A Randomized Phase 2 Study of CDX-1127 (Varlilumab) in Combination With Nivolumab in Patients With Relapsed or Refractory Aggressive B-cell Lymphomas
Phase: PHASE2
Conditions: ALK-Positive Large B-Cell Lymphoma, Diffuse Large B-Cell Lymphoma Activated B-Cell Type, Diffuse Large B-Cell Lymphoma Associated With Chronic Inflammation, Diffuse Large B-Cell Lymphoma Germinal Center B-Cell Type, Diffuse Large B-Cell Lymphoma, Not Otherwise Specified, EBV-Positive Diffuse Large B-Cell Lymphoma, Not Otherwise Specified, EBV-Positive Mucocutaneous Ulcer, HHV8-Positive Diffuse Large B-Cell Lymphoma, Not Otherwise Specified, High Grade B-Cell Lymphoma With MYC and BCL2 and/or BCL6 Rearrangements, High Grade B-Cell Lymphoma, Not Otherwise Specified, Intravascular Large B-Cell Lymphoma, Large B-Cell Lymphoma With 11q Aberration, Large B-Cell Lymphoma With IRF4 Rearrangement, Plasmablastic Lymphoma, Primary Diffuse Large B-Cell Lymphoma of the Central Nervous System, Primary Effusion Lymphoma, Recurrent B-Cell Non-Hodgkin Lymphoma, Recurrent Burkitt Lymphoma, Recurrent Diffuse Large B-Cell Lymphoma, Recurrent Gray-Zone Lymphoma, Recurrent High Grade B-Cell Lymphoma With MYC and BCL2 or BCL6 Rearrangements, Recurrent High Grade B-Cell Lymphoma With MYC, BCL2, and BCL6 Rearrangements, Recurrent Lymphomatoid Granulomatosis, Recurrent Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type, Recurrent Primary Mediastinal Large B-Cell Lymphoma, Recurrent T-Cell/Histiocyte-Rich Large B-Cell Lymphoma, Refractory B-Cell Non-Hodgkin Lymphoma, Refractory Burkitt Lymphoma, Refractory Diffuse Large B-Cell Lymphoma, Refractory Gray-Zone Lymphoma, Refractory High Grade B-Cell Lymphoma With MYC and BCL2 or BCL6 Rearrangements, Refractory High Grade B-Cell Lymphoma With MYC, BCL2, and BCL6 Rearrangements, Refractory Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg Type, Refractory Primary Mediastinal Large B-Cell Lymphoma, Refractory T-Cell/Histiocyte-Rich Large B-Cell Lymphoma
Sponsor: National Cancer Institute (NCI)

NCI Protocol #: 10089                                                     i 
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To:  
CTEP Protocol and Information Office 
From: 
Stephen Ansell, MD, PhD; J.C. Villasboas, MD 
Date:  
February 18, 2021 
Re: 
Protocol Amendment #8 (PVD 17Feb2021) in response to RRA from CTEP 
(28Jan2021) for NCI protocol #10089: “A Randomized Phase 2 Study of 
Varlilumab (CDX-1127) in Combination with Nivolumab in Patients with 
Relapsed or Refractory Aggressive B-cell Lymphomas” 
 
SUMMARY OF CHANGES:  
Protocol (PVD 02/17/2021) 
 
I.   Response to Request for Amendment from CTEP: 
# 
Section 
Comments 
1. 
7.1.1.2 
V2.3 of the CAEPR for nivolumab has been replaced with V2.4. Changes include: 
 
• 
The SPEER grades have been updated. 
 
• 
Added New Risk: 
• 
Less Likely: CD4 lymphocytes decreased 
• 
Rare: Enterocolitis; Eye disorders - Other (Vogt-Koyanagi-Harada); 
Hepatobiliary disorders - Other (immune-mediated hepatitis); Renal and 
urinary disorders - Other (immune-mediated nephritis) 
 
• 
Modified Specific Protocol Exceptions to Expedited Reporting (SPEER) reporting 
requirements:  
• 
Added: CD4 lymphocytes decreased 
 
• 
Provided Further Clarification: 
• 
Immune system disorders - Other (sarcoid granuloma) is now reported as 
Immune system disorders - Other (sarcoidosis). 
 
 

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A Randomized Phase 2 Study of CDX-1127 (Varlilumab) in Combination with Nivolumab 
in Patients with Relapsed or Refractory Aggressive B-cell Lymphomas 
 
  
 
Corresponding Organization: LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
 
 
Principal Investigator: 
Stephen Ansell, MD, PhD 
Mayo Clinic 
200 First Street Southwest 
Rochester, Minnesota 55905 
Telephone: (507) 284-2511 
Email: ansell.stephen@mayo.edu 
 
Co-Principal Investigator: Jose Caetano Villasboas, MD 
 
Mayo Clinic  
 
200 First Street Southwest 
 
Rochester, Minnesota 55905 
Telephone: (507) 284-2511    
Email: villasboas@mayo.edu 
 
 
 
Participating Organizations:  
LAO-11030 / University Health Network Princess Margaret Cancer Center LAO 
Note: Participation is restricted to sites located in the United States 
LAO-CA043 / City of Hope Comprehensive Cancer Center LAO 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / University of Pittsburgh Cancer Institute LAO 
LAO-TX035 / University of Texas MD Anderson Cancer Center LAO 
LAO-NCI / National Cancer Institute LAO 
EDDOP / Early Drug Development Opportunity Program 
CATCHUP / Creating Access to Targeted Cancer Therapy for Underserved Populations 
 
 
 
 
 
 

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Statistician 
Project Manager 
 
 
 
Betsy LaPlant, MS 
Elizabeth Mikula 
Mayo Clinic 
Mayo Clinic 
Telephone: (507) 538-7146   
Telephone: (507) 538-6232 
Email: laplant.betsy@mayo.edu 
Email: mikula.elizabeth@.mayo.edu 
 
 
NCI-Supplied Agents:   
CDX-1127 (Varlilumab) (NSC 778372) 
Nivolumab (BMS-936558, MDX-1106, and ONO-4538) (NSC #748726) 
 
 
IND #:   
IND Sponsor:  DCTD, NCI 
 
Clinical Trials.gov Registration: NCT03038672 
 
Protocol Type / Version # / Version Date: 
 
Original / Version 1 / December 12, 2016 
Resubmission / Version 2 / February 15, 2017 
Resubmission / Version 3 / March 15, 2017 
Resubmission / Version 4 / BRC and FDA Comments / July 20, 2017 
Resubmission / Version 5 / CTEP and CIRB Comments / August 4, 2017 
Amendment 1 / Version 6 / August 1, 2018 
Amendment 2 / Version 7 / November 28, 2018 
Amendment 3 / Version 8 / December 26, 2018 
Amendment 4 / Version 9 / May 15, 2019 
Amendment 5 / Version 10 / November 7, 2019 
Amendment 6 / Version 12 / July 28, 2020 
Amendment 7 / Version 13 / September 24, 2020 
Amendment 8 / Version 14 / February 17, 2021 
 

