurrent glucocorticoids). 
Setting: Bintrafusp alfa should be administered in a setting that allows for immediate access to an 
intensive care unit or equivalent environment and administration of therapy for anaphylaxis, such 
as the ability to implement immediate resuscitation measures. Glucocorticoids (dexamethasone 10 
mg), epinephrine (1:1,000 dilution), allergy medications (IV antihistamines), bronchodilators, or 
equivalents, and oxygen should be available for immediate access.
NOTE: Treatment with bintrafusp alfa is planned to be administered on an outpatient basis. At the 
discretion of the investigator (e.g., for additional monitoring, participant social reasons, scheduling 
logistics, etc.), participants may be treated on an inpatient basis. Any such cases of elective 
hospital admission are not considered reportable serious adverse events per Section 8.1.2.
Observation period: Participants must be monitored for infusion-related reactions after bintrafusp 
alfa infusions for a minimum of 30 minutes for the first 4 infusions and as clinically indicated 
thereafter.
Reported adverse events and potential risks are described in Section 14.1.2. Participants will be 
encouraged to report any and all adverse events.
3.4
DOSE MODIFICATIONS
3.4.1
Discontinuation
Treatment with bintrafusp alfa will be discontinued in participants experiencing specific adverse 
events; subjects will remain on study for follow up of survival. Treatment will be discontinued in 
any participant in the case of: 

Any Grade 4 or higher adverse drug reactions (ADRs) graded according to NCI CTCAE v5.0 
and assessed as possibly related to that agent by the Investigator, except for laboratory values 
that are asymptomatic or resolve to Grade ≤ 1 or baseline grade within 7 days without medical 
intervention. 

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
Any Grade 3 ADRs possibly attributed to any agent except for any of the following:
o
Transient (≤ 48 hours) Grade 3 nausea and vomiting, headache, flu-like symptoms, 
fever, controlled with appropriate medical management.
o
Tumor flare phenomenon defined as local pain, irritation, or rash localized at sites 
of known or suspected tumor.
o
Endocrinopathy that can be medically managed with hormone replacement.
o
Keratoacanthoma and squamous cell carcinoma of the skin. Suspicious skin lesions 
will be evaluated by dermatology and managed per recommendations (Appendix 
B: Recommendations for Management of IRRs and AEs, Table C), including 
potential removal of the lesion. 
o
Grade 3 laboratory test abnormalities that resolve to Grade ≤ 1 or to baseline Grade 
within 7 days with appropriate medical management or Grade 3 laboratory test 
abnormalities that are determined not to be clinically significant or asymptomatic.
o
Grade 3 anemia with Hgb <8.0 g/dL that is clinically manageable with PRBC 
transfusions does not require treatment discontinuation.
o
Any Grade 3 ADR which in the opinion of the investigator is not clinically relevant 
or can be managed with minimal risk to the participant (e.g. placement of a pleural 
catheter for recurrent inflammatory pleural effusions).
3.4.2
Dose delay

Bintrafusp alfa should be withheld for Grade ≥ 2 epistaxis or any Grade ≥ 2 toxicity 
possibly attributed to the study agent until resolution to Grade ≤ 1 unless the toxicity in the 
opinion of the investigator is not clinically relevant or can be medically managed with 
minimal risk to the participant. Should a clinically relevant grade 2 or 3 toxicity persist for 
more than 4 weeks, consideration should be given to discontinuing treatment at the 
discretion of the investigator. 

Laboratory abnormalities which are clinically non-significant and/or unrelated to the agent 
in the judgement of the investigator, will not lead to dose delays. 

Grade 3 fatigue, headache, nausea, emesis that resolve to Grade ≤ 1 with appropriate 
medical management will not lead to dose delays. 

Management recommendations for infusion-related adverse reactions are found in 
Appendix B: Recommendations for Management of IRRs and AEs, Table A Management 
of Infusion-related Reactions and should be followed along with institutional standards.

Immune-related adverse reactions (irAE) should lead to treatment modifications and 
management per the summarized NCCN recommendations found in in Appendix B: 
Recommendations for Management of IRRs and irAEs, Table B Management of immune-
related adverse events. Investigators may refer to the relevant guidelines available by 
ASCO (62), SITC (63), NCCN (64), and ESMO (65).

For non-medical logistical reasons, unrelated acute illnesses, or palliative radiation, 
scheduled assessments and dosing can be delayed up to 2 months. Following this interval 
treatment may resume, and where at all possible, dosing should be restarted to keep in line 
with the original treatment schedule.

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
Local tumor flare phenomenon defined as local pain, irritation, or rash localized at sites of 
known or suspected lesions will not be considered adverse event or lead to dose 
interruptions.
3.4.3
Monitoring post-biopsy
For biopsy performed in the ENT clinic, monitoring will be per the ENT surgeon performing the 
biopsy. If the biopsy is done in Interventional Radiology, the standard clinical recovery procedures 
for patient safety will apply.
3.4.4
Dose reductions
Bintrafusp alfa doses may be reduced to a 600 mg or 300 mg flat dose per investigator discretion 
(e.g., for  ≥ grade 1 hemorrhage due to bintrafusp alfa).
3.5
ASSESSMENTS ON TREATMENT
Upon confirmation of eligibility and successful registration, and following completion of the 
Screening/Baseline visits, participants will begin treatment with bintrafusp alfa.
Following initial agent administration on Week 1, pre-dose assessments may be performed up to 
5 days prior to the day of scheduled administration, except where otherwise noted. Results of all 
applicable procedures and tests are to be reviewed prior to each scheduled administration. 
Additional clinical and other appropriate evaluations may be performed as clinically indicated. 
Refer to the Study Calendar (Section 3.7) for an overview of all tests and procedures to be 
conducted during screening/ baseline, on study/ during treatment, upon discontinuation of 
treatment, and during follow up. 
3.6
STUDY INTERVENTION COMPLIANCE
Adherence to the protocol will be verified by reviewing the Medical Administration Record 
(MAR) section of the medical record, which will serve as source documentation.

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3.7
STUDY CALENDAR
Post Treatment 
Follow-up14
Procedure
Screening1
Baseline 2
Week 1
Subsequent 
Weeks 
(2N+1)3, 14
End of
 treatment4, 14
Safety5
Long
 Term6
Treatment
Bintrafusp alfa 7
X
X
Assessments
Histologic confirmation
X
Height
X
Medical History and Performance Status
X
X
Physical Exam (including weight, signs & symptoms, skin assessment) 
X
X
X
X
X
X
Vital signs (including pulse oximetry), weight
X
X
X
X
X
X
HIV, HCV, HBV
X
NIH Advance Directives Form8
X
12-lead EKG
X
X
X
CBC with differential
X
X
X
X
X
X
Biochemical profile (acute care, mineral, hepatic panels)
X
X
X
X
X
X
Coagulation profile (PT, INR, PTT/aPTT)
X
Troponin I
X
Creatine kinase (CK/CPK)
X
CD4 (if indicated)
X
Lymphocyte phenotype TBNK (T, B, and natural killer cells)
X
LDH
X
CRP
X
X
X
TSH, Free T4, lipase, amylase
X
X
X
X9
Tumor markers
X
X15
Urinalysis
X
X
24-hour urine collection (if indicated)
X
Pregnancy test (urine/serum HCG in WOCBP)
X
X
X
X

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Post Treatment 
Follow-up14
Procedure
Screening1
Baseline 2
Week 1
Subsequent 
Weeks 
(2N+1)3, 14
End of
 treatment4, 14
Safety5
Long
 Term6
Tumor imaging and assessment
X
X10
X
PET/CT scans13
X
Adverse Events
X
X
X
X
Concomitant Medications
X
X
X
X
X
Correlative Research Studies (Section 5.1)
Tumor tissue (biopsy)11
X
X
Blood samples12
X
X
X
Telephone follow-up
X
X
1.
Screening evaluations performed within 28 days prior to the first drug administration, unless specified in Section 2.2.2
2.
Baseline evaluation performed within 14 days prior to the first drug administration.
3.
Every odd numbered week for up to 51 weeks. Allowance for scheduling changes: Brief changes (up to 1 days earlier or up to 3 
days later) in bintrafusp alfa administration and indicated evaluations may occasionally be required due to travel delays or 
restrictions, airport closure, inclement weather, family responsibilities, security alerts, government holidays, complications of 
disease not attributable to disease progression or protocol therapy, etc. These delays will not be considered protocol deviation. 
The timing of subsequent bintrafusp alfa administrations will be adjusted to maintain a minimum interval of 11 days between 
bintrafusp alfa administrations. Any dose that cannot be accommodated within this window will be skipped and the dose not 
made up. In the event of a durable PR or CR after one year on trial, further treatment may be held (even if a total of 26 doses has 
not been given) and scheduled assessments may be performed at 3-month (+/- 2 weeks) intervals at the discretion of the 
investigator. 
4.
End of Treatment visit (EOT): within 14 days of the decision to discontinue treatment prematurely before completion of 26 doses. 
Clinical Center clinic visit preferred; if the participant cannot return to the Clinical Center for this visit, a request will be made to 
collect required clinical labs (specify as needed) from a local physician or laboratory. If this is not possible, participants may be 
assessed by telephone/email for symptoms. Does not need to be completed if drug is withheld after 26 doses.
5.
28 days (+/- 7 days) following last treatment. Clinical Center clinic visit preferred; if the participant cannot return to the Clinical 
Center for this visit, they may be assessed by telephone/email for adverse events.

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6.
Subsequent Post-treatment follow-up: Every 3 months (+/- 2 weeks), starting after the safety visit for the first year, followed by 
every 6 months (+/- 4 weeks) for years 2-5, and then annually (+/- 6 weeks) thereafter at the discretion of the investigator. Follow-
ups may be done by phone/email or by clinic visit at the discretion of the investigator. Follow-up via telephone/email will include 
survival, adverse events, and assessment of further tumor therapy; furthermore, routine outside blood, urine, and imaging results 
may be collected and used for analysis at the discretion of the investigator. Any other evaluations and tests should be performed 
as clinically indicated. Participants who have not progressed on treatment will be scanned until progression. Those that completed 
the previous 26-doses course and have progression will be invited for an additional course (26 doses) at the time of progression. 
7.
Bintrafusp alfa administered IV at flat dose of 1,200 mg.
8.
As indicated in Section 12.3, all subjects will be offered the opportunity to complete an NIH advance directive form. This should 
be done preferably at baseline but can be done at any time during the study as long as the capacity to do so is retained. The 
completion of the form is strongly recommended but is not required.
9.
Every 6 weeks.
10. Imaging (Section 6.3) will be performed every 8 weeks (+/- 1 week). In the event of a PR or CR, tumor imaging assessments may 
be performed every 3 months (+/- 2 weeks) at the discretion of the investigator. Tumor assessment should be continued beyond 
end of treatment in participants who have not experienced PD until they experience PD in order to assess PFS. Additional imaging 
to be performed at the investigator’s discretion. Imaging performed in outside facilities maybe utilized in the case of travel 
restrictions or delays, airport closures, inclement weather, family responsibilities, security alerts and government holidays, etc. 
Nuclear bone scan or imaging may be done for individuals with known/suspected bone lesions at screening; in these cases bone 
scans should be done in follow-up for response assessments. 
11. Optional biopsies: at baseline (within 2 weeks prior to first treatment) and within 2 weeks of first imaging restaging; optional 
biopsy at/near progression, where clinically feasible. 
12. Where feasible, blood samples for Correlative Research Studies (see Section 5) will be collected at baseline, W1, W3, W9, and 
at the EOT. Collection can occur +/- 3 days for any specified timepoint. May also be collected at restaging visits/at time of 
biopsies per PI discretion. 
Where feasible, samples for PK analysis/ADA will be drawn prior to infusion on W1, W3 and W9 and/or with EOT labs if 
participant comes off treatment prior to any of these timepoints.
13. PET/CT (FDG or Dotatate) scans will be done at screening and at the time of first treatment response evaluation (w8). Then a 
third one at/near radiographic progression (if there is progression). Effort will be made to keep the same PET/CT type, depending 
on logistics and availability.

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14. Any visits for which administration of trial medication is not planned such as treatment held for AEs, EOT and post-treatment 
follow-up, assessment may be a telehealth (remote) visit with a member of the study team (e.g., if the patient is not able to return 
to the NIH CC). Remote visits will be conducted in compliance with NIH guidelines and FDA regulations. A patient may be 
referred to their local provider or asked to come to the NIH CC for an in-person assessment, if clinically indicated, and at the 
discretion of the PI.  In the case of any visits with participants’ local providers, records will be requested. Labs may be drawn 
locally (interlaboratory variability is not a concern, as these are routine, standardized laboratory tests).
15. Tumor markers (Chromogranin and Neuron Specific Enolase) to be drawn with each restaging. 

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3.8
COST AND COMPENSATION 
3.8.1
Costs
NIH does not bill health insurance companies or participants for any research or related clinical 
care that participants received at the NIH Clinical Center. If some tests and procedures are 
performed outside the NIH Clinical Center, participants may have to pay for these costs if they are 
not covered by insurance company. Medications that are not part of this study will not be provided 
or paid for by the NIH Clinical Center. 
3.8.2
Compensation
There will be no compensation provided in this study.
3.8.3
Reimbursement 
The NCI will cover the costs of some expenses associated with protocol participation. Some of 
these costs may be paid directly by the NIH and some may be reimbursed to the 
participant/guardian as appropriate. The amount and form of these payments are determined by 
the NCI Travel and Lodging Reimbursement Policy.
3.9
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY CRITERIA
Prior to removal from study, effort must be made to have all subjects complete a safety visit 
approximately 28 days after the last dose of study therapy. Additional visits and follow up will 
continue as per Section 3.7. Participants who refuse to return for this visit will be asked to review 
any safety concerns by phone within this time period. 
3.9.1
Criteria for removal from protocol therapy

Participant requests to be withdrawn from active therapy.