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SCHEMA 
 
 
 
 

NCI Protocol #: 10089                                                       4 
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TABLE OF CONTENTS 
 
SCHEMA .........................................................................................................................................3 
TABLE OF CONTENTS .................................................................................................................4 
1. 
OBJECTIVES ......................................................................................................................6 
1.1 
Primary Objectives ...................................................................................................7 
1.2 
Secondary Objectives ...............................................................................................7 
1.3 
Exploratory Objectives ............................................................................................7 
2. 
BACKGROUND .................................................................................................................7 
2.1 
Study Disease ...........................................................................................................7 
2.2 
CTEP IND Agents ...................................................................................................8 
2.3 
Rationale ................................................................................................................15 
2.4 
Correlative Studies Background ............................................................................17 
2.5 
Rationale for Modification of the Dosage of Nivolumab After 4 Months ............21 
3. 
PATIENT SELECTION ....................................................................................................23 
3.1 
Eligibility Criteria ..................................................................................................23 
3.2 
Exclusion Criteria ..................................................................................................25 
3.3 
Inclusion of Women and Minorities ......................................................................28 
4. 
REGISTRATION PROCEDURES ...................................................................................28 
4.1 
Investigator and Research Associate Registration with CTEP ..............................29 
4.2 
Site Registration .....................................................................................................30 
4.3 
Patient Registration ................................................................................................32 
4.4 
General Guidelines .................................................................................................33 
5. 
TREATMENT PLAN ........................................................................................................33 
5.1 
Agent Administration .............................................................................................33 
5.2 
General Concomitant Medication and Supportive Care Guidelines ......................34 
5.3 
Duration of Therapy ...............................................................................................34 
5.4 
Duration of Follow Up Following End of Therapy ...............................................35 
5.5 
Criteria for Removal from Study ...........................................................................35 
5.6 
Criteria to Resume Treatment Following a Drug-Related Adverse Event ............36 
5.7 
Treatment of Study Drug Related Infusion Reactions ...........................................36 
6. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................38 
6.1 
Dose Modifications for Group 1 (Nivolumab alone) and Group 2 
(Nivolumab and CDX-1127 (Varlilumab) .............................................................39 
7. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................46 
7.1 
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs) ...............46 
7.2 
Adverse Event Characteristics ...............................................................................54 

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7.3 
Expedited Adverse Event Reporting ......................................................................55 
7.4 
Routine Adverse Event Reporting .........................................................................57 
7.5 
Secondary Malignancy ...........................................................................................58 
7.6 
Second Malignancy ................................................................................................58 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................58 
8.1 
CTEP IND Agent(s) ...............................................................................................58 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................63 
9.1 
Specimen Requirements for Correlative Studies ...................................................63 
9.2 
Integrated Correlative Studies ................................................................................68 
9.3 
Exploratory/Ancillary Correlative Studies ............................................................69 
10. 
STUDY CALENDAR .......................................................................................................76 
11. 
MEASUREMENT OF EFFECT........................................................................................79 
11.1 
Antitumor Effect – Hematological Tumors ...........................................................79 
12. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS .............................................................................................................84 
12.1 
Study Oversight .....................................................................................................84 
12.2 
Data Reporting .......................................................................................................85 
12.3 
CTEP Multicenter Guidelines ................................................................................87 
12.4 
Collaborative Agreements Language .....................................................................87 
13. 
STATISTICAL CONSIDERATIONS...............................................................................89 
13.1 
Study Design/Endpoints.........................................................................................89 
13.2 
Sample Size/Accrual Rate ......................................................................................91 
13.3 
Stratification Factors ..............................................................................................92 
13.4 
Analysis of Secondary Endpoints ..........................................................................92 
13.5 
Analysis of Exploratory Endpoints ........................................................................93 
13.6 
Reporting and Exclusions ......................................................................................94 
13.7 
Adverse Event Stopping Rule ................................................................................95 
REFERENCES ..............................................................................................................................97 
APPENDIX A: PERFORMANCE STATUS CRITERIA ...........................................................102 
APPENDIX B: PATIENT WALLET CARD ..............................................................................103 
APPENDIX C: BIOASSAY TEMPLATES ................................................................................105 
APPENDIX D: MANAGEMENT ALGORITHMS FOR ENDOCRINOPATHY, 
GASTROINTESTINAL, HEPATIC, NEUROLOGICAL, PULMONARY, RENAL, 
AND SKIN ADVERSE EVENTS ...................................................................................106 
APPENDIX E: SPECIMEN CHECKLIST AND SHIPPING INSTRUCTIONS .......................114 

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APPENDIX F: PANEL FOR CYTOF ANALYSIS ....................................................................117 
OBJECTIVES

NCI Protocol #: 10089                                                       7 
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1.1 
Primary Objectives 
 
1.1.1 To determine the anti-tumor activity of combination therapy with CDX-1127 
(varlilumab) and nivolumab as compared to nivolumab alone in patients with advanced 
aggressive B-cell non-Hodgkin lymphomas (NHL) based on the lymphoma response to 
immunomodulatory therapy criteria or LYRIC  (Cheson et al., 2016). 
 
1.2 
Secondary Objectives 
 
1.2.1 To assess the safety and tolerability profile of treatment with a combination of CDX-
1127 (varlilumab) and nivolumab in patients with advanced aggressive B-cell NHL. 
 
1.2.2 To evaluate the duration of response, progression-free survival and overall survival 
 
1.3 
Exploratory Objectives 
 
1.3.1 To determine the effect of combination therapy with CDX-1127 (varlilumab) and 
nivolumab on the immune system as assessed by immunohistochemistry (IHC), mass 
cytometry (CyTOF),  changes in serum cytokine profile and immunogenicity assays. 
 
1.3.2 To describe the pharmacokinetic profile of CDX-1127 (varlilumab) and nivolumab when 
used in combination. 
 
2. BACKGROUND 
 
2.1 
Study Disease 
 
Diffuse large B-cell lymphoma (DLBCL) remains the most common lymphoma 
worldwide and corresponded to 32.5% of a total of 596,476 non-Hodgkin lymphomas 
(NHL) diagnosed between 2008 and 2011 in the United States (Green et al., 2010 and 
Dong et al., 2002).  Standard frontline treatment with chemo immunotherapy will cure 
about two thirds of these patients but a significant proportion will be either refractory to 
treatment or develop relapsed disease.  Salvage treatment options in the 
relapsed/refractory settings are limited and most of these patients will unfortunately die 
from progressive disease. 
 