Unacceptable Toxicity as defined in Section 3.4.1 that require treatment 
discontinuation. 

Completion of treatment.

Disease Progression: Clinical or radiographic progression of disease, except where 
per investigator clinically appropriate and the participant is achieving clinically 
meaningful benefit from treatment with bintrafusp alfa (See also Section 3.9.1.1). 

Intercurrent illness that prevents further administration of the treatment. 

Start of another systemic anticancer treatment or participation in another 
investigational therapeutic trial. Focal palliative radiotherapy, ablation, or surgery to a 
site of disease will not necessitate removal from protocol therapy.

Investigator discretion.

Non-compliance with study treatment or procedure requirements. 

Positive pregnancy test.

Study is cancelled for any reason. 

Permanent loss of capacity to give consent.

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Participants who are off-treatment but still on-study will have remaining study procedures 
completed as indicated by the study protocol. 
3.9.1.1
Treatment Beyond Progression
Response patterns to immunotherapy have included observations of clinical response after initial 
increases in tumor burden (termed “pseudo-progression”). Consequently, it is preferable that 
where clinically appropriate, participants remain on treatment past initial radiographic progression 
until disease progression is confirmed by subsequent imaging, 4 to 6 weeks (preferably 6 weeks 
but not later) after progression has been determined per RECIST1.1. (1) If progression is based on 
the occurrence of a new lesion in an area not scanned at Baseline, a further on-study scan 6 weeks 
later should be considered before performing the 28-day Safety follow-up visit. Clinically 
appropriate context entails the following:

There are no new or concerning symptoms.

There is no decline in ECOG PS.

The Investigator does not consider it necessary to administer urgent salvage medical 
intervention.
3.9.2
Off-Study Criteria

Participant requests to be withdrawn from study.

Screen failure.

Participant lost to follow up.

Death.

Investigator discretion. 

Study is cancelled for any reason.
3.9.3
Lost to Follow-up
A participant will be considered lost to follow-up if he or she fails to return for 4 consecutive 
scheduled visits and is unable to be contacted by the study site staff. 
The following actions must be taken if a participant fails to return to the clinic for a required study 
visit:

The site will attempt to contact the participant and reschedule the missed visit within 4 
weeks and counsel the participant on the importance of maintaining the assigned visit 
schedule and ascertain if the participant wishes to and/or should continue in the study.

Before a participant is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the participant (where possible, 3 telephone calls and, if 
necessary, an IRB approved certified letter to the participant’s last known mailing address 
or local equivalent methods). These contact attempts should be documented in the 
participant’s medical record or study file. 

Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.

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3.9.4
Trial discontinuation

Evidence of inefficacy of the investigational drug (evidence of inefficacy may arise from 
this trial or from other trials). 

Occurrence of significant previously unknown adverse reactions or unexpected intensity 
or incidence of known adverse reaction (unfavorable safety findings may arise from 
clinical or non-clinical examinations, e.g., toxicology). 

Sponsor decision that continuation of trial is unjustifiable for medical or ethical reasons. 

Poor enrollment of participants, making completion of trial unlikely within acceptable time 
frame. 

Discontinuation of development of the investigational drug. 

Termination or suspension upon request of health authorities.
4
CONCOMITANT MEDICATIONS/MEASURES
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).
For this protocol, a prescription medication is defined as a medication that can be prescribed only 
by a properly authorized/licensed clinician. Medications to be reported in the Case Report Form 
(CRF) are concomitant prescription medications, over the counter (OTC) medications, herbal 
supplements, and IV medications and fluids. If changes occur during the trial period, 
documentation of drug dosage, frequency, route, and date may also be included on the CRF. All 
concomitant medications received starting from 30 days prior to the first dose of trial treatment 
and 30 days after the last dose of trial treatment should be recorded.
4.1
ACCEPTABLE MEDICATIONS/MEASURES
All routine and appropriate treatments and supportive care (including blood products) that the 
investigator considers necessary for a participant’s welfare or symptom alleviation may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care. 
Palliative radiotherapy to non-targeted lesions delivered in a normal organ-sparing technique may 
be administered during the trial. The assessment of PD will not be based on the necessity for 
palliative radiotherapy. 
Traditional herbal or homeopathic or natural medicines should be avoided. Ingredients for such 
medicines have not been fully studied, and their use may result in unanticipated drug-drug 
interactions that may cause toxicity or confound assessment of toxicity. Herbal medications 
include, but are not limited to St. John’s Wort, kava, ephedra, gingko biloba, yohimbe, saw 
palmetto, black cohosh, ginseng, turmeric, and curcumin. 

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4.2
PROHIBITED MEDICATIONS
Medications or vaccinations specifically prohibited in the exclusion criteria (see Section 2.1.2) are 
not allowed during the ongoing trial. If there is a clinical indication for a prohibited 
medication/measure during the trial, discontinuation from trial therapy may be required, but the 
participant may remain on study for follow up. The following treatments should not be 
administered during the trial: 

Other immunotherapies or immunosuppressive drugs (for example, chemotherapy or systemic 
glucocorticoids except for prophylaxis or treatment of allergic reactions, endocrine 
replacement therapy as low dose prednisone [≤ 10 mg daily] or equivalent, for the treatment 
of irAEs, or for short courses (≤ 14 days) as appropriate medical therapy for unrelated medical 
conditions (e.g., asthma). Glucocorticoids with no or minimal systemic effect (topical, 
inhalation) are allowed. 

Prophylactic use of glucocorticoids for infusion related reactions. NOTE: Glucocorticoid 
administration prior to CT scans in participants with intravenous contrast allergy is allowed. 

Any live vaccine therapies for the prevention of infectious disease. Examples of live vaccines 
include, but are not limited to, the following: measles, mumps, rubella, varicella/zoster, yellow 
fever, rabies, BCG, and typhoid vaccine. Administration of inactivated vaccines is allowed 
(for example, inactivated influenza vaccines, recombinant zoster vaccine, or locally approved 
COVID vaccines). 

Systemic anticancer treatment. 
5
CORRELATIVE STUDIES FOR RESEARCH
5.1
SUMMARY
A description of research correlative studies including a brief statement of rationale and processing 
information is provided below. The list is not all inclusive and studies may or may not be 
performed in select participants based on investigator discretion and available resources. Studies 
may include, but are not limited to, the following:

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Test / Assay
Collection Details
(approx. volume, 
tube type1)
Collection Time 
(+/- 48hrs)
Location of Specimen 
Analysis
Storage
Tumor Tissue
Sequencing, gene expression analysis, 
proteomics, and methylation
NIDCD or NFGCF
Immune markers (IHC)
FFPE / snap 
frozen tissue
GMB TIME Lab, London Lab
Organoid cultures
London Lab
Cell line and participant derived xenograft 
development
London Lab and NCI PDM
RNA expression level of 770 genes
T cell clonality (ImmunoSeq)
Tumor tissue
See Study Calendar
LTIB and NFGCF
NIDCD tissue 
repository
Blood Samples
WBC DNA Sequencing3
NFGCF
Standard and 123 immune cell subsets 
(FACS)
Functional Analysis of immune cell subsets 
(FACS)
Antigen Specific Immune Response 
(Cytokine Staining Assay)
LTIB
T cell clonality (ImmunoSeq)
60-80 mL blood 
for PBMCs, 
Sodium Heparin 
tubes (green top)
See Study Calendar
LTIB and NFGCF
CSP

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RNA expression level of 770 genes
Soluble factors (incl. sCD27, sCD40L, 
ELISA)
8 mL blood for 
serum, SST
LTIB
Circulating free tumor DNA(PCR)
10 mL (Streck 
tubes)
LTIB and NIH Core Facility 
Extracellular/ exosome DNA
10 mL (Streck 
tubes)
Dr. Jenifer Jones Lab
CSP
Pharmacokinetics/ADA(ELISA)
8 mL blood for 
serum (SST)
EMD Serono
CSP
TGFβ1 levels (ELISA/bead based multiplex 
assay) 
10 mL EDTA 
lavender top tube
LTIB
CSP
1 Tubes/media may be adjusted at the time of collection based upon materials available or to ensure the optimal samples are collected 
for planned analyses. 
2 LTIB: Laboratory of Tumor Immunology, NIDCD: National Institute of Deafness and Craniofacial Disorders, NFGCF: NCI 
Frederick Genomic Core Facility; NCI Participant-Derived Models Repository: NCI PDM; SST: serum separation tubes 
3 Control for sequencing studies of tumor, circulating tumor DNA, and extracellular/exosome DNA
Research blood samples will be sent to the Clinical Services Program – Leidos Biomedical Research, Inc. (CSP) for barcoding, initial 
processing and storage. Tissue will be sent to the NIDCD tissue repository. From these facilities, coded, linked samples will be sent to 
the designated labs for analysis upon request

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5.2
SAMPLE COLLECTION AND PROCESSING
For the planned analyses described below, laboratories may share resources or collaborate if 
appropriate. Portions of all samples may be banked for future research analyses; prospective 
consent will be obtained during the informed consent process. 
For adult subjects: The amount of blood that may be drawn from adult participants for research 
purposes shall not exceed 10.5 mL/kg or 550 mL, whichever is smaller, over any eight-week 
period.
5.2.1
Peripheral blood collection
Subjects will have approximately 130 mL of peripheral blood drawn at each time point specified 
in Study Calendar 3.7 (six to eight, 10-mL green top sodium heparin tubes for PBMC samples, 
two 8-mL serum-separating tube for serum samples, three 10-mL lavender EDTA tubes).
5.2.1.1
Immune Phenotyping – PBMCs
Where possible, exploratory immunologic studies will be conducted to evaluate the study drug’s 
effect on the immune response before and after treatment, to gain insight into potential biomarkers, 
and help improve the administered therapy. Blood will be collected as per Study Calendar. The 
following immune assays may be performed at the Laboratory of Tumor Immunology and Biology 
(LTIB) at the NCI’s Center for Cancer Research (CCR) in select participants where adequate 
samples are available:
1. PBMCs may be analyzed for changes in standard immune cell types (CD4 and CD8 T cells, 
natural killer [NK] cells, regulatory T cells [Tregs], myeloid-derived suppressor cells 
[MDSCs], and dendritic cells) as well as 123 immune cell subsets, using multi-color flow 
cytometry.
2. PBMCs from selected subjects may be analyzed for function of specific immune cell 
subsets, including CD4 and CD8 T cells, NK cells, Tregs, and MDSCs using flow-based 
assays.
3. PBMCs may be analyzed for tumor antigen-specific immune responses using an 
intracellular cytokine staining assay. PBMCs will be stimulated in vitro with overlapping 
15-mer peptide pools encoding tumor-associated antigens; control peptide pools will 
involve the use of human leukocyte antigen peptide as a negative control and CEFT peptide 
mix as a positive control. CEFT is a mixture of peptides of CMV, Epstein-Barr virus, 
influenza, and tetanus toxin. Post-stimulation analyses of CD4 and CD8 T cells will involve 
the production of IFN-γ, IL-2, TNF, and the degranulation marker CD107a. If sufficient 
PBMCs are available, assays may also be performed for the development of T cells to other 
tumor-associated antigens.
4. Changes in T-cell clonality score using Adaptive Biotechnologies TCR-seq assay.
5. Changes in inflammatory gene signature using Nanostring’s nCounter Human PanCancer 
Immune Profiling Panel.
5.2.1.2
Soluble Factors
Samples for soluble factor analysis will be collected as per Study Calendar (Section 3.7). 
Where possible, sera and/or plasma may be analyzed pre- and post-therapy for the following 
soluble factors: sCD27, sCD40 ligand using commercial ELISA kits. Also, sera and/or plasma 