Somatic alterations have been identified in DLBCL patients who fail to achieve durable 
remissions (Wilcox et al., 2009) but the role played by the host immune system in this 
context is unknown.  Checkpoint blockade therapy is used in a variety of cancers and 
works by modulating the host’s immune system towards an effective anti-tumoral attack.  
Trials using programmed cell death protein 1 (PD-1) inhibitors in advanced 
hematological malignancies demonstrated remarkable activity in patients with Hodgkin 
lymphoma (HL) (Yang et al., 2014, Yang et al., 2015), leading to the recent regulatory 
approval of Nivolumab in the United Stated.  Unfortunately, results in the DLBCL cohort 
were marginal and short lived (Yang et al., 2012, Keir et al., 2008). 
 

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Therefore, there is a critical need to extend the benefits of immunotherapy to patients 
with advanced DLBCL and other aggressive NHL.  We hypothesize that the combination 
of two immunomodulatory agents will increase the anti-tumor activity compared to 
single-agent Nivolumab and improve clinical outcomes for this group of patients with no 
significant increase in toxicity. 
 
2.2 
CTEP IND Agents 
 
2.2.1 CDX-1127 (Varlilumab) 
Antibodies that recognize immune cell surface molecules can be used to enhance or 
target immune responses against tumors.  These include antibodies that activate antigen 
presenting cells (e.g. anti-CD40), antibodies that block immune checkpoints (e.g. anti-
CTLA-4, anti-PD-1), and T cell costimulatory antibodies (e.g. anti-4-1BB). The 
costimulatory molecule CD27 is a member of the tumor necrosis factor (TNF) receptor 
superfamily, and is constitutively expressed on the majority of mature T-cells, memory B 
cells, and a portion of natural killer cells.  The interaction of CD27 with its ligand CD70 
plays key roles in the following processes: 
 
•  Co-stimulation through CD27 on T cells causes activation, proliferation, survival, 
and maturation of effector capacity and memory; 
 
•  Costimulation through CD27 on human B cells activates and promotes the 
generation of plasma cells, proliferation, and the production of immunoglobulin; 
 
•  Costimulation through CD27 on natural killer cells induces cytolytic activity. 
 
Antibodies targeting CD27 can potentially be either agonists or antagonists of these 
CD27-CD70 pathway activities.  In addition to the immune enhancing properties of 
agonist anti-CD27 mAbs, CD27-targeting antibodies may also provide direct therapeutic 
effects against tumors with CD27 expression.  The expression of CD27 on various types 
of lymphomas and leukemias such as Chronic Lymphocytic Leukemia, Mantle Cell 
Lymphoma, Primary Central Nervous System Lymphoma, Burkitt’s Lymphoma, and 
Marginal Zone B cell Lymphoma has been well documented (van Oers et al., 1993; 
Ranheim et al., 1995; Trentin et al., 1997; Molica et al., 1998; Murase et al., 1998; Dong 
et al., 2002).  CD27 expression is present on most B cell malignancies at varying levels, 
and is also expressed by adult T-cell leukemia/lymphoma (van Oers et al., 1993; 
Ranheim et al., 1995; Shao et al., 2010).  CDX-1127 (Varlilumab) was selected on the 
basis of its agonistic properties and direct therapeutic effect against CD27 expressing 
tumors. 
 
CDX-1127 (Varlilumab) is an agonist anti-CD27 monoclonal antibody that is expected to 
activate CD27 expressing T-cells in the context of T cell receptor stimulation.  Based on 
strong pre-clinical efficacy data, other agonist antibodies recognizing lymphocyte 
costimulatory molecules, notably CD28, CD40, and CD137, have entered the clinic and 
have been associated with varying degrees of acute toxicity and clinical activity. 
 

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CD27 has distinct properties, including a restricted distribution of expression, 
requirement for concomitant T-cell receptor activation, comparable expression patterns in 
human and non-human primates in which toxicity studies have been conducted, and lack 
of observed toxicity in preclinical studies, that suggest agonist anti-CD27 monoclonal 
antibodies may have less acute toxicity than other agonist monoclonal antibodies 
targeting costimulatory molecules that have been studied in the clinic to date. 
 
CDX-1127 (Varlilumab) binds to human CD27 and has shown strong reactivity with 
human lymphoma and leukemia cell lines, including the Burkitt’s cell lines Raji, Daudi, 
and Ramos.  CDX-1127 (Varlilumab) acts as an agonist of CD27 and reacts with the 
ligand binding site of CD27 as demonstrated by inhibition of CD70 binding to CD27.  
CDX-1127 (Varlilumab) does not bind other tumor necrosis factor receptor (TNFR) 
family members.  As shown in both lymphocyte proliferation and cytokine induction 
studies, CDX-1127 (varlilumab) does not lead to direct activation of lymphocytes in the 
absence of signaling through the T cell receptor (TCR).  BCL1 B-lymphoma and CT26 
(colon cancer) tumor challenge models using human CD27-transgenic mice (Tg) showed 
treatment of mice with CDX-1127 (varlilumab) resulted in substantial improved survival 
at the higher dose levels (> 150 μg x 5) while a biologically effective response was 
observed for ≥ 0.5 mg/kg x 5 repeated dose in this model.  CDX-1127 (Varlilumab) also 
showed significant anti-tumor effects against a variety of human tumor cell lines 
including Raji, Daudi, Namalwa and CCRF-CEM cell challenge in SCID mice. 
 
T cell lymphomas and leukemias often express elevated levels of CD27, which could 
serve as a direct target for CDX-1127 (varlilumab).  In fact, CDX-1127 (varlilumab) is 
effective against both T and B cell derived tumors in xenograft models.  In addition, 
CDX-1127 (varlilumab) has potent anti-tumor activity against the EG7 mouse thymoma 
in syngeneic tumor models that rely on T cell mediated immunity for response. In vitro 
studies were conducted to investigate the effect of CDX-1127 (varlilumab) on 
proliferation and survival of CD27-expressing human T cell lines and primary T cell 
lymphomas or leukemia from patients.  The CDX-1127 (varlilumab) antibody was coated 
to wells to provide optimal cross-linking of the CD27 receptor, and the results compared 
to an irrelevant human IgG1 isotype control.  There was no evidence of enhanced tumor 
cell proliferation or viability in the presence of CDX-1127 (varlilumab).  Some decrease 
in proliferation was observed by CDX-1127 (varlilumab), but additional studies will be 
required to determine if this effect is significant.  Importantly, using CRF-CEM cells 
which are known to respond to anti-CD3, we did not observe increased viability with 
CDX-1127 (varlilumab), even in the context of T cell receptor stimulation.  These studies 
demonstrate that crosslinking CD27 on human tumor cell lines or primary tumor cells of 
T cell origin does not significantly impact their growth or viability. 
 
CDX-1127 (Varlilumab) has similar binding properties to human and non-human primate 
CD27.  This has been demonstrated using recombinant purified protein from both species 
as well as by flow cytometry on relevant cell populations from peripheral blood and also 
by immunohistochemistry analysis on tissue sections.  However, the pharmacological 
relevance of the monkey model to patients is not yet available. 
 

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In a preliminary non-GLP pilot toxicology study, single i.v. doses of CDX-1127 
(varlilumab) administered to Cynomolgus macaques were well tolerated and no animals 
exhibited signs of toxicity over the 29 day follow-up.  Clinical chemistry parameter 
values on Days 2, 3, and 8 were comparable to those observed at pre-dose with the 
exception of AST serum levels, which were increased in all animals at Day 2, possibly 
related to ketamine administration (Davy et al., 1987, Gibhard et al., 2009). There were 
no major changes in circulating lymphocyte populations, with the exception of a transient 
decrease of natural killer cells. 
 
In a repeat-dose GLP toxicology study in Cynomolgus macaques, five administrations of 
CDX-1127 (varlilumab), each one week apart, at the dose levels of 0, 0.25, 2.5 and 25 
mg/kg/day did not result in any morbidity or mortality or changes in the assessed 
parameters of clinical condition, food appetence, body weights, body temperature, 
clinical pathology, ophthalmic and electrocardiography parameters, pathology 
(macroscopic, microscopic and organ weights) parameters and bone marrow smears.  
Anti-CDX-1127 (varlilumab) antibodies were detected in a very small proportion of 0.25 
and 2.5 mg/kg/day treated animals at the end of dosing and detectable at the end of 
recovery in some animals.  Peripheral blood mononuclear cell analysis at necropsy 
showed no significant changes in most cell populations.  Altered regulatory T and natural 
killer cells in animals administered CDX-1127 (varlilumab) at 0.25 mg/kg/day were 
noted.  Levels of IL-6 and IL-1β were undetectable in all animals at all timepoints.  
Approximately 58% of samples collected from animals in this study had detectable levels 
of IFN-γ.  Samples with detectable levels were observed in animals from all dose levels 
(including controls) and at all timepoints.  There was no correlation of the frequency of 
samples with detectable IFN-γ levels or mean IFN-γ levels with dose level or time after 
dosing.  It was concluded that changes in IFN-γ levels were not test article related.  There 
was evidence of systemic accumulation of CDX-1127 (varlilumab) at all dose levels, 
suggesting time-dependent kinetics; consistent with a slow elimination process as 
demonstrated by the low plasma clearance and long mean residence time and half-lives 
observed for CDX-1127 (varlilumab).  Based on these results, the NOEL (no observable 
effect level) and NOAEL (no observable adverse effect level) of CDX-1127 (varlilumab) 
was considered to be 25 mg/kg/day administered once weekly to Cynomolgus monkeys 
for five weeks and two weeks of recovery. 
 
A tissue cross-reactivity study was performed with observed tissue binding of CDX-1127 
(varlilumab) being similar between human and Cynomolgus macaque tissues.  Highly 
specific CDX-1127 (varlilumab)-FITC staining of mononuclear cells was observed and 
attributed to staining of target CD27 at the membrane and in the cytoplasm of these cells 
in human and Cynomolgus monkey tissues.  Unexpected staining was observed in 
Cynomolgus monkey pituitary epithelium, but was restricted to the cytoplasm and did not 
correlate with any findings in the toxicology study.  As a consequence of that, and the 
lack of such binding in human tissues, it is unlikely to be of clinical relevance. 
 
A phase I study evaluated the safety, tolerability and efficacy of single-agent CDX-1127 
(varlilumab) in patients with advanced hematologic malignancies (NCT01460134; Ansell 
et al, 2014). In the dose-escalation phase, patients received CDX-1127 (varlilumab) in 5 

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dose-levels ranging from 0.1 to 10 mg/kg IV weekly.  A total of 24 patients with 
advanced hematological malignancies received single-agent CDX-1127 (varlilumab) 
given as a single dose followed by a 28-day observation period that was then followed by 
a multi-dose period consisting of 4 weekly doses followed by a 4-week observation 
period.  Retreatment with up to 4 additional cycles (4 weekly doses followed by 8-week 
observation period) was allowed for patients with stable disease.  No dose-limiting 
toxicity (DLT) was observed and MTD was not reached.  Treatment-related adverse 
events were infrequent and nearly all mild to moderate in severity.  No overlapping in 
toxicity with checkpoint inhibitor blockade therapy (endocrinopathies, colitis and 
pneumonitis) was observed.  The half-life of CDX-1127 (varlilumab) ranged from 6 days 
(at 1 mg/kg) to 10.6 days (at 10 mg/kg) with linear pharmacokinetics.  One patient 
experienced a complete response (a patient with heavily pretreated Hodgkin lymphoma 
treated at the 0.3 mg/kg dose-level) and 3 patients with NHL had stable disease with 
duration of response up to 14 months.  Correlative studies demonstrated that treatment 
with CDX-1127 (varlilumab) was associated with reduction of circulating Treg and 
increase in pro-inflammatory cytokines. 
 
2.2.2 Nivolumab 
 
Nivolumab (BMS-936558, MDX-1106, and ONO-4538) is a fully human monoclonal 
immunoglobulin G4 (IgG4) antibody (HuMAb) that is specific for human programmed 
death-1 (PD-1, cluster of differentiation 279 [CD279]) cell surface membrane receptor 
(Investigator Brochure, 2014).  PD-1 is a negative regulatory molecule that is expressed 
transiently following T-cell activation and on chronically stimulated T cells characterized 
by an “exhausted” phenotype.  Nivolumab binds to cynomolgus monkey PD-1 but not 
mouse, rat, or rabbit molecules.  Clinical activity of nivolumab has been observed in 
patients with melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma 
(RCC).  The combination of nivolumab and ipilimumab (anti-cytotoxic T lymphocyte 
associated antigen-4 [anti-CTLA-4]) in a phase 1/2 trial showed markedly enhanced 
clinical activity with an acceptable safety profile in melanoma patients (Wolchok et al., 
2013). 
 
The clinical use of monoclonal antibodies to T-cell inhibitory receptors has provided 
transformative information on the nature of the immune system and cancer.  An emerging 
picture suggests that endogenous immune responses can mediate effective tumor 
regression and/or improved survival even in patients with large volume tumors resistant 
to other forms of therapy.  Some of the unique features of this type of therapy, based 
largely on experience in advanced melanoma, include:  improved overall survival (OS) 
with or without radiographic responses or improved progression-free survival (PFS); 
responses that may be delayed or occur after radiographic disease progression; 
combinations of immune modulators with enhanced or novel activities (in the example of 
ipilimumab and nivolumab); and toxicity that is almost exclusively immune or 
inflammatory in nature.  It is not yet clear what factors determine responses and which 
components of the immune system are needed for this to occur.  It seems likely that both 
memory helper and effector cells would be needed to sustain long-term responses. 
Increasing emphasis has been placed on understanding the relationships of the tumor, 

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cellular infiltrate, and immunologic milieu surrounding each tumor. 
 