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may be analyzed for changes in cytokines (IFN-γ, IL-10, IL-12, IL-2, IL-4, etc.), chemokines, 
antibodies, tumor-associated antigens, and/or other markers using ELISA or multiplexed assays 
(e.g., Mesoscale, Luminex, cytokine bead array). 
5.2.2
Tumor tissue samples
Archival tumor samples will be requested, where available. For participants with lesions amenable 
to biopsy, tumor biopsies will be performed (see Section 2.4 and Study Calendar 3.7). Selection 
of site for biopsy will be as per Section 2.4; an attempt will be made for site-matching between 
pre-treatment and on-treatment tumor biopsies. The biopsy will be performed per routine standard 
of care, by ENT/Surgery consultants or Interventional Radiology, with Imaging guidance (e.g., 
ultrasound or CT) as appropriate. Conscious sedation may be used, if warranted, and the use and 
risks to the participant are minimal. Endoscopy, CT or other imaging guidance will be used as 
appropriate. If these procedures are not considered to be of minimal risk to the participant, the 
biopsy will not be performed, and this will not be reported as a deviation of the protocol. The 
participant will consent at the time of the procedure. For the biopsies, if the participant refuses, the 
refusal will be documented in the medical record and in the research record. 
Tumor samples will be sent to the Laboratory of Pathology for disease evaluation; remaining 
samples will be used for research. Tissue samples for research may also be stored in the NIDCD 
tissue repository. 
5.2.2.1
RNA and T-cell Receptor Clonality Analysis of Blood and Tumor Tissue
Where possible, RNA expression and T-cell receptor clonality analysis will be done on the 
peripheral blood as well as archived tumor tissue or optional biopsies to help further evaluate 
changes in immune response and RNA expression levels with treatment as well as to determine 
tumor and infiltrating lymphocyte characteristics which may be predictive of response to 
treatment. In addition, these analyses will also be used to gauge resistance mechanisms and 
additional targets for future therapy. Coded, linked samples may be analyzed for RNA expression 
levels using the Nanostring platform and T-cell receptor clonality using the ImmunoSeq platform 
(LTIB and NCI Frederick Genomic Core Facility).
5.2.2.2
Bintrafusp alfa Pharmacokinetics
Serum PK measurements of Bintrafusp alfa (schedule per Study Calendar) may be measured. 
Coded, linked samples will be shipped to EMD Serono for analysis under existing CRADA, to 
collect data which will provide insight into population PKs of bintrafusp alfa in participants 
receiving these novel combinations.
5.2.2.3
ADA
Anti-Drug Antibody (ADA) development may lead to loss of efficacy of administered monoclonal 
antibodies. Measuring titers (schedule per Study Calendar) will examine if lack of efficacy of 
bintrafusp alfa is due to ADA development. Serum samples may be analyzed by EMD Serono with 
ELISA, under existing CRADA. 
5.2.2.4
Analyses of Tumor Tissue for Immune Markers 
Study of immune infiltration as well as immune mediated pathways such as PD-L1 status within 
the tumor microenvironment pre vs. post treatment by IHC and/or multiplex immunofluorescence 
may be performed by the GMB TIME Lab or by Dr. Nyall London (NIDCD). Where available, 
archival tumor samples may be requested for pre-treatment analysis (preferably tissue samples 

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from the last 6 months). For participants with lesions amenable to biopsy, biopsies may be 
performed as described in Section 5.2.2. 
5.2.3
Sequencing, gene expression analysis, proteomics, and methylation
Studies characterizing the mutations, gene expression profile, protein analysis, and methylation 
status of ONB specimens will be performed at the NIDCD genomics core facility. Tissue samples 
for research will be stored and obtained from the NIDCD tissue repository.
5.2.4
Organoid cultures
Organoid cultures will be established from tissue specimens in the lab of Dr. Nyall London. This 
will be performed as recently described (67). Specimens directly from either core needle biopsy 
or endoscopic nasal biopsy will be utilized to generate these organoids in vitro. The organoids will 
be utilized to test novel immunotherapeutic approaches as well as interrogate and investigate 
alternative mechanisms of tumorigenesis such as epigenetic regulators and assess the effects of 
small molecule inhibition of these pathways.
5.2.5
Blood genomic material
WBC DNA as a control for sequencing studies as well as circulating tumor DNA and extracellular 
vesicle/exosome DNA will be analyzed in this portion of the protocol. Blood will be collected 
according to the study calendar and transferred to the LTIB. Genomic material may be used as a 
control for sequencing studies. Furthermore, serum and genomic materials may be collected to 
study circulating tumor DNA.
5.3
SAMPLE STORAGE, TRACKING AND DISPOSITION
Samples will be ordered in CRIS and tracked through a Clinical Trial Data Management system. 
Should a CRIS screen not be available, the CRIS downtime procedures will be followed. 
Samples will not be sent outside the National Institutes for Health (NIH) without appropriate 
approvals and/or agreements, if required. 
5.3.1
Sample Management and Storage at Clinical Services Program – Leidos Biomedical 
Research, Inc. (CSP) 
Clinical Services Program – Leidos Biomedical Research, Inc. 
Attn: Theresa Burks 
1050 Boyles Street 
Bldg. 496/Room 121 
Frederick, MD 21702 
On days samples are drawn, Jen Bangh at CSP (part of NCI Frederick Central Repositories) should 
be notified (phone: [301] 846-5893; fax [301] 846-6222). She will arrange same-day courier 
delivery of the specimens. 
All data associated with the participant samples is protected by using a secure database. All 
Clinical Support Laboratory Staff receive annual training in maintaining records’ confidentiality. 
All samples drawn at the NIH Clinical Center will be transported to the Clinical Support 
Laboratory at the Frederick National Laboratory for Cancer Research by couriers. 
Samples will be tracked and managed by Central Repository database, where there is no link to 
personal identifiable information. All samples will be stored in either a -80ºC freezer or vapor 

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phase liquid nitrogen. These freezers are located at NCI Frederick Central Repository in Frederick, 
Maryland. 
NCI Frederick Central Repositories (managed under a subcontract) store, among other things, 
biological specimens in support of NIH clinical studies. All specimens are stored in secure, 
limited-access facilities with sufficient security, backup, and emergency support capability and 
monitoring to ensure long-term integrity of the specimens for research. 
Specimens are stored in accordance with applicable HHS and FDA Protection of Human Subjects 
Regulations in accordance with the subcontractor’s Federal-wide Assurance. The subcontractor’s 
role limited to clinical research databases and repositories containing participant specimens. The 
subcontractor does not conduct or have any vested interest in research on human participants but 
does provide services and support the efforts of its customers, many of which are involved in 
research on human participants. 
It is the intent and purpose of the subcontractor to accept only coded, linked samples and sample 
information. To the limit of our ability, every effort will be made to ensure that protected 
information is not sent electronically or by hard copy or on vial labels. 
Sample data is stored in the Biospecimen Inventory System II (BSI). This inventory tracking 
system is used to manage the storage and retrieval of specimens as well as to maintain specimen 
data. BSI is designed for controlled, concurrent access. It provides a real-time, multi-user 
environment for tracking millions of specimens. The system controls how and in what order 
database updates and searches are performed. This control prevents deadlocks and race conditions. 
For security, BSI has user password access, 3 types of user access levels, and 36 user permissions 
(levels of access) that can be set to control access to the system functions. BSI provides audit 
tracking for processes that are done to specimens including shipping, returning to inventory, 
aliquoting, thawing, additives, and other processes. BSI tracks the ancestry of specimens as they 
are aliquoted, as well as discrepancies and discrepancy resolution for specimens received by the 
repository. If a specimen goes out of the inventory, the system maintains data associated with the 
withdrawal request. Vials are labeled with a unique BSI ID which is printed in both eye-readable 
and bar-coded format. No participant-specific information is encoded in this ID. 
Investigators are granted view, input, and withdrawal authority only for their specimens. They may 
not view specimen data or access specimens for which they have not been authorized. Access to 
specimen storage is confined to repository staff. Visitors to the repositories are escorted by 
repository staff at all times.
5.3.2
Procedures for Storage of Specimens in NIDCD
All participants will also be consented for study #18-DC-0051 entitled “Biospecimen procurement 
for NIDCD clinical protocols”. Procedures detailed in this protocol will be followed regarding 
tumor tissue management. In brief, following enrollment, subjects will be registered and assigned 
a code in CTDB under which the limited demographic and clinical information will be stored. 
Only the code will be used on the specimens to electronically log the specimens using a task-
specific bar-code technology software which has full security and audit functions consistent with 
NIH requirements. Samples and the limited demographic and clinical information will not contain 
PII. Data should be entered within 2 weeks of participant enrollment onto the protocol. The access 
to the code keys will be limited to those designated by the Primary Investigator and will be kept 
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Samples will be stored in freezers, liquid nitrogen containers or tissue cartridge shelves in the 
NIDCD Core laboratory, located in building 10 on the NIH campus, secured by locked doors. 
NIDCD Biospecimen Tissue Core
Building 10, Room 7S244
Attn: Christian Samaniego Dávila, PhD
Notify Christian Samaniego of all incoming specimens: 
Phone: 301-827-6894, cell: 240-495-9775, email: christian.samaniego@nih.gov 
Backup contact #1: Nyall London: Cell: 801-5477-7851, email: nyall.london@nih.gov
Backup contact #2: Clint Allen: Cell: 979-324-5307, email: clint.allen@nih.gov 
Access to samples from a protocol for research purposes will be by permission of the Principal 
Investigator of that protocol in order to be used (1) for research purposes associated with protocol 
objectives for which the samples were collected, or (2) for a new research activity following 
submission and IRB approval of a new protocol and consent, or (3) for use only as unlinked or 
coded samples under the Office of Human Subjects Research Protections (OHSRP) Exemption 
Form guidelines stipulating that the activity is exempt from IRB review. The use of all samples 
will be fully tracked and audit lists of when each sample was used and who used it can be generated 
upon need or request. 
Samples, and associated data, will be stored permanently unless the participant withdraws 
consent. If researchers have samples remaining once they have completed all studies associated 
with the protocol and participant consent has not been withdrawn, samples may be kept 
permanently for possible use in future IRB approved investigations.
5.3.3
Protocol Completion/Sample Destruction
All specimens obtained in the protocol are used as defined in the protocol. Any specimens that are 
remaining at the completion of the protocol will be stored in the conditions described above. The 
study will remain open so long as sample or data analysis continues. Samples from consenting 
subjects will be stored until they are no longer of scientific value or if a subject withdraws consent 
for their continued use, at which time they will be destroyed. 
If the participant withdraws consent the participants data will be excluded from future 
distributions, but data that have already been distributed for approved research use will not be able 
to be retrieved.
The PI will record any loss or unanticipated destruction of samples as a deviation. Reporting will 
be per the requirements of Section 7.2.
5.4
SAMPLES FOR GENETIC/GENOMIC ANALYSIS
5.4.1
Description of the scope of genetic/genomic analysis
The research correlates for this study are expected to include DNA/RNA sequencing of tumors, 
including circulating tumor (ct) DNA. In addition, whole exome sequencing may include 
evaluation for known cancer-related mutations. 
5.4.2
Description of how privacy and confidentiality of medical information/biological 
specimens will be maximized
For any genetic studies performed, the results will be deposited in a database such as dbGaP per 
NIH requirements. Although there is controlled access to such a database, such a submission 

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carries theoretical risks of revealing the identity of the subject. This is discussed in the consent. 
Confidentiality for genetic samples will be maintained as described (Section 6.1). 
5.4.3
Management of Results
Subjects will be contacted if a clinically actionable gene variant is discovered. Clinically 
actionable findings for the purpose of this study are defined as disorders appearing in the American 
College of Medical Genetics and Genomics recommendations for the return of incidental findings 
that is current at the time of primary analysis. (A list of current guidelines is maintained on the 
CCR intranet: https://ccrod.cancer.gov/confluence/display/CCRCRO/Incidental+Findings+Lists). 
5.4.4
Genetic Counseling
Subjects who remain on the study will be contacted at this time with a request to provide a blood 
sample to be sent to a CLIA certified laboratory. If the research findings are verified in the CLIA 
certified lab, the subject will be offered the opportunity to come to NIH (at our expense) to have 
genetic education and counseling to explain this result. If the subject does not want to come to 
NIH, a referral to a local genetic healthcare provider will be provided (at their expense).
This is the only time during the course of the study that incidental findings will be returned. No 
interrogations regarding clinically actionable findings will be made after the primary analysis.
6
DATA COLLECTION AND EVALUATION 
6.1
DATA COLLECTION
The PI will be responsible for overseeing entry of data into a 21 CFR Part 11-compliant data 
capture system provided by the NCI CCR and ensuring data accuracy, consistency and timeliness. 
The principal investigator, associate investigators/research nurses and/or a contracted data 
manager will assist with the data management efforts. Primary and final analyzed data will have 
identifiers so that research data can be attributed to an individual human subject participant.
All adverse events, including clinically significant abnormal findings on laboratory evaluations, 
regardless of severity, will be followed until return to baseline or stabilization of event. 
Document AEs from the first study intervention, study day 1, through 28 days after the subject 
received the last product administration. After 28 days, only adverse events which are serious and 
related to the study investigational agent need to be recorded. 
An abnormal laboratory value will be recorded in the database as an AE only if the laboratory 
abnormality is characterized by any of the following:

Results in discontinuation from the study

Is associated with clinical signs or symptoms 

Requires treatment or any other therapeutic intervention

Is associated with death or another serious adverse event, including hospitalization. 

Is judged by the Investigator to be of significant clinical impact

If any abnormal laboratory result is considered clinically significant, the investigator will 
provide details about the action taken with respect to the test drug and about the 
participant’s outcome.

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End of study procedures: Data will be stored according to HHS, FDA regulations, and NIH 
Intramural Records Retention Schedule as applicable. 
Loss or destruction of data: Should we become aware that a major breach in our plan to protect 
subject confidentiality and trial data has occurred, this will be reported expeditiously per 
requirements in Section 7.2.1. 
6.2
DATA SHARING PLANS
6.2.1
Human Data Sharing Plan
What data will be shared?
I will share human data generated in this research for future research as follows 

Coded, linked data in an NIH-funded or approved public repository.

Coded, linked data in BTRIS (automatic for activities in the Clinical Center)

Identified or coded, linked data with approved outside collaborators under appropriate 
agreements.
How and where will the data be shared? 
Data will be shared through:

An NIH-funded or approved public repository: clinicaltrials.gov, dbGaP

BTRIS (automatic for activities in the Clinical Center)

Approved outside collaborators under appropriate individual agreements.

Publication and/or public presentations.
When will the data be shared? 