PD-1, a 55-kDa type 1 transmembrane protein, is a member of the CD28 family of T-cell 
co-stimulatory receptors that include Ig super family member CD28, CTLA-4, inducible 
co-stimulator (ICOS), and B and T lymphocyte attenuator (BTLA) (Investigator 
Brochure, 2014).  PD-1 is transiently but highly expressed on activated T cells 
functioning to limit immune effectors at the site of activation.  Chronic stimulation may 
prevent the re-methylation of the PD-1 gene leading to continuous expression and 
characterizes a state of “exhausted” T cells that lose function and proliferative capacity 
while enhancing a suppressive tumor microenvironment.  PD-1 may act together with 
other T-cell modulating molecules, including CTLA-4, TIM-3, lymphocyte-activation 
gene 3 (LAG-3) as well as indoleamine-pyrrole 2, 3-dioxygenase 1 (IDO-1), cytokines, 
and transforming growth factor beta (TGF-beta).   
 
Two ligands specific for PD-1 have been identified:  PD-ligand 1 (PD-L1, also known as 
B7-H1 or CD274, expressed on tumor, antigen-presenting cells [APCs], and dendritic 
cells [DCs]) and PD-L2 (also known as B7-DC or CD273, expressed on endothelial 
cells).  The interaction of PD-1 with PD-L1 and PD-L2 results in negative regulatory 
stimuli that down-modulate the activated T-cell immune response through SHP-1 
phosphatase. 
 
PD-1 knockout mice develop strain-specific lupus-like glomerulonephritis (C57BL/6) 
and cardiomyopathy (BALB/c).  In transplantable tumor models that expressed PD-1 and 
LAG-3 on tumor-infiltrating CD4+ and CD8+ T cells dual anti-LAG-3/anti-PD-1 antibody 
treatment cured most mice of established tumors that were largely resistant to single 
antibody treatment (Woo et al., 2012).  Despite minimal immunopathologic sequelae in 
PD-1 and LAG-3 single knockout mice, dual knockout mice abrogated self-tolerance 
with resultant autoimmune infiltrates in multiple organs, leading to eventual lethality. 
 
PD-L1 expression is found on a number of tumors, and is associated with poor prognoses 
based on OS in many tumors, including melanoma (Taube et al., 2012), renal (Thompson 
et al., 2004; Thompson et al., 2005; Thompson et al., 2006), esophageal (Ohigashi et al. 
2005), gastric (Wu et al., 2006), ovarian (Dong et al., 2003), pancreatic (Nomi et al., 
2007), lung (Zitvogel et al., 2006), and other cancers (Investigator Brochure, 2014). 
 
The PD-1/PD-L1 axis plays a role in human infections, particularly in hepatitis C virus 
(HCV) and human immunodeficiency virus (HIV).  In these cases, high expression levels 
of PD-1 were found in viral-specific CD8+ T cells that also display a non-responsive or 
exhausted phenotype.  Non-responsive PD-1-high T cells were observed in simian 
immunodeficiency virus (SIV) infection in rhesus macaques.  Treatment of SIV-infected 
macaques with an anti-PD-1 mAb (3 mg/kg x4) resulted in decreased viral loads and 
increased survival along with expanded T cells with increased T-cell functionality.   
 
 
2.2.2.1 Nonclinical Development of Nivolumab 
 

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In intravenous (IV) repeat-dose toxicology studies in cynomolgus monkeys, nivolumab 
alone was well tolerated (Investigator Brochure, 2014).  Combination studies have 
highlighted the potential for toxicity when combined with ipilimumab, MDX-1408, and 
BMS-986016.  Nivolumab bound specifically to PD-1 (and not to related members of 
the CD28 family such as CD28, ICOS, CTLA-4, and BTLA) with a Kd = 3.06 nM.  A 
surrogate rat anti-mouse PD-1 antibody (4H2) was derived and expressed as chimeric 
IgG1 murine antibody.  Antitumor activity was seen for several tumor models, 
including colon carcinoma and fibrosarcoma. 
 
 
2.2.2.2 Clinical Development of Nivolumab 
 
Nivolumab is being evaluated as monotherapy and in combination with cytotoxic 
chemotherapy, other immunotherapy (such as ipilimumab), anti-angiogenesis therapy, 
and targeted therapies in completed and ongoing BMS-sponsored clinical trials in 
NSCLC, melanoma, RCC, hepatocellular carcinoma (HCC), gastrointestinal (GI) 
malignancies including microsatellite instability (MSI) in colorectal cancer, and triple-
negative breast cancer (TNBC) with an expanding group of indications (Investigator 
Brochure, 2014).  In addition, two investigator-sponsored trials (ISTs) of nivolumab in 
combination with a peptide vaccine in melanoma are being conducted in the adjuvant 
setting and advanced disease.  
 
Seven nivolumab studies were conducted in Japan, including six studies in advanced 
solid tumors and recurrent or unresectable stage III/IV melanoma sponsored by Ono 
Pharmaceuticals Co. Ltd., and one IST in recurrent or advanced platinum-refractory 
ovarian cancer.   
 
 
2.2.2.2.1. Pharmacokinetics 
 
Pharmacokinetics (PK) of nivolumab was linear in the range of 0.3 to 10 mg/kg, with 
dose-proportional increases in maximum serum concentration (Cmax) and area under 
the concentration-time curve from time zero to infinity (AUC0-∞), with low to 
moderate inter-subject variability observed at each dose level (Investigator Brochure, 
2014).  Clearance of nivolumab is independent of dose in the dose range (0.1 to 10 
mg/kg) and tumor types studied.  Body weight normalized dosing showed 
approximately constant trough concentrations over a wide range of body weights.  
The mean terminal elimination half-life of BMS-936558 is 17 to 25 days consistent 
with the half-life of endogenous IgG4.   
 
 
 
2.2.2.2.2. Efficacy 
 
In a phase 1 (1, 3, and 10 mg/kg nivolumab doses) dose-escalation study the 3 mg/kg 
dose was chosen for expanded cohorts. Among 236 patients, objective responses 

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(ORs) (complete or partial responses [CR or PR]) were seen in NSCLC, melanoma, 
and RCC.  ORs were observed at all doses (Sznol et al., 2013).  Median OS was 16.8 
months across doses and 20.3 months at the 3 mg/kg dose.  Median OS across all 
dose cohorts was 9.2 months and 9.6 months for squamous and non-squamous 
NSCLC, respectively (Brahmer et al., 2013).  In the RCC cohort, median duration of 
response was 12.9 months for both doses with 5 of the 10 responses lasting ≥ 1 year 
(Drake et al., 2013).   
 