Before publication.

At the time of publication or shortly thereafter.
6.2.2
Genomic Data Sharing Plan
Unlinked genomic data will be deposited in public genomic databases such as dbGaP in 
compliance with the NIH Genomic Data Sharing Policy.
6.3
RESPONSE ASSESSMENT
For the purposes of this study, during the study participants should be re-evaluated for response 
every 8 weeks (+/- 1 week), according to the Study Calendar. 
The Investigator may perform scans in addition to a scheduled trial scan for medical reasons or if 
the Investigator suspects PD.
Tumor assessments may include the following evaluations: physical examination (with photograph 
and measurement of skin lesions, as applicable); cross-sectional imaging using computed 
tomography (CT) or magnetic resonance imaging (MRI) scan of the skull base, neck, chest, 
abdomen, and pelvis; nuclear bone scan for subjects with known/suspected bone lesions; and CT 
of the skull base and MRI  of brain (at baseline and follow ups as clinically warranted based on 
symptoms/findings per investigator discretion). The preferred method of disease assessment is CT 
with contrast. If CT with contrast is contraindicated, CT of the chest without contrast and MRI 
scan of the skull base, neck, abdomen/pelvis is preferred. 

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Radiologic imaging: Brain MRI/CT at the baseline and if needed at follow ups. CT scan of skull 
base, neck, chest, abdomen, and pelvis. or MRI. 
In addition, PET (FDG or Dotatate) scan will be acquired at the time of first treatment response 
evaluation, and at/near radiographic progression, where clinically feasible. PET scan may also be 
acquired per investigator discretion to characterize metabolic activity of lesions (target/non-
target/new) beyond cross-sectional measurement-based response categories, such as in cases of, 
discordant response among lesions, durable partial response, or other indeterminate radiological 
changes.
For each participant, the Investigator will designate 1 or more of the following measures of tumor 
status to follow for determining response: CT or MRI images of primary and / or metastatic tumor 
masses, physical examination findings, and the results of other assessments.
The measure(s) to be chosen for sequential evaluation during the trial have to correspond to the 
measures used to document the progressive tumor status that qualifies the subject for enrollment. 
Post-baseline response assessments should follow the lesions identified at baseline. The same 
modality of assessment (e.g., CT) used to identify/evaluate lesions at baseline should be used 
throughout the course of the study unless subject safety necessitates a change (e.g., allergic 
reaction to contrast media).
To assess the primary endpoint of objective response, tumor lesions will be categorized at baseline 
to target and non-target lesions and used for comparison with subsequent measurements according 
to the international criteria proposed by the revised Response Evaluation Criteria in Solid Tumors 
(RECIST) guideline (version 1.1).(1) 
All available images collected during the trial period will be considered. Results for the evaluations 
will be recorded with as much specificity as possible so that pre- and post-treatment results will 
provide the best opportunity for evaluating tumor response. 
Per RECIST 1.1 initial disease progression should be confirmed by imaging after 4 to 6 weeks 
(preferably 6 weeks, but not later than 8 weeks).
Per RECIST 1.1 any CR or PR should be confirmed by a repeat imaging assessment no sooner 
than 4 weeks (preferably at the scheduled 6-week interval). Participants who obtain a confirmation 
scan do not need to undergo the next scheduled imaging assessment if it is due <4 weeks later; 
imaging may resume at the subsequent scheduled timepoint.
If progression is based on the occurrence of a new lesion in an area not scanned at Baseline, a 
further on-study scan 6 weeks later should be considered before performing the 28-Day Safety 
Follow-up visit. 
6.3.1
Disease Parameters
At baseline, tumor lesions will be selected and categorized as target or non-target lesions, defined 
as described below. 
All tumor measurements must be recorded in millimeters (or decimal fractions of centimeters). 
A sum of the longest diameters (SLD) of the non-nodal target lesions will be calculated and 
reported as the baseline SLD. 

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6.3.1.1
Measurable disease
Measurable lesions are defined as those that can be accurately measured in at least one 
dimension (longest diameter to be recorded) as: 
By CT scan: 
o Scan slice thickness 5 mm or under: as >10 mm
o Scan slice thickness >5 mm: double the slice thickness 
With calipers on clinical exam: >10 mm.
Malignant lymph nodes. To be considered pathologically enlarged and measurable, a lymph node 
must be >15 mm in short axis when assessed by CT scan (CT scan slice thickness recommended 
to be no greater than 5 mm). 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 or pathological lymph nodes with ≥10 to <15 mm short axis), are considered 
non-measurable disease. Bone lesions, leptomeningeal disease, ascites, pleural/pericardial 
effusions, lymphangitis cutis/pulmonis, inflammatory breast disease, and abdominal masses (not 
followed by CT or MRI), are considered as non-measurable.
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 participant, these are preferred for selection as target lesions.
6.3.1.2
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. 

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6.3.2
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: Clinical lesions will only be considered measurable when they are superficial 
(e.g., skin nodules and palpable lymph nodes) and 10 mm 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. 
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: The RECIST 1.1 guidelines has defined measurability of lesions on 
CT scan based on the assumption that CT slice thickness is 5 mm or less. If CT scans have slice 
thickness greater than 5 mm, the minimum size for a measurable lesion should be twice the slice 
thickness. 
MRI is also acceptable in certain situations (e.g., for body scans), as detailed per Section 2.4 and 
6.3. 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 preferably be the same as was used at baseline and the 
lesions measured/assessed on the same pulse sequence. Ideally, the same type of scanner should 
be preferably 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: 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 
advised. However, such techniques may be useful to confirm complete pathological response when 

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biopsies are obtained or to determine relapse in trials where recurrence following complete 
response (CR) or surgical resection is an endpoint.
Tumor markers: Tumor markers alone cannot be used to assess response. If markers are initially 
above the upper normal limit, they must normalize for a participant 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 germ cell 
tumors, 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.
6.3.3
Response Criteria
Tumor responses to treatment will be assigned based on the evaluation of the response of target, 
non-target, and new lesions according to RECIST 1.1.
6.3.3.1
Target Lesions Evaluation
Complete Response (CR): Disappearance of all target lesions. Any pathological lymph nodes 
(whether target or non-target) must have reduction in short axis to <10 mm.
Partial Response (PR): At least a 30% decrease in the sum of the diameters of target lesions, taking 
as reference the baseline sum of diameters.

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Progressive Disease (PD): At least a 20% increase in the sum of the diameters of target lesions, 
taking as reference the smallest sum on study (this includes the baseline sum if that is the smallest 
on study). In addition to the relative increase of 20%, the sum must also demonstrate an absolute 
increase of at least 5 mm. (Note: the appearance of one or more new lesions is also considered 
progression).
Stable Disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to 
qualify for PD, taking as reference the smallest sum of diameters while on study.
6.3.3.2
Non-Target Lesions Evaluation
Complete Response (CR): Disappearance of all non-target lesions and normalization of tumor 
marker level. All lymph nodes must be non-pathological in size (<10 mm short axis).
Note: If tumor markers are initially above the upper normal limit, they must normalize for a 
participant to be considered in complete clinical response.
Non-CR/Non-PD: Persistence of one or more non-target lesion(s) and/or maintenance of tumor 
marker level above the normal limits.
Progressive Disease (PD): Appearance of one or more new lesions and/or unequivocal progression 
of existing non-target lesions. Unequivocal progression should not normally trump target lesion 
status. It must be representative of overall disease status change, not a single lesion increase.
Although a clear progression of “non-target” lesions only is exceptional, the opinion of the treating 
physician should prevail in such circumstances, and the progression status should be confirmed at 
a later time by the review panel (or Principal Investigator).
6.3.4
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 participant’s best response assignment will depend on 
the achievement of both measurement and confirmation criteria (See Appendix C: Best Overall 
Response per RECIST 1.1).
6.3.5
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.
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. 
6.3.6
Progression-Free Survival
PFS is defined as the duration of time from start of treatment to time of progression or death, 
whichever occurs first.

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6.3.7
Immune-Related Response Criteria
As an exploratory endpoint antitumor activity will also be evaluated according to iRECIST. (3)
Using iRECIST criteria the following will be incorporated into assessment:
1. An increase in the sum of target lesions of more than 20%, unequivocal increase in non-target 
lesions or new lesions result in iUPD (unconfirmed progressive disease); iUPD can be assigned 
multiple times as long as iCPD (confirmed progressive disease) is not confirmed at the next 
assessment.
2. Progression is confirmed in the target lesion category if the next imaging assessment after iUPD 
(4–8 weeks later) confirms a further increase in sum of measures of target disease from iUPD, with 
an increase of at least 5 mm. Progression is confirmed in the non-target lesion category if 
subsequent imaging, done 4–8 weeks after iUPD, shows a further unequivocal increase in non-
target lesions. Progression is confirmed in the new lesion category if at next assessment additional 
new lesions appear or an increase in size of previously seen new lesions is seen (≥5 mm for sum 
of new lesion target).
3. However, the criteria for iCPD (after iUPD) are not considered to have been met if complete 
response, partial response, or stable disease criteria (compared with baseline and as defined by 
RECIST 1.1) are met at the next assessment after iUPD. The status is reset (unlike RECIST 1.1, 
in which any progression precludes later complete response, partial response, or stable disease). 
iCR, iPR, or iSD should then be assigned; and if no change is detected, then the timepoint response 
is iUPD.
6.4
TOXICITY CRITERIA
The following adverse event management guidelines are intended to ensure the safety of each 
participant while on the study.  The descriptions and grading scales found in the revised NCI 
Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 will be utilized for AE 
reporting. All appropriate treatment areas should have access to a copy of the CTCAE version 5.0. 
A copy of the CTCAE version 5.0 can be downloaded from the CTEP web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm). 

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7
NIH REPORTING REQUIREMENTS / DATA AND SAFETY MONITORING PLAN
7.1
DEFINITIONS
Please refer to definitions provided in Policy 801: Reporting Research Events found  at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements.
7.2
OHSRP OFFICE OF COMPLIANCE AND TRAINING / IRB REPORTING
7.2.1
Expedited Reporting 
Please refer to the reporting requirements in Policy 801: Reporting Research Events and Policy 
802 
Non-Compliance 
Human 
Subjects 
Research 
found 
at: 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements.
Note: Only IND Safety Reports that meet the definition of an unanticipated problem will need to 
be reported per these policies.
7.2.2
IRB Requirements for PI Reporting at Continuing Review
Please refer to the reporting requirements in Policy 801: Reporting Research Events found at 
https://irbo.nih.gov/confluence/pages/viewpage.action?pageId=36241835#Policies&Guidance-
800Series-ComplianceandResearchEventReportingRequirements. 
7.3
NCI CLINICAL DIRECTOR REPORTING 
Problems expeditiously reported to the OHSRP in the NIH eIRB system will also be reported to 
the NCI Clinical Director/designee; therefore a separate submission for these reports is not 
necessary.
In addition to those reports, deaths not reported to the OHSRP/IRB that occur within 30 days after 
receiving a research intervention should be reported via email unless they are due to progressive 
disease. 
To report these deaths, please send an email describing the circumstances of the death to 
NCICCRQA@mail.nih.gov within one business day of learning of the death.
7.4
NIH REQUIRED DATA AND SAFETY MONITORING PLAN
7.4.1
Principal Investigator/Research Team 
The clinical research team will meet on a regular basis (approximately weekly) when participants 
are being actively treated on the trial to discuss each participant. Decisions about dose level 
enrollment and dose escalation if applicable will be made based on the toxicity data from prior 
participants. 
All data will be collected in a timely manner and reviewed by the principal investigator or a lead 
associate investigator. Events meeting requirements for expedited reporting as described in Section 
7.2.1 will be submitted within the appropriate timelines.  
The principal investigator will review adverse event and response data on each participant to 
ensure safety and data accuracy. The principal investigator will personally conduct or supervise 

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the investigation and provide appropriate delegation of responsibilities to other members of the 
research staff. 
7.4.2
Data Safety Monitoring Board (DSMB)
The DSMB is an independent group of at least 3 experts that monitors participant safety and 
advises The Sponsor. DSMB members will be separate and independent of study staff participating 
in this trial and should not have scientific, financial, or other conflicts of interest related to this 
trial. The DSMB will consist of members with appropriate expertise to contribute to the 
interpretation of data from this trial. A quorum will consist of a simple majority.
The DSMB will review cumulative safety data and interim analysis data (see Section 10.4.5) 
generated in review timeframe from this trial at least annually.
The DSMB will meet when trial halting criteria (see Section 3.2) are met, or as requested by the 
sponsor or PI.
The DSMB will have a final review meeting at the end of the study.
Procedures for DSMB reviews/meetings will be defined in the DSMB charter. The DSMB will 
review applicable data, including, but not limited to, enrollment, demographics, dosing data, 
clinical laboratory data, and safety data, at scheduled timepoints during this trial as defined in the 
DSMB charter. The DSMB will review blinded aggregate data in the open session of the DSMB 
meetings.
Additional data may be requested by the DSMB, and interim statistical reports may be generated 
as deemed necessary and appropriate by the Sponsor. As an outcome of each review/meeting, the 
DSMB will make a recommendation as to the advisability of proceeding with study product 
administration, and to continue, modify, or terminate this trial.
8
SPONSOR PROTOCOL / SAFETY REPORTING
8.1
DEFINITIONS
8.1.1
Adverse Event 
Any untoward medical occurrence in a participant or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment. An adverse event (AE) can therefore be any unfavorable and unintended sign (including 
an abnormal laboratory finding), symptom, or disease temporally associated with the use of a 
medicinal (investigational) product, whether or not related to the medicinal (investigational) 
product (ICH E6 (R2)).
8.1.2
Serious Adverse Event (SAE)
An adverse event or suspected adverse reaction is considered serious if in the view of the 
investigator or the sponsor, it results in any of the following:

Death;

A life-threatening adverse event (see Section 8.1.3);

In participant hospitalization or prolongation of existing hospitalization:

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o
A hospitalization/admission that is pre-planned (i.e., elective or scheduled surgery 
arranged prior to the start of the study), a planned hospitalization for pre-existing 
condition, or a procedure required by the protocol, without a serious deterioration in 
health, is not considered a serious adverse event.
o
A hospitalization/admission that is solely driven by non-medical reasons (e.g., 
hospitalization for participant convenience) is not considered a serious adverse event. 
o
Emergency room visits or stays in observation units that do not result in admission to 
the hospital would not be considered a serious adverse event. The reason for seeking 
medical care should be evaluated for meeting one of the other serious criteria.

Persistent or significant incapacity or substantial disruption of the ability to conduct normal 
life functions;

A congenital anomaly/birth defect;

Important medical events that may not result in death, be life-threatening, or require 
hospitalization may be considered a serious adverse drug experience when, based upon 
appropriate medical judgment, they may jeopardize the participant or subject and may 
require medical or surgical intervention to prevent one of the outcomes listed in this 
definition.
8.1.3
Life-threatening 
An adverse event or suspected adverse reaction is considered “life-threatening” if, in the view of 
either the investigator or sponsor, its occurrence places the participant or subject at immediate risk 
of death. It does not include an adverse event or suspected adverse reaction that, had it occurred in 
a more severe form, might have caused death (21CFR312.32).
8.1.4
Severity
The severity of each Adverse Event will be assessed utilizing the CTCAE version 5.0.
8.1.5
Relationship to Study Product
All Aes will have their relationship to study product assessed using the terms:  related or not 
related.  

Related – There is a reasonable possibility that the study product caused the adverse event. 
Reasonable possibility means that there is evidence to suggest a causal relationship 
between the study product and the adverse event.

Not Related – There is not a reasonable possibility that the administration of the study 
product caused the event.
8.1.6
Adverse Events of Special Interest (AESI)
An adverse event of special interest (AESI) is one of scientific and medical interest specific to 
understanding of the Investigational Product(s) and may require close monitoring and rapid 
communication by the investigator to the sponsor. An AESI may be serious or non-serious. The 
rapid reporting of AESIs allows ongoing surveillance of these events to characterize and 
understand them in association with the use of these investigational products. 

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Only AESIs that match the definition of SAE will be reported as other SAEs within 7 days from 
the knowledge of event. Other non-SAE AESIs should not be reported to OSRO but only collected 
in the clinical database.
The adverse events related to following, regardless of site, will be collected as an AESI to enable 
evaluation of potential risk factors, such as site/past radiation/associated infection at site/recent 
instrumentation and other variables such as time to onset, exposure history, grade of bleeding, 
anatomical sites, etc. can be collected.

Mucosal bleeding

Cutaneous lesions possibly due to TGF-beta 
8.2
ASSESSMENT OF SAFETY EVENTS
AE information collected will include event description, date of onset, assessment of severity and 
relationship to study product and alternate etiology (if not related to study product), date of 
resolution of the event, seriousness and outcome. The assessment of severity and relationship to 
the study product will be done only by those with the training and authority to make a diagnosis 
and listed on the Form FDA 1572 as the site principal investigator or sub-investigator. AEs 
occurring during the collection and reporting period will be documented appropriately regardless 
of relationship. AEs will be followed through resolution.
SAEs will be:

Assessed for severity and relationship to study product and alternate etiology (if not related 
to study product) by a licensed study physician listed on the Form FDA 1572 as the site 
principal investigator or sub-investigator.

Recorded on the appropriate SAE report form, the medical record and captured in the 
clinical database.

Followed through resolution by a licensed study physician listed on the Form FDA 1572 
as the site principal investigator or sub-investigator.
For timeframe of recording adverse events, please refer to Section 6.1. 
8.3
REPORTING OF SERIOUS ADVERSE EVENTS
Any AE that meets protocol-defined serious criteria or meets the definition of Adverse Event of 
Special Interest that require expedited reporting must be submitted immediately (within 24 hours 
of awareness) to OSRO Safety using the CCR SAE report form.
All SAE reporting must include the elements described in Section 8.2.
SAE reports will be submitted to the Center for Cancer Research (CCR) at: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator. CCR SAE report form and 
instructions 
can 
be 
found 
at: 
https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions 
Following the assessment of the SAE by OSRO, other supporting documentation of the event may 
be requested by the OSRO Safety and should be provided as soon as possible.

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8.4
WAIVER OF EXPEDITED REPORTING TO CCR
As overall survival, which includes death or hospitalization due to disease progression are part of 
the study objectives, and captured as an endpoint in this study, they will not be reported in 
expedited manner to the sponsor. However, if there is evidence suggesting a causal relationship 
between the study drug and the event, report the event in an expedited manner according to Section 
8.3.
Hospitalization that is deemed to be due to disease progression, and not attributable to the 
intervention will not be reported as an SAE. The event, and the assessment that it was caused by 
disease progression will be documented in the medical records. The causality assessment of 
hospitalization will be re-evaluated any time when new information is received. If the causality 
assessment changes from disease progression to related to the study intervention, SAE report will 
be sent to the Sponsor in an expedited manner according to Section 8.3. If there is any uncertainty 
whether the intervention is a contributing factor to the event, the event should be reported as AE 
or SAE as appropriate.
8.5
SAFETY REPORTING CRITERIA TO THE PHARMACEUTICAL COLLABORATORS
Reporting will be per the collaborative agreement. 
8.6
REPORTING PREGNANCY 
All 
required 
pregnancy 
reports/follow-up 
to 
OSRO 
will 
be 
submitted 
to: 
OSROSafety@mail.nih.gov and to the CCR PI and study coordinator.  Forms and instructions can 
be found here: https://ccrod.cancer.gov/confluence/display/CCRCRO/Forms+and+Instructions 
8.6.1
Maternal exposure
If a participant becomes pregnant during the course of the study, the study treatment should be 
discontinued immediately, and the pregnancy reported to the Sponsor no later than 24 hours of 
when the Investigator becomes aware of it. The Investigator should notify the Sponsor no later 
than 24 hours of when the outcome of the Pregnancy becomes known.
Pregnancy itself is not regarded as an SAE. However, congenital abnormalities or birth defects 
and spontaneous miscarriages that meet serious criteria (Section 8.1.2) should be reported as SAEs. 
The outcome of all pregnancies should be followed up and documented.
8.6.2
Paternal exposure
Male participants should refrain from fathering a child or donating sperm during the study and for 
125 days after the last dose of bintrafusp alfa.
Pregnancy of the participant’s partner is not considered to be an AE. The outcome of all 
pregnancies occurring from the date of the first dose until 125 days after the last dose should, if 
possible, be followed up and documented. Pregnant partners may be offered the opportunity to 
participate in an institutional pregnancy registry protocol (e.g., the NIH IRP pregnancy registry 
study) to provide data about the outcome of the pregnancy for safety reporting purposes.
8.7
REGULATORY REPORTING FOR STUDIES CONDUCTED UNDER CCR-SPONSORED IND
Following notification from the investigator, CCR, the IND sponsor, will report any suspected 
adverse reaction that is both serious and unexpected.  CCR will report an AE as a suspected adverse 

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reaction only if there is evidence to suggest a causal relationship between the study product and 
the adverse event.  CCR will notify FDA and all participating investigators (i.e., all investigators 
to whom the sponsor is providing drug under its INDs or under any investigator’s IND) in an IND 
safety report of potential serious risks from clinical trials or any other source, as soon as possible, 
in accordance to 21 CFR Part 312.32. 
All serious events will be reported to the FDA at least annually in a summary format.
8.8
SPONSOR PROTOCOL DEVIATION REPORTING
A Protocol Deviation is defined as any non-compliance with the clinical trial Protocol, Manual of 
Operational Procedures (MOP) and other Sponsor approved study related documents, GCP, or 
protocol-specific procedural requirements on the part of the participant, the Investigator, or the 
study site staff inclusive of site personnel performing procedures or providing services in support 
of the clinical trial.
It is the responsibility of the study Staff to document any protocol deviation identified by the Staff 
or the site Monitor in the CCR Protocol Deviation Tracking System (PDTS) online application. 
The entries into the PDTS online application should be timely, complete, and maintained per CCR 
PDTS user requirements. 
In addition, any deviation to the protocol should be documented in the participant’s source records 
and reported to the reviewing IRB per their guidelines. OSRO required protocol deviation 
reporting is consistent with E6(R2) GCP: Integrated Addendum to ICH E6(R1): 4.5 Compliance 
with Protocol; 5.18.3 (a), and 5.20 Noncompliance; and ICH E3 16.2.2 Protocol deviations.
9
CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure: 

that the rights of the participants are protected; 

that the study is implemented per the approved protocol, Good Clinical Practice and 
standard operating procedures; and, 

that the quality and integrity of study data and data collection methods are maintained.  
Monitoring for this study will be performed by NCI CCR Office of Sponsor and Regulatory 
Oversight (OSRO) and Regulatory Oversight Support (SROS) Services contractor. Clinical site 
monitoring activities will be based on OSRO standards, FDA Guidance E6(R2) Good Clinical 
Practice: Integrated Addendum to ICH E6(R1) March 2018, and applicable regulatory 
requirements.
Details of clinical site monitoring will be documented in a Clinical Monitoring Plan (CMP) 
developed by OSRO. CMPs will be protocol-specific, risk-based and tailored to address human 
subject protections and integrity of the study data. OSRO will determine the intensity and 
frequency of monitoring based on several factors, including study type, phase, risk, complexity, 
expected enrollment rate, and any unique attributes of the study and the site. The Sponsor will 
conduct a periodic review of the CMP to confirm the plan's continued appropriateness. A change 
to the protocol, significant or pervasive non-compliance with GCP, or the protocol may trigger 
CMP updates.
OSRO SROS Monitoring visits and related activities will be conducted throughout the life cycle 
of each protocol. The first activity is before the study starts to conduct a Site Assessment Visit 

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(SAV) (as warranted), followed by a Site Initiation Visit (SIV), Interim Monitoring Visit(s) 
(IMVs), and a study Close-Out Visit (COV).
Some monitoring activities may be performed remotely, while others will occur at the study site. 
Monitoring visit reports will describe visit activities, observations, and associated action items or 
follow-up required for resolution of any issues, discrepancies, or deviations. Monitoring reports 
will be distributed to the study PI, NCI CCR QA, CCR Protocol Support Office, coordinating 
center (if applicable) and the Sponsor regulatory file.
The site Monitor will inform the study team of any deviations observed during monitoring visits. 
If unresolved, the Monitor will request that the site Staff enter the deviations in the CCR Protocol 
Deviation Tracking System (PDTS) for deviation reporting to the Sponsor and as applicable per 
institutional and IRB guidance.
10 STATISTICAL CONSIDERATIONS  
10.1 STATISTICAL HYPOTHESIS
10.1.1 Primary Efficacy Endpoint
To assess Overall Response Rate (ORR) according to RECIST 1.1.
10.1.2 Secondary Efficacy Endpoints
To assess: 

Safety and tolerability of bintrafusp alfa in participants with recurrent or metastatic ONB

Progression Free Survival

Duration of response

Overall Survival
10.2 SAMPLE SIZE DETERMINATION
There is no published literature on the anticipated efficacy of any specific treatment for participants 
with ONB. In these rare participants, the objective will be to determine if a modest response rate 
is possible while keeping the study size small. Thus, in immune checkpoint-naïve participants, this 
trial will be conducted using a Simon optimal two-stage phase II trial design (Simon R, Controlled 
Clinical Trials 10:1-10, 1989) to rule out an unacceptably low response rate (CR+PR) of 5% 
(p0=0.05) in favor of an improved response rate of 20% (p1=0.20). With alpha=0.10(one sided 
alpha; equals two-sided alpha = 0.20; probability of accepting a poor treatment=0.10) and beta = 
0.20 (probability of rejecting a good treatment=0.20), the first stage will enroll 12 evaluable 
participants, and if 0 of the 12 has a response, then no further participants will be accrued.  If 1 or 
more of the first 12 participants has a response, then accrual would continue until a total of 21 
evaluable participants have been treated. As it may take up to several months to determine if a 
participant has experienced a response, a temporary pause in the accrual may be necessary to 
ensure that enrollment to the second stage is warranted. If there are 1-2 participants with a response 
out of 21 participants, this would likely be an uninterestingly low response rate. If there were 3 or 
more of 21 (14.3%) who experienced a response, this would be sufficiently interesting to warrant 
further study in later trials. Even if there are fewer than 3 responses, this will provide information 
on degree of efficacy of a single agent in a rare disease where there is currently no published 

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information. Under the null hypothesis (5% response rate), the probability of early termination is 
54.0%.
It is expected that approximately 6-8 participants per year may enroll on this trial. Thus, in order 
to enroll up to 21 evaluable CN participants, it is expected that accrual will be completed within 3 
to 4 years. We will also enroll up to 8 immune checkpoint-resistant (CR) participants; this cohort 
will be evaluated separately for OR. Accrual for CR participants will occur in two stages: initially 
5 CR participants will be enrolled; if responses are observed in one or more participants, the second 
stage will enroll another 3 participants. Accrual for CR participants will end when the needed 
number of CN participants have been accrued. To allow for a small number of inevaluable 
participants, the accrual ceiling will be set at 32 participants (21 in the main CN cohort, 8 in the 
exploratory CR cohort, and 3 additional participants for inevaluable).
10.3 POPULATIONS FOR ANALYSES
Intention to treat: any subjects who enroll onto the trial and provide consent and who receive at 
least one dose of bintrafusp alfa will be included in the efficacy and safety evaluations. Only the 
immune checkpoint-naïve participants will be included in the primary endpoint analysis. The CN 
and CR populations will be reported separately for the secondary and exploratory endpoints. 
10.3.1 Evaluable for Toxicity
All participants will be evaluable for toxicity from the time of their first treatment with bintrafusp 
alfa.
10.3.2 Evaluable for Objective Response
Only those participants 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 participants will have their response classified according to the definitions stated 
in Section 6.3 (Note: Participants who exhibit objective disease progression prior to the end of 
cycle 1 will also be considered evaluable.)
10.3.3 Evaluable Non-Target Disease Response:
Participants 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. 
10.4 STATISTICAL ANALYSES
10.4.1 Analysis of the Primary Endpoints
The fraction of evaluable participants who experience a response will be reported along with a 
95% two-sided confidence interval.
10.4.2 Analysis of the Secondary Endpoint(s)
PFS will be determined using the Kaplan-Meier method and will be reported along with 95% 
confidence intervals. PFS will be defined as the time from the date of first treatment to the date of 
disease progression or death (any cause) whichever occurs first. Subjects who do not have disease 
progression or have not died at the end of follow up will be censored at the last known date the 
subject was progression free.