In an advanced melanoma phase 1 study, nivolumab and ipilimumab were 
administered IV every 3 weeks for 4 doses followed by nivolumab alone every 3 
weeks for 4 doses (concurrent regimen) (Wolchok et al., 2013).  The combined 
treatment was subsequently administered every 12 weeks for up to 8 doses.  In a 
sequenced regimen, patients previously treated with ipilimumab received nivolumab 
every 2 weeks for up to 48 doses.  In the concurrent regimen (53 patients), 53% of 
patients had an OR at doses 1 mg/kg nivolumab and 3 mg/kg ipilimumab, with tumor 
reduction of 80% or more (modified World Health Organization [mWHO] criteria).  
In the sequenced-regimen (33 patients), the objective response rate (ORR) was 20%. 
 
In a phase 1 study of nivolumab plus platinum-based doublet chemotherapy (PT-
doublet) in chemotherapy-naïve NSCLC patients, 43 patients were treated with 
nivolumab + PT-doublet (Rizvi et al., 2013).  No dose-limiting toxicities (DLTs) 
were reported and total/confirmed ORRs were 43/33%, 40/33%, and 31/31% in 
nivolumab/gemcitabine/cisplatin, nivolumab/pemetrexed/cisplatin, and 
nivolumab/carboplatin/paclitaxel arms, respectively. 
 
 
2.2.2.2.3. Toxicology 
 
A maximum tolerated dose (MTD) of nivolumab was not defined (Topalian et al., 
2012).  Serious adverse events (SAEs) occurred in 32 of 296 patients (11%) similar to 
the immune-related inflammatory events seen with ipilimumab:  pneumonitis, 
vitiligo, colitis, hepatitis, hypophysitis, and thyroiditis (with noted pulmonary toxicity 
resulting in 3 deaths. Renal failure, symptomatic pancreatic and DM, neurologic 
events, and vasculitis have also been reported.).   In combination with ipilimumab in 
the concurrent-regimen group (Wolchok et al., 2013), grade 3 or 4 treatment-related 
events were noted in 53% of patients.  Skin rash represents the majority of these 
events.   
 
 
2.2.2.2.4. Pharmacodynamics/Biomarkers 
 
Tumor-cell expression (melanoma) of PD-L1 was characterized in combination with 
ipilimumab with the use of IHC staining and pharmacodynamics changes in the 
peripheral-blood absolute lymphocyte count (Wolchok et al., 2013).  With PD-L1 
positivity defined as expression in at least 5% of tumor cells, biopsy specimens from 
21 of 56 patients (38%) were PD-L1–positive.  Among patients treated with the 

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concurrent regimen of nivolumab and ipilimumab, ORs were observed in patients 
with either PD-L1–positive tumor samples (6 of 13 patients) or PD-L1–negative 
tumor samples (9 of 22).  In the sequenced regimen cohorts, a higher number of 
overall responses was seen among patients with PD-L1–positive tumor samples (4 of 
8 patients) than among patients with PD-L1–negative tumor samples (1 of 13) 
suggesting the possibility that these tumors have higher response rates to the 
combination. The relationship between PDL-1 expression and responses may not be 
present in patients treated with the combination.  Tissue expression of PDL-2, 
interferon-γ (IFN- γ), IDO, and T cell CD8+ are of current interest.  Until more 
reliable data based on standardized procedures for tissue collection and assays are 
available, PD-L1 status cannot be used to select patients for treatment at this time.   
 
 
2.3 
Rationale 
 
2.3.1 Combination Therapy using CDX-1127 (Varlilumab) and Nivolumab in Hematological 
Malignancies 
 
Malignant cells are able to escape immune surveillance by co-opting cellular mechanisms 
such as immune checkpoint pathways (Green et al., 2010; Dong et al., 2002; Wilcox et 
al., 2009) or inducing T-cell exhaustion (Yang et al, 2014; Yang et al., 2015; Yang et al., 
2012).  These immune checkpoints are natural control mechanisms that prevent T-cell 
hyperactivation following an antigenic challenge (Keir et al., 2008; Francisco et al., 
2010).  The programmed death 1 (PD-1) pathway is an immune checkpoint with a clearly 
established role in tumor-mediated immunosuppression.  Some neoplastic cells are able 
to express cognate ligands (PD-L1 and PD-L2) that are recognized by the PD-1 receptor 
expressed on the surface of activated effector T-cells.  Activation of the PD-1: PD-L1/2 
axis leads to a cascade of intracellular events that result in decreased T-cell survival and 
function.  Monoclonal antibodies that recognize the PD-1 receptor are able to block its 
interaction with the ligands and result in release of an effective anti-tumoral immune 
response.  Nivolumab is a fully human immunoglobulin G4 (IgG4) with high affinity 
against the PD-1 receptor with anti-tumoral activity against a number of solid tumors and 
hematological malignancies (OPDIVO Package Insert, 2014). 
The single-agent safety and efficacy of nivolumab in hematological malignancies has 
been evaluated in a phase I dose-escalation study (NCT01592370).  Patients with 
advanced hematological malignancies received nivolumab at a dose of 1 mg/kg with 
escalation to 3 mg/kg. Since the maximum tolerated dose (MTD) was not reached, 
patients in the expansion cohorts received 3 mg/kg at week 1, week 4, and then every 2 
weeks.  Results from the expansion cohort that included 23 patients with advanced classic 
Hodgkin lymphoma (CHL) have now been published (Ansell et al., 2014).  Nivolumab 
was safe and well tolerated in this patient population and yielded an objective response in 
20 patients (ORR 87%).  Results from the experience in a small cohort of non-Hodgkin 
lymphoma (NHL) and other hematological malignancies demonstrated limited single 
agent activity in B-cell NHL (ORR 26%) multiple myeloma (ORR 4%), and T-cell NHL 
(ORR 17%) (Lesokhin et al., 2016). 