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OS will be evaluated using Kaplan-Meier methods. OS will be defined as the time from the date 
of first treatment to the date of death (any cause). Subjects who are alive at the end of follow up 
will be censored at the last known date alive.
Duration of 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 PD or death is 
objectively documented and is evaluated using the Kaplan-Meier method. Analysis of safety and 
tolerability is as described in the Section 10.4.3.
10.4.3 Safety Analyses
The fraction of participants who experience a toxicity, by grade and type of toxicity, will be 
tabulated. In addition, overall safety will be assessed by descriptive analyses using tabulated 
frequencies of AEs by grade using CTCAE Version 5 for the study population in terms of 
treatment-emergent AEs, SAEs, and clinically significant changes in safety laboratory tests, 
physical examinations, ECGs, and vital signs. Adverse events leading to premature discontinuation 
from the study intervention and serious treatment-emergent AEs will be presented either in a Table 
or a Listing.
10.4.4 Baseline Descriptive Statistics
Baseline demographic characteristics will be reported.
10.4.5 Planned Interim Analyses
As indicated in the two-stage design (Section 10.2), the number of responses after 12 evaluable 
checkpoint naïve participants have been treated will be noted and will be used to determine if 
enrollment to the second stage of accrual may proceed. After the first restaging scan of the last 
evaluable patient required for the interim analysis, enrollment to the checkpoint naïve cohort will 
be halted to allow for an analysis by the study statistician. An interim analysis report will be created 
by the study statistician to document the number of responses in the first stage and will be reviewed 
by the PI and study team. The memo will be provided to and approved by the study sponsor prior 
to continuation of accrual. Alternatively, if the required number of responses is observed before 
that time, the memo may be generated, reviewed and provided to the study sponsor at that point 
without a pause in accrual. 
The interim analysis report will also be provided to the DSMB.
10.4.6 Tabulation of Individual Participant Data
Individual responses may be depicted using a waterfall plot or a spider diagram. In addition, to 
assess feasibility, the participant description of symptomatic adverse events (complimentary to 
clinician reported CTCAE) and missing data will be tabulated.
10.4.7  Exploratory Analyses
The exploratory objectives are intended to collect data for use in planning future scientific 
investigations or clinical research. These analyses are expected to be performed only using 
descriptive techniques, reporting descriptive statistics including confidence intervals when 
appropriate. Any statistical tests performed for evaluation of exploratory objectives will be done 
without formal adjustment for multiple comparisons, but in the context of the number of tests 
performed.

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11 COLLABORATIVE AGREEMENTS 
11.1 COOPERATIVE RESEARCH AND DEVELOPMENT AGREEMENT (CRADA)
A CRADA (02666) is in place with EMD Serono for the supply of bintrafusp alfa. 
12 HUMAN SUBJECTS PROTECTIONS 
12.1 RATIONALE FOR SUBJECT SELECTION
Subjects from all racial/ethnic groups are eligible for this study if they meet the eligibility criteria. 
Efforts will be made to extend accrual to a representative population. Due to impaired cellular 
immunity which may affect the efficacy of treatment, participants with poorly controlled HIV as 
well as patents with detectable viral loads of hepatitis B and C will be excluded. 
As there is a risk of severe bleeding with this study drug, participants must be willing to receive 
blood transfusions if medically necessary for their own safety. Participants must be able to receive 
blood transfusions in order to minimize the risks of receiving bintrafusp alfa.
12.2 PARTICIPATION OF CHILDREN
Individuals under the age of 18 will not be eligible to participate in this study because of unknown 
toxicities in pediatric participants. 
The effects of bintrafusp alfa on the developing human fetus are unknown. For this reason and 
because immunotherapeutic agents as well as other therapeutic agents used in this trial may be 
teratogenic, women of child-bearing potential and men must agree to use highly effective 
contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and up 
to 65 days for women and 125 days for men following the last dose of any study treatment. 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.
12.3 PARTICIPATION OF SUBJECTS UNABLE TO GIVE CONSENT
Adults unable to provide consent are excluded from enrolling in the protocol. However, it is 
possible that subjects enrolled in the protocol may permanently lose the capacity to consent for 
themselves during the course of this study.  In the event this occurs, the subjects will be removed 
from treatment and remain in the study to be followed-up for overall survival. Due to the rarity of 
ONB, it is important to keep any enrolled subjects in follow-up for overall survival to learn more 
about the outcome of the disease. All subjects ≥ age 18 will be offered the opportunity to fill in 
their wishes for research and care, and assign a substitute decision maker on the “NIH Advance 
Directive for Health Care and Medical Research Participation” form so that another person can 
make decisions about their medical care in the event that they become incapacitated or cognitively 
impaired during the course of the study. 
Note: The PI or AI will contact the NIH Ability to Consent Assessment Team (ACAT) for 
evaluation to assess ongoing capacity of the subjects and to identify a LAR, as needed.
Please see Section 12.6.1 for consent procedure.

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12.4 EVALUATION OF BENEFITS AND RISKS/DISCOMFORTS
Participants will receive evaluation of their disease at the National Cancer Institute’s Clinical 
Center. The potential benefit to a participant that goes onto study is a reduction in the bulk of their 
tumor which may or may not have a favorable impact on symptoms and/or survival. 
Potential adverse reactions attributable to the administration of the study drug utilized in this trial 
are discussed in Section 14.1.2. All care will be taken to minimize side effects, but they can be 
unpredictable in nature and severity. Participants will be examined and evaluated prior to 
enrollment. All evaluations to monitor the treatment of participants will be recorded in the medical 
record. If participants suffer any physical injury as a result of the participation in this study, 
immediate medical treatment is available at the Clinical Center, National Cancer Institute, 
Bethesda, Maryland. 
Although no compensation is available, any injury will be evaluated and treated in keeping with 
the benefits or care to which participants are entitled under applicable regulations.
12.5 RISK/BENEFIT ASSESSMENT
12.5.1 Known Potential Risks
12.5.1.1
Potential Risks Associated with Bintrafusp alfa
Potential adverse reactions attributable to the administration of the study drugs utilized in this trial 
are discussed in Section 14.1.2. Risks include the possible occurrence of any of a range of side 
effects which are listed in the Consent Document or this protocol document. Frequent monitoring 
for adverse effects will help to minimize the risks associated with administration of the study 
agents. 
Participants may be harmed from being in this study by toxicity due to the drug or combination of 
drugs given during this study. M7824 is similar to immune check point inhibitors. There are 
preliminary data to suggest that not all patients benefit from immune check point inhibitors nor 
M7824. Additionally, there are preliminary data to suggest that an unexpectedly rapid progression 
of disease occurs in some patients receiving immunotherapy such as immune checkpoint 
inhibitors. 
12.5.1.2
Risk of Optional Biopsies
All care will be taken to minimize risks that may be incurred by tumor sampling. There are 
potential risks associated with this procedure including pain or bleeding caused by the anesthesia 
needle as well as the biopsy procedure itself. An allergic reaction to the local anesthetic may occur. 
There may be bruising at the site of biopsy. Continuous bleeding and infection are rare and very 
often is easily controlled. Potential risks and discomforts will be minimized to the greatest extent 
possible by using personnel with appropriate training and monitoring.  
12.5.1.3
Risks Due to Radiation
The study will involve radiation from the following sources:

Up to 7 CT scans (C/A/P) per year for disease assessment

Up to 3 FDG or Dotatate PET/CT scans per year for disease assessment

3 CT-guided biopsies

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
Up to 2 bone scans
Subjects in this study may be exposed to approximately 14.28 rem maximum annually. 
The radiation exposure that participants may get in this study will expose them to the roughly the 
same amount of radiation as 47.6 years of background radiation. The risk of getting cancer from 
the radiation exposure in this study is 1.4 out of 100 (1.4%) and of getting a fatal cancer is 0.7 out 
of 100 (0.7%).  
Note: As the FDG PET/CT scans have a higher possible radiation exposure than Dotatate PET/CT, 
this scan was used in the possible maximum radiation exposure above and in the informed consent 
document. 
12.5.1.4
Risks Due to Contrast Agents for CT 
Contrast agents can cause allergic reactions and kidney damage. Allergic reactions can include 
mild itching associated with hives but can also result in a serious life-threatening emergency from 
difficulty breathing. If this occurs, it is treatable.
12.5.1.5
Risks Due to MRI
People are at risk for injury from the MRI magnet if they have some kinds of metal in their body.  
People with fear of confined spaces may become anxious during an MRI. Those with back 
problems may have back pain or discomfort from lying in the scanner.  The noise from the scanner 
is loud enough to damage hearing, especially in people who already have hearing loss. Everyone 
having a research MRI scan will be fitted with hearing protection. 
There are no known long-term risks of MRI scans.
12.5.1.6
Risks Due to Gadolinium as a Contrast Agent in MRI
During part of the MRI, people receive gadolinium, a contrast agent, through an intravenous (IV) 
catheter (small tube). It will be done for research purposes. 
The risks of an IV catheter include bleeding, infection, or inflammation of the skin and vein with 
pain and swelling.  
Mild symptoms from gadolinium infusion occur in fewer than 1% of those who receive it and 
usually go away quickly.  Mild symptoms may include coldness in the arm during the injection, a 
metallic taste, headache, and nausea.  The risks due to gadolinium have been explained in detail in 
the consent document.
12.5.1.7
Risks Due to EKG 
Other than possibly experiencing some minor skin irritation from the electrodes there are no 
anticipated risks related to complete the electrocardiogram
12.5.1.8
Blood Sampling Risks 
Risks of blood draws include pain and bruising in the area where the needle is placed, 
lightheadedness, and rarely, fainting. When large amounts of blood are collected, low red blood 
cell count (anemia) can develop.

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12.5.1.9
Non-Physical Risks of Genetic Research

Risk of receiving unwanted information:  Anxiety and stress may arise as a result of the 
anticipation that unwanted information regarding disease related DNA sequencing or 
disease tendencies, or misattributed paternity. Participants will be clearly informed that the 
data related to DNA sequencing and genetic analysis is coded, investigational and will not 
be shared with participants, family members or health care providers.

Risk related to possibility that information may be released: This includes the risk that data 
related to genotype, DNA sequencing or risk for disease tendency or trait can be released 
to members of the public, insurers, employers, or law enforcement agencies. Although 
there are no plans to release results to the participants, family members or health care 
providers, this risk will be included in the informed consent document.