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T-cell exhaustion has been recognized as another important mechanism by which 
lymphoma cells escape an immune attack.  Our group has demonstrated that the tumor 
microenvironment in NHL produces profound immunosuppression mediated by 
regulatory T-cells (Treg) (Yang et al., 2006a; Yang et al., 2006b; Yang et al. 2007; Yang 
et al., 2009; Ai et al., 2009; Hilchey et al., 2007) and suppressive monocytic cells (SMC) 
(Wilcox et al., 2009; Xiu et al., 2015).  Strategies aimed at reversing T-cell exhaustion 
using agonistic molecules have the potential to produce an effective anti-tumoral 
response.  The co-stimulatory molecule CD27 is constitutively expressed in many normal 
immune cells including T-cells, B-cells and NK cells van de Ven et al., 2015).  T-cell 
function and survival is enhanced once CD27 binds to its ligand (CD70) on the surface of 
antigen presenting cells in the context of T-cell receptor engagement.  Pre-clinical studies 
demonstrated that immune tolerance and exhaustion might be prevented or reversed by 
signaling through CD27.  CDX-1127 (Varlilumab) is an agonistic IgG1 monoclonal 
antibody that recognizes CD27 (He et al., 2013; Vitale et al., 2012; Thomas et al., 2014). 
CDX-1127 (Varlilumab) has also demonstrated direct anti-tumoral activity in xenograft 
models of human lymphoma and leukemia cell lines via antibody-dependent cell-
mediated cytotoxicity (ADCC).  Given that CD27 expression has been demonstrated in 
many hematological malignancies (Dong et al., 2002), this constitutes another potential 
mechanism by which CDX-1127 (varlilumab) may enhance tumor eradication. 
A phase 1 study evaluated the safety, tolerability and efficacy of single-agent CDX-1127 
(varlilumab) in patients with advanced hematologic malignancies (NCT01460134) 
(Ansell et al., 2014).  In the dose-escalation phase, patients received CDX-1127 
(varlilumab) in 5 dose-levels ranging from 0.1 to 10 mg/kg IV weekly.  A total of 24 
patients with advanced hematological malignancies received single-agent CDX-1127 
(varlilumab) given as a single dose followed by a 28-day observation period that was then 
followed by a multi-dose period consisting of 4 weekly doses followed by a 4-week 
observation period.  Retreatment with up to 4 additional cycles (4 weekly doses followed 
by 8-week observation period) was allowed for patients with stable disease.  No dose-
limiting toxicity (DLT) was observed and MTD was not reached. Treatment-related 
adverse events were infrequent and nearly all mild to moderate in severity.  No 
overlapping in toxicity with checkpoint inhibitor blockade therapy (endocrinopathies, 
colitis, and pneumonitis) was observed.  The half-life of CDX-1127 (varlilumab) ranged 
from 6 days (at 1 mg/kg) to 10.6 days (at 10 mg/kg) with linear pharmacokinetics. One 
patient experienced a complete response (patient with heavily pretreated Hodgkin 
lymphoma treated at the 0.3 mg/kg dose-level) and 3 patients with NHL had stable 
disease with duration of response up to 14 months.  Correlative studies demonstrated that 
treatment with CDX-1127 (varlilumab) was associated with reduction of circulating Treg 
and increase in pro-inflammatory cytokines. 
The preliminary results of a phase 1 dose-escalation study combining CDX-1127 
(varlilumab) and nivolumab in advanced solid malignancies were recently released 
(Sanborn et al., 2016).  A total of 35 patients with advanced solid tumors (colorectal 
cancer, melanoma, gynecological cancers and head/neck cancers) were treated with 
escalating doses of CDX-1127 (varlilumab) (0.1, 1.0 & 10 mg/kg) in combination with 
nivolumab (3 mg/kg) every 2 weeks for 4 doses.  Repeat treatments with combination 
therapy were permitted for 4 additional cycles in patients deriving clinical benefit (stable 

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disease or better).  Therapy was well tolerated and MTD was not reached.  Correlative 
studies demonstrated increase in inflammatory cytokines, decrease in circulating CD4+ 
and regulatory T-cells as well as increase in tumor-infiltrating lymphocytes.   
 
We hypothesize that combination therapy using a PD-1 inhibitor (nivolumab) and a 
CD27 agonist (CDX-1127; varlilumab) in patients with advanced hematological 
malignancies is safe and produces a synergistic effect compared to single-agent 
nivolumab.  To test this hypothesis we propose a randomized phase 2 trial comparing 
single-agent immunotherapy using nivolumab versus dual immunotherapy (CDX-1127 
(varlilumab) and nivolumab) in patients with relapsed or refractory aggressive B-cell 
NHL.  Primary endpoint is response rate and patients in the control arm (nivolumab 
alone) would be allowed to cross over to the combination arm at the time of progression. 
 
2.4 
Correlative Studies Background 
 
2.4.1 Integrated Biomarkers 
 
 
Quantification and Characterization of CD27+ Cells in the Tumor Microenvironment 
by Immunohistochemistry (IHC) 
 
The costimulatory molecule CD27 is a member of the tumor necrosis factor (TNF) 
receptor superfamily, and is constitutively expressed on the majority of mature T-
cells, memory B cells, and a portion of natural killer cells.  The interaction of CD27 
with its ligand (CD70) plays key roles in activation, proliferation and survival 
processes of different immune cells.  CD27 expression is also present on most B-cell 
malignancies at varying levels.  It is therefore postulated that CDX-1127 (varlilumab) 
- an agonist anti-CD27 monoclonal antibody – may exert its anti-tumor activity 
through activation of CD27-expressing T-cells in the context of T cell receptor 
stimulation and also through direct cytotoxic activity on tumor cells expressing 
CD27. 
 
We therefore hypothesize that the expression of CD27 in the tumor cells and/or on its 
surrounding microenvironment is required for CDX-1127’s (varlilumab’s) anti-
tumoral activity.  We further hypothesize that the level of expression of CD27 along 
with its localization (tumor cells vs. immune cells) may serve as a predictive 
biomarker for the activity of CDX-1127 (varlilumab) in patients with B-cell 
lymphomas.  To test this hypothesis we will assess CD27 expression level and 
localization by IHC on tumor biopsies obtained at the time of registration from 
patients treated under this protocol.  CD27 expression will not be required for 
participation in the study (integral biomarker).  The level of CD27 expression along 
with its localization (tumor cells vs. immune cells) will be compared between patients 
who achieve clinical benefit from treatment with CDX-1127 (varlilumab). For 
patients in group 1 (nivolumab single-agent) who agree to undergo a repeat biopsy to 
confirm progression of disease and then cross over to group 2 (combinatory therapy 
with CDX-1127 (varlilumab) and nivolumab), the CD27 IHC assay will be repeated 

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and compared to baseline. 
 
The CD27 expression evaluation via IHC will be performed centrally by Mosaic 
Laboratories, L.L.C. (12 Spectrum Pointe Drive, Lake Forest, CA 92630) using a 
proprietary assay using the rabbit mAb clone EPR8569 from Abcam. CD27 staining 
will be evaluated by image analysis using an Aperio image analysis algorithm and the 
final score will be expressed as % of cells at 0 (unstained), 1+, 2+ and 3+, in addition 
to number of CD27+ cells/mm2. Validation report can be provided upon request.  
 