Risk to family or relatives:  Family members or relatives may or may not want to be aware 
of familial tendencies or genetic risks of disease which may cause anxiety about possible 
future health problems. As previously noted, participants will be notified of any medically 
significant and actionable incidental findings. Study results will not be shared with 
participants.
12.5.2 Known Potential Benefits
As per Section 12.4 the potential benefit to a participant that goes onto study is a reduction in the 
bulk of their tumor which may or may not have favorable impact on symptoms and/or survival.
12.5.3 Assessment of Potential Risks and Benefits
Metastatic or refractory/recurrent ONB need improved therapy options. Studies suggest that a 
portion of ONB PD-L1 expression and presence of an associated inflammatory infiltrate. Thus, 
ONB may be susceptible to checkpoint inhibition. The information gained from this study will 
allow us to determine that bintrafusp alfa are tolerated in participants with metastatic or recurrent 
ONB. Furthermore, additional secondary outcomes will allow us to probe into the possibility of 
improvement in disease progression with bintrafusp alfa. Lastly, information gained from 
experimental aims will allow us to potentially improve treatment options in the future.
A number of clinically appropriate strategies to minimize risks to participants have been built into 
the protocol through the means of inclusion/exclusion criteria, monitoring strategies, and 
management guidelines. 
The potential benefit to a participant that participates in this study is better control of their tumor 
growth and disease recurrence which may or may not have a favorable impact on symptoms and/or 
survival. 
Potential adverse reactions attributable to the administration of the study drug utilized in this trial 
are discussed in Section 14.1.2. All care will be taken to minimize side effects, but they can be 
unpredictable in nature and severity.
12.6 CONSENT PROCESS AND DOCUMENTATION
The informed consent document will be provided as a physical or electronic document to the 
participant or consent designee(s) as applicable for review prior to consenting.  A designated study 
investigator will carefully explain the procedures and tests involved in this study, and the 
associated risks, discomforts and benefits. In order to minimize potential coercion, as much time 

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as is needed to review the document will be given, including an opportunity to discuss it with 
friends, family members and/or other advisors, and to ask questions of any designated study 
investigator. A signed informed consent document will be obtained prior to entry onto the study.
The initial consent process as well as re-consent, when required, may take place in person or 
remotely (e.g., via telephone or other NIH approved remote platforms used in compliance with 
policy, including HRPP Policy 303) per discretion of the designated study investigator and with 
the agreement of the participant/consent designee(s).  Whether in person or remote, the privacy of 
the subject will be maintained. Consenting investigators (and participant/consent designee, when 
in person) will be located in a private area (e.g., clinic consult room). When consent is conducted 
remotely, the participant/consent designee will be informed of the private nature of the discussion 
and will be encouraged to relocate to a more private setting if needed.  
Consent will be documented with required signatures on the physical document (which includes 
the printout of an electronic document sent to participant) or as described below, with a manual 
(non-electronic) signature on the electronic document. When required, witness signature will be 
obtained similarly as described for the investigator and participant. 
Manual (non-electronic) signature on electronic document:
When a manual signature on an electronic document is used for the documentation of consent 
at the NIH Clinical Center, this study will use the following to obtain the required signatures: 

Adobe platform (which is not 21 CFR Part 11 compliant); or

iMedConsent platform (which is 21 CFR Part 11 compliant)
During the consent process, participants and investigators will view individual copies of the 
approved consent document on screens at their respective locations (if remote consent); the 
same screen may be used when in the same location, but is not required.
Both the investigator and the subject will sign the document with a hand signature using a 
finger, stylus or mouse.
Note: Refer to the CCR SOP PM-2, Obtaining and Documenting the Informed Consent 
Process for additional information (e.g., verification of participant identity when obtaining 
consent remotely) found at: 
https://ccrod.cancer.gov/confluence/pages/viewpage.action?pageId=73203825
12.6.1 Consent Process for Adults Who Lack Capacity to Consent to Research Participation
For participants addressed in Section 12.3, an LAR will be identified consistent with Policy 403 
and informed consent obtained from the LAR, as described in Section 12.6. 
13 REGULATORY AND OPERATIONAL CONSIDERATIONS 
13.1 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification, documenting the reason for study suspension or 
termination, will be provided by the suspending or terminating party to study participants, 
investigator, funding agency, the Investigational New Drug (IND) sponsor and regulatory 
authorities.  If the study is prematurely terminated or suspended, the Principal Investigator (PI) 

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will promptly inform study participants, the Institutional Review Board (IRB), and sponsor and 
will provide the reason(s) for the termination or suspension.  Study participants will be contacted, 
as applicable, and be informed of changes to study visit schedule. 
Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants

Demonstration of efficacy that would warrant stopping   

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable

Determination that the primary endpoint has been met

Determination of futility
Study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the sponsor, IRB and as applicable, Food and Drug Administration (FDA).
13.2 QUALITY ASSURANCE AND QUALITY CONTROL
The clinical site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion.  An individualized quality management plan 
will be developed to describe the site’s quality management.
Quality control (QC) procedures will be implemented beginning with the data entry system and 
data QC checks that will be run on the database will be generated. Any missing data or data 
anomalies will be communicated to the site(s) for clarification/resolution.
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical 
trial is conducted, and data are generated, and biological specimens are collected, documented 
(recorded), and reported in compliance with the protocol, International Conference on 
Harmonisation Good Clinical Practice (ICH GCP), and applicable regulatory requirements (e.g., 
Good Laboratory Practices (GLP), Good Manufacturing Practices (GMP)). 
The investigational site will provide direct access to all trial related sites, source data/documents, 
and reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and 
regulatory authorities.
13.3 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial. The study leadership in conjunction with the NCI has established policies and 
procedures for all study group members to disclose all conflicts of interest and will establish a 
mechanism for the management of all reported dualities of interest.
13.4 CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s). This confidentiality is extended to cover testing of biological 
samples and genetic tests in addition to the clinical information relating to participants. Therefore, 

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the study protocol, documentation, data, and all other information generated will be held in strict 
confidence. No information concerning the study or the data will be released to any unauthorized 
third party without prior written approval of the sponsor. 
All research activities will be conducted in as private a setting as possible.
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical 
study site will permit access to such records.
The study participant’s contact information will be securely stored at the clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure location 
for as long a period as dictated by the reviewing IRB, Institutional policies, or sponsor 
requirements.
Study participant research data, which is for purposes of statistical analysis and scientific reporting, 
will be transmitted to and stored at the National Cancer Institute Center for Cancer Research (NCI 
CCR). This will not include the participant’s contact or identifying information. Rather, individual 
participants and their research data will be identified by a unique study identification number. The 
study data entry and study management systems used by the clinical site(s) and by NCI CCR 
research staff will be secured and password protected. At the end of the study, all study databases 
will be archived at the NIH.
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued 
by the National Institutes of Health (NIH). This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any civil, 
criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local 
level. By protecting researchers and institutions from being compelled to disclose information that 
would identify research participants, Certificates of Confidentiality help achieve the research 
objectives and promote participation in studies by helping assure confidentiality and privacy to 
participants.
14 PHARMACEUTICAL INFORMATION
14.1 BINTRAFUSP ALFA (M7824, MSB0011359C) (IND # 154950)
14.1.1 Source/Acquisition and Accountability 
Bintrafusp alfa is manufactured and supplied for the trial by EMD Serono Research and 
Development Institute. 
14.1.2 Toxicity 
Most of the observed AEs with bintrafusp alfa are similar with class effects of monoclonal 
antibody blockade of the anti-PD-1/PD-L1 axis, with additional cutaneous side effects presumed 
to be related to TGF-β signaling modulation. The safety data summarized from April 2020  include 
data on the pooled expansion cohorts (630 participants): treatment-related (TR) treatment-
emergent adverse events (TEAEs) were reported in 426 (67.6%) participants. (47) Most TR 

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TEAEs were low grade (Grade 1 or 2), while Grade ≥ 3 TR TEAEs occurred in 142 participants 
(22.5%), and immune related adverse events (irAEs) occurred in 137 (21.7%) participants. 
Treatment-related TEAE Leading to Permanent Treatment Discontinuation by System 
Organ Class and Preferred Term in ≥ 2 participants in the Pooled Analysis of Dose 
Expansion Cohorts 
TEAEs leading to death occurred in 79 (12.5%) participants with similar rates in EMR200647-001 
and MS200647-0008; 7 deaths were due to treatment-related TEAE:1 participant had dyspnea, 
hemolysis and thrombocytopenia, 1 participant had an intracranial tumor hemorrhage, 1 participant 
had pneumonia, 2 participants died of interstitial lung disease, 1 participant due to sudden death, 
and 1 due to septic shock. 
Common TEAEs (occurring in more than 10% of participants) were:

Anemia (29%)

Decreased appetite (25%)

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
Fatigue (tiredness) (22%)

Pruritus (itching) (21%) 

Dyspnea (shortness of breath) (21%)

Constipation (19%)

Nausea (19%)

Pyrexia (fever) (19%)

Asthenia (weakness, fatigue) (17%) 

Diarrhea (16%)

Abdominal pain (15%)

Vomiting (14%)

Cough (13%)

Headache (12%)

Epistaxis (12%)

Rash (11%)

Elevation of aspartate aminotransferase (AST, liver enzyme) (11%)

Leg or arm swelling (10%)
Skin-related adverse events which were possibly due to TGF-β inhibition, occurred in 11% of 
participants and included keratoacanthomas (7%), squamous cell carcinoma of the skin (3%), and 
hyperkeratosis (1%) and are important identified risks with bintrafusp alfa. 
Anemia, alterations in would healing or repair of tissue damage, and embryofetal toxicity remain 
important potential risks. 
At least 2 instances of nodular regenerative hyperplasia have been observed with the use of this 
agent.
In addition, mucosal bleeding events (e.g. gum bleeding, nose bleeds, coughing up blood, blood 
in urine or stool) are a potential risk for bintrafusp alfa, included in the informed consent document.  
Infusion-related Reactions (including reactions, signs and symptoms) occurred in 38 (6%) 
participants in the pooled safety analysis, and all IRRs were of Grade 1 or 2 intensity; most of the 
IRRs had an onset after the first or second infusion; those with onset after the third infusion (or 
later) were less frequent. Consequently, the administration of premedication is not required. As 
per Section 3.2.3, if an Investigator deems necessary to administer a premedication to a particular 
participant, an antihistamine (e.g. 25 to 50 mg diphenhydramine) and paracetamol 
(acetaminophen, 500 to 650 mg intravenously or equivalent oral dose) 30 to 60 minutes prior to 
bintrafusp alfa infusion is recommended. Premedication should be administered for subsequent 
bintrafusp alfa doses based upon clinical judgment and presence/severity of prior infusion 
reactions. This regimen may be modified based on local treatment standards and guidelines as 
appropriate provided it does not include systemic corticosteroids.

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In addition, immune-mediated side effects might be possible (immune- related pneumonitis, 
immune-related colitis, immune-related hepatitis, immune-related endocrinopathies (thyroid 
disorders, adrenal insufficiency, new onset type I diabetes mellitus, pituitary disorders), immune-
related nephritis and renal dysfunction and other immune-related AEs (arthralgias, arthritis, 
myositis, myocarditis, Guillain-Barré syndrome, uveitis, thrombocytopenia, dry eyes, dry mouth, 
psoriasis, neuritis). Per IB, in the pooled expansion cohorts the incidence of all immune-related 
AEs was 21.7% (123 of 630 participants), with Grade 3 and 4 events being 8.5% (53 participants), 
2.9% (18 participants) leading to discontinuation and 0.3% (2 participants) leading to death. 
Please refer to the IB for detailed toxicity information. 
14.1.3 Formulation and preparation 
Bintrafusp alfa is provided as a sterile liquid formulation and packaged at a 10 mg/mL 
concentration in USP/ Ph Eur type I 50R vials that are filled with drug product solution to allow 
an extractable volume of 60 mL (600 mg/60 mL). The vials are closed with rubber stoppers in 
serum format complying with USP and Ph Eur with an aluminum crimp seal closure. Each single-
use vial contains 600mg of bintrafusp alfa, formulated as 10mg/mL of active, 6% (w/v) Trehalose, 
40 mM NaCl, 5 mM Methionine, 0.05% (w/v) Tween 20, 10 mM LHistidine at pH 5.5. 
The liquid formulation is diluted directly with 0.9% sodium chloride solution for injection. The 
estimated volumes of delivery are anticipated to be no more than 250mL. The verified 
concentration range in the infusion solution is 0.16 mg/mL to 9.6 mg/mL.
14.1.4 Stability and Storage 
Bintrafusp alfa must be stored at 2℃ to 8℃ until use. Product stored at room temperature for 
extended periods of time might be subject to degradation. Bintrafusp alfa must not be frozen. 
Rough shaking of the reconstituted solution must be avoided. 
The chemical and physical in-use stability for the infusion solution of bintrafusp alfa in 0.9% 
sodium chloride for injection has been demonstrated for a total of 72 hours at room temperature; 
however, from a microbiological point of view, the diluted solution should be used immediately 
and is not intended to be stored unless dilution has taken place in controlled and validated aseptic 
conditions. No other drugs should be added to the infusion containers containing bintrafusp alfa. 
See Manual of Preparation of approved ancillary supplies. 
14.1.5 Administration procedures
See Section 3.3.3.
14.1.6 Incompatibilities
Not available.

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pembrolizumab in recurrent/metastatic head and neck squamous cell carcinoma: pooled analyses 
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16 LIST OF ABBREVIATIONS
Abbreviation
Term
AACR
American Association for Cancer Research
AAO-HNS
American Academy of Otolaryngology-Head and Neck Surgery
ACAT
Ability to Consent Assessment Team
ADA
anti-drug antibodies
ADR
adverse drug reactions
AE
Adverse Event/Adverse Experience
AESI
Adverse Event/Experience of Special Interest
AHNS
American Head and Neck Society
ALT
alanine transaminase
ANC
Absolute neutrophil count
ARS
American Rhinologic Society
ASCO
American Society of Clinical Oncology
AST
aspartate aminotransferase
BARON
Bintrafusp alfa in Recurrent/Metastatic Olfactory 
Neuroblastoma
β-HCG
Beta human growth hormone
BSI
Biospecimen Inventory System
BTRIS
Biomedical Translational Research Information System
CAP or C/A/P
Chest, abdomen, pelvis
CBC
Complete blood count
CCR
Center for Cancer Research
CD4
cluster of differentiation 4
CD8
cluster of differentiation 8
CFR
Code of Federal Regulations
CK
Creatine kinase
CLIA
Clinical Laboratory Improvement Amendment
CN
checkpoint-naïve
CNS
Central nervous system
CONSORT
Consolidated Standards of Reporting Trials
COV
Close-out Visit
CR
checkpoint-resistant
CR
Complete Response
CSP
Clinical Services Program
CRADA
Cooperative Research and Development Agreement
CRIS
Clinical Research Information System
CRF
Case Report Form
CT
Computed Tomography
ct DNA
Circulating tumor DNA
CTCAE
Common Terminology Criteria for Adverse Events
dbGaP
database of Genotypes and Phenotypes
DNA
Deoxynucleic acid

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Abbreviation
Term
DOR
Duration of Response
ECG / EKG
Electrocardiogram
ECOG
Eastern Cooperative Oncology Group
EDTA
Ethylenediaminetetraacetic acid
ELISA
enzyme-linked immunosorbent assay)
FDA
Food and Drug Administration
FDG
 fluorodeoxyglucose
FFPE
Flash frozen, paraffin embedded
EOT
End of treatment 
FT4
free thyroxine
GCP
Good Clinical Practice
GLP
Good Laboratory Practices
GMB
Genitourinary malignancies branch
GMP
Good Manufacturing Practices
GOT
Glutamic oxaloacetic transaminase
GPT
glutamate pyruvate transaminase
HBV
Hepatitis B virus
HCV
Hepatitis C virus
HHS
Health and Human Services
HIV
Human immunodeficiency virus
H&P
History and Pathology
IB
Investigator’s Brochure
ICBMs
immune checkpoint blockade monoclonal antibodies
ICH
International Conference on Harmonisation
iCPD
confirmed progressive disease
IHC
Immunohistochemistry
IMV
Interim Monitoring Visit
IND
Investigational New Drug 
INR
International Normalized Ratio
irAE
Immune-related adverse reactions
IRB
Institutional Review Board
IRBO
Institutional Review Board Office
iRECIST
immune Response Evaluation Criteria in Solid Tumors
IRR
Immune-related reaction
iUPD
unconfirmed progressive disease
IV
Intravenous
LAR
Legally Authorized Representative
LTIB
Laboratory of Tumor Immunology
MAR
Medical Administration Record
MDSC
myeloid-derived suppressor cell
MRI
Magnetic Resonance Imaging
MUGA
multi-gated acquisition scan

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Abbreviation
Term
N
Number (typically refers to subjects)
NASBS
North America Skull Base Society
NCI
National Cancer Institute 
NCI PDM
NCI Participant-Derived Models Repository
NCT
National Clinical Trial (number)
NFGCF
NCI Frederick Genomic Core Facility
NIDCD
National Institute of Deafness and Craniofacial Disorders
NIH
National Institutes of Health
NK
natural killer cells
NORD
National Organization for Rare Disorders
NSAID
Non-steroidal anti-inflammatory drugs
NSCLC
Non- small cell lung cancer 
OHSRP
Office for Human Subjects Research Protections
ONB
Olfactory Neuroblastoma
ORR
objective response rate
OS
Overall survival
OSRO
Office of Sponsor and Regulatory Oversight
OTC
over the counter
PBMC
peripheral blood mononuclear cell
PCR
Polymerase Chain Reaction
PD
Progressive Disease
PD-1
programmed death 1
PD-L1
programmed death-ligand 1
PET
Positron Emission Tomography
PFS
Progression-free survival
PI
Principal Investigator
PK
pharmacokinetics
PR
Partial Response
PS
Performance Status
PT
Prothromibn time
PTT/aPTT
Partial Thromboplastin Time/activated Partial Thromboplastin 
Time
QA
Quality Assurance
QC
Quality Control
RECIST
Response Evaluation Criteria in Solid Tumors
RNA
Ribonucleic acid
SAE
Serious Adverse Event/Serious Adverse Experience
SAV
Site Assessment Visit
SIV
Site Initiation Visit
SEER
Surveillance Epidemiology and End Results
SD
Stable Disease
SLD
sum of the longest diameters

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Abbreviation
Term
SOP
Standard Operating Procedure
SST
serum separation tubes
TBNK
T, B, and natural killer cells
TEAE
treatment-emergent adverse events
TGF-β
transforming growth factor beta
TGF-βRII
human TGF-β receptor II
TR
treatment-related
TRAIL
tumor necrosis factor-related apoptosis-inducing ligand
TSH
thyroid stimulating hormone
ULN
Upper limit of normal
US
United States
WBC
White blood cell
WOCBP
Women of child-bearing potential

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

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17.2 APPENDIX B: RECOMMENDATIONS FOR MANAGEMENT OF IRRS AND AES
TABLE A MANAGEMENT OF INFUSION-RELATED REACTIONS
NCI-CTCAE 5.0 Grade
Treatment Modification for Infused Agent
(Bintrafusp alfa)
Grade 1 – mild
Mild transient reaction; infusion interruption 
not indicated; intervention not indicated.
Consider decreasing the infusion rate of the 
particular agent by 50% and monitoring 
closely for any worsening.
Grade 2 – moderate
Therapy or infusion interruption indicated but 
responds promptly to symptomatic treatment 
(e.g., antihistamines, NSAIDs, narcotics, i.v. 
fluids); prophylactic medications indicated for 
≤ 24 hours.
Consider temporarily discontinuing infusion 
of the particular agent.
Consider resuming infusion of the particular 
agent at 50% of previous rate once infusion 
related reaction has resolved or decreased to 
at least Grade 1 in severity and monitor 
closely for any worsening.
Grade 3 or Grade 4 – severe or life-
threatening
Grade 3: Prolonged (e.g., not rapidly 
responsive to symptomatic medication and/or 
brief interruption of infusion); hospitalization 
indicated for clinical sequelae.
Grade 4: Life-threatening consequences; 
urgent intervention indicated.
Stop the infusion immediately and disconnect 
infusion tubing from the subject.
For grade 3 events: Consider withdrawing 
immediately from treatment with that 
particular agent and not offering any further 
treatment with that agent based upon if the 
clinical condition can be safely managed. 
For grade 4 events: Withdraw immediately 
from treatment and do not offer further 
treatment with that agent.
If the infusion rate of bintrafusp alfa has been decreased by 50% or interrupted due to an infusion 
reaction, keep it decreased for the next scheduled infusion. If no infusion reaction is observed in 
the next scheduled infusion, the infusion rate may be returned to baseline at the subsequent 
infusions based on investigator’s medical judgment.
If hypersensitivity reaction occurs, the subject should be treated according to the best available 
medical practice.

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TABLE B Management of immune-related Adverse Events
Recommended guidance and management for specific irAEs as provided in the current NCCN
guideline available at http://www.nccn.org.
According to American Society of Clinical Oncology Clinical Practice Guideline (Brahmer 2018),
treatment of irAEs is mainly dependent upon severity as defined by NCI-CTCAE v5.0. In general, management by 
NCI-CTCAE v5.0 grading is listed below:

Grade 1: study intervention should be continued with close monitoring, with the exception of some 
neurologic, hematologic, and cardiac toxicities.

Grade 2: study intervention may be suspended for some Grade 2 toxicities, with
consideration of resuming when symptoms revert to Grade 1 or less. Corticosteroids may be administered 
(initial dose of 0.5 to 1 mg/kg/day of prednisone or equivalent).

Grade 3: study intervention is generally suspended and the high-dose corticosteroids (prednisone 1 to 2 
mg/kg/day or methylprednisolone 1 to 2 mg/kg/day) treatment should be initiated. Corticosteroids should 
be tapered over the course of at least 4 to 6 weeks. Some refractory cases may require infliximab or other 
immunosuppressive therapy.

Grade 4: in general, permanent discontinuation of study intervention is recommended, with the exception 
of endocrinopathies that have been controlled by hormone replacement.
Permanent treatment discontinuation is required in case of immune-related Grade 4 rash/inflammatory dermatitis, 
nephritis, autoimmune hemolytic anemia, hemolytic uremic syndrome, aplastic anemia, immune thrombocytopenia, 
and acquired thrombotic thrombocytopenic purpura.
For Grade 4 immune-related lymphopenia, permanent treatment discontinuation will be required, if lymphopenia is 
considered immune-related in nature, no clear alternative explanation exists for the event, and it does not resolve 
within 14 days. Permanent treatment discontinuation is not required when the AE is manifested by a single 
laboratory value out of normal range without any clinical correlates. In this case, treatment should be held until the 
etiology is determined. If the event is not considered immune-related and resolves to Grade ≤ 1, restarting 
treatment may be considered.
For organ/system specific management guidelines, see the current NCCN guideline available at 
http://www.nccn.org.
TABLE C Management of TGF-β mediated Skin Adverse Events
Skin assessment must be performed at baseline and at least every 6 weeks during treatment and at the end of 
treatment or 28 (±5 days) days post-treatment safety follow-up (if not performed in the previous 6 weeks).

Hyperkeratosis

Keratoacanthoma

Cutaneous squamous cell carcinoma (cSCC)

Basal cell carcinoma

Actinic keratosis
Management

Baseline skin assessment with detailed medical history

Discontinuation or termination not required in most cases. Continuation of treatment should be evaluated 
by the Investigator.

Emollients may be used

Develop diagnostic and treatment plan in collaboration with Investigator and dermatologist

Treatment follow-up will depend on number and localization of lesions.
o
Single lesion: full excision may be recommended
o
Multiple lesion or location not suitable for full excision: Mohrs surgery, cryotherapy or other 
standard treatment options depending on pathology. Topical retinoids may be used after 
discussion with Investigator.

Close clinical follow-up for re-evaluation, resolution and potential recurrence should be implemented

In general, treatment of TGF-β mediated skin lesions should be based on local guidelines/standard of 
care.

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Additional consideration: Keratoacanthoma lesions may resolve spontaneously without surgical intervention 
within weeks after discontinuing bintrafusp alfa.
Consult with Medical Monitor as needed for management of TGF-β mediated skin lesions.

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Management of Mucosal/Non-tumor and Tumor Bleeding
Mucosal Bleeding

Events of mild to moderate severity are a potential risk for bintrafusp alfa.

In general, these reactions resolve without discontinuation of treatment.

Events may include, but are not limited to the following:
o
Epistaxis
o
Hemoptysis 
o
Gingival bleeding
o
Hematuria
Non-tumor Bleeding
Grading
Management
Grade 2

If resolves to Grade ≤ 1 by the day before the 
next infusion, study intervention may be 
continued

If not resolved to Grade ≤ 1 by the day before the 
next infusion, but is manageable and /or not 
clinically relevant, consult Medical Monitor to 
assess if clinically reasonable to administer the 
following infusion.
Grade 3

Permanently discontinue treatment unless an 
alternative explanation can be identified (such as 
concomitant use of antithrombotic agents, 
traumatic events, etc.) 

In case of alternative explanations, hold study 
treatment until the event recovers to Grade ≤ 1
Grade 4

Treatment must be permanently discontinued if 
no alternative explanation is identified.
Tumor Bleeding
Grade ≥ 2

Study treatment must be held till the event 
recovers to Grade ≤ 1

Permanently discontinue treatment if the 
Investigator considers the participant to be at risk 
for additional severe bleeding.
Guideline on Alterations in Wound Healing or Repair of Tissue Damage

Alterations of wound healing and tissue damage repair are considered an important risk for bintrafusp 
alfa

Management should be discussed with Medical Monitor for participants requiring surgery on study.

It is recommended to hold study intervention for approximately 4 weeks post major surgery for 
observation.

Post-operative wound healing should be closely monitored

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17.3 APPENDIX C: BEST OVERALL RESPONSE PER RECIST 1.1
RECIST version 1.1 will be used in this study for assessment of tumor response.(1)
For Participants with Measurable Disease (i.e., Target Disease)
Target 
Lesions
Non-Target 
Lesions
New 
Lesions
Overall 
Response
Best Overall Response when 
Confirmation is Required*
CR
CR
No
CR
>4 wks. Confirmation**
CR
Non-
CR/Non-PD
No
PR
CR
Not 
evaluated
No
PR
PR
Non-
CR/Non-
PD/not 
evaluated
No
PR
>4 wks. Confirmation**
SD
Non-
CR/Non-
PD/not 
evaluated
No
SD
Documented at least once >4 
wks. from baseline**
PD
Any
Yes or 
No
PD
Any
PD***
Yes or 
No
PD
Any
Any
Yes
PD
no prior SD, PR or CR
*
See RECIST 1.1 manuscript for further details on what is evidence of a 
new lesion.
**
Only for non-randomized trials with response as primary endpoint.
***
In exceptional circumstances, unequivocal progression in non-target 
lesions may be accepted as disease progression.
Note: Participants with a global deterioration of health status requiring 
discontinuation of treatment without objective evidence of disease 
progression at that time should be reported as “symptomatic 
deterioration.” Every effort should be made to document the objective 
progression even after discontinuation of treatment.

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For Participants with Non-Measurable Disease (i.e., Non-Target Disease)
Non-Target Lesions
New Lesions
Overall Response
CR
No
CR
Non-CR/non-PD
No
Non-CR/non-PD*
Not all evaluated
No
not evaluated
Unequivocal PD
Yes or No
PD
Any
Yes
PD
* ‘Non-CR/non-PD’ is preferred over ‘stable disease’ for non-target disease since 
SD is increasingly used as an endpoint for assessment of efficacy in some trials 
so to assign this category when no lesions can be measured is not advised