2.4.2 Exploratory Biomarkers 
 
 
Comprehensive Analysis of Immune Cell Subpopulations using Mass Cytometry 
(CyTOF) 
 
CyTOF (cytometry at time-of-flight) or mass cytometry is a new single-cell 
proteomics platform that uses mass spectrometry to evaluate more than 45 
simultaneous parameters on a single-cell level (Bendall et al., 2012).  This technology 
uses nonradioactive non-biological isotopes as reporters tagged to antibodies.  
Measurements are based on mass spectrometry, which largely avoids the hurdles of 
interference and spectral overlap seen with standard fluorescence-based flow 
cytometry.  CyTOF is an ideal platform for the study of the tumor microenvironment 
given its ability to assess a large number of simultaneous parameters and resolve 
small differences in a heterogeneous population of cells. Taking advantage of the 
simultaneous assessment of several parameters per cell, CyTOF retains the ability to 
quantitate main lineage subsets in samples as small as 100,000 cells (Yao et al., 
2015).  This is particularly useful in situations where cell count is limited - such as 
tumor biopsies - or in the assessment of rare immune cell subsets. 
 
CyTOF is therefore a powerful tool to study a complex biological system such as the 
microenvironment of B-cell lymphomas, especially in the context of a study using 
immune modulating drugs.  Since both Nivolumab and CDX-1127 (varlilumab) may 
have a broad range of effects on different populations of cells – including tumor cells 
and host immune cells – an assay that simultaneously characterize these effects is 
necessary. The CyTOF assays will be performed on two different specimen types: (1) 
single-cell suspensions created from tumor samples obtained at the time of 
registration and at the time of treatment cross over (for patients in group 1) and on (2) 
peripheral blood mononuclear cells (PBMC) obtained before the infusion of the study 
drugs during the first 24 weeks of treatment. 
 
Unstimulated specimens will be stained using a custom-designed 34-parameter global 
phenotyping panel recognizing 36 surface proteins and acquired on CyTOF2TM.  
EQ™ Four Element Calibration Beads (Fluidigm) will be used for instrument 
calibration and normalization between experiments.  Cisplatin (195Pt) will be used as 
a cell viability marker.  The primary assay will allow identification of major immune 
cell populations (T-cells, B-cell, NK cell, monocyte/macrophages) along with 
detailed characterization of T-cell subsets (cytotoxic, regulatory, helper 1, helper 2, 

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helper 9, helper 17, helper 22, follicular helper, central memory, effector memory, 
naïve) and separately evaluate them for expression of markers of T-cell exhaustion 
(PD-1, LAG-3, TIM-3) and expression of co-stimulatory molecules (CD27, CD28, 
ICOS).  Specimens with a surplus of cells will also be stained in parallel with a 
separate 22-parameter phenotyping panel recognizing surface and intracellular 
proteins in order to detail the phenotype of monocyte/macrophage subpopulations. 
See section 9.3 for details on the CyTOF assay panels.  Analysis of immune cell 
subsets will be largely exploratory and reported descriptively. 
 
 
 
Identification and Characterization of Intratumoral Immune Cells by 
Immunohistochemistry (IHC) 
 
Expression of PD-L1 has been demonstrated to associate with clinical response of 
cancer patients treated with nivolumab.  It is also postulated that CD8+ cytotoxic T-
cell infiltration is critical to mediate anti-tumoral immunity in the context of PD-1 
blockade.  In the phase 1 trial dose-escalation study combining nivolumab with CDX-
1127 (varlilumab) there was an increase in tumor-infiltrating lymphocytes (TILs) at 
all CDX-1127 (varlilumab) dose-levels.  A trend towards increase in PD-L1 
expression and CD8+ TILs was observed in patients with stable disease or better 
responses.  Therefore, multiple markers including T cell, tumor cells, as well as 
related co-stimulatory and inhibitory markers will be stained to identify if there is any 
association of expression of these markers with the clinical activity of the study 
drugs. 
 
Serial 4-μm paraffin-embedded sections will be used for IHC.  The tissue will be 
deparaffinized with three changes of xylene and cleared through graded series of 
ethanol.  Endogenous peroxidase will be quenched by incubation in 50% 
methanol/H2O2 and after rinsing with tap water; all sections will be pretreated for 30 
minutes with 50 mmol/L EDTA using a steamer and cooled for additional 5 minutes. 
All staining will be done automatically on DAKO Autostainer using the following 
antibodies to CD11c (Leica Microsystems 5D11), CD14 (Cell Marque EPR 3653), 
CD163 (DAKO 1F8), CD68 (DAKO PG-M1), CXCL13 (R&D Systems 53610), 
FOXP3 (Abcam 236AE/7), CD3 (R&D Systems), PD-L1 (405.9A11), PD-L2 
(366C.9E5), CD8a (Dako M7103) and PD-1 (Abcam NAT).  The sections will be 
viewed with an Olympus BXFA51 microscope and pictures taken with an Olympus 
DP71 camera.  Stained slides will be scored by expert hematopathologist.  Analysis 
of intra-tumoral immune cell subsets by IHC will be largely exploratory and reported 
descriptively. 
 
 
Evaluation of Genetic Alterations Involving Chromosome 9p24.1 
 
PD-L1 overexpression on tumor cells can due to genetic lesions affecting the PD-L1 
gene locus on chromosome 9 often through gene amplification or copy number 
variation.  To evaluate if these genetic events are associated with response to therapy 
using nivolumab and CDX-1127 (varlilumab), we will perform fluorescent in-situ 

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hybridization (FISH) to assess copy number at chromosome locus 9p24.1.  The 
bacterial artificial chromosome probes (CHORI; www.chori.org) RP11-599H2O, 
which maps to 9p24.1 and includes CD274 (encoding PD-L1, labeled with Spectrum 
Orange), and RP11-635N21, which also maps to 9p24.1 and includes PDCD1LG2 
(encoding PD-L2, labeled with Spectrum Green), will be cohybridized.  A control 
centromeric probe, Spectrum Aqua–labeled CEP9 (Abbott Molecular) that maps to 
9p11-q11, will be hybridized according to the manufacturer's recommendations.  
Nuclei with a target: control probe ratio of at least 3:1 will be classified as amplified, 
those with a probe ratio of more than 1:1 but less than 3:1 will be classified as relative 
copy gain, and those with a probe ratio of 1:1 but with more than two copies of each 
probe will be classified as polysomic for chromosome 9p.  Analysis of genetic 
alterations Involving chromosome 9p24.1 by FISH will be largely exploratory and 
reported descriptively. 
 
 
 
Evaluation of Serum Cytokine Profile 
 
Immunomodulatory drugs such as nivolumab and CDX-1127 (varlilumab) lead to 
changes in the tumor mileau through their interaction with different components of 
the immune system.  Correlative studies from the early phase trials of single-agent 
CDX-1127 (varlilumab) and combinatory therapy using nivolumab and CDX-1127 
(varlilumab) demonstrated increase in pro-inflammatory cytokines such as IL-12, 
MIP-1β, monocyte chemotactic protein 1 (MCP-1), monokine induced by interferon γ 
(MIG/CXCL9), inducible protein-10 (IP-10/CXCL10) and IL-6.  The profile of 
cytokine elevation may therefore be associated with response to therapy with the 
study drugs and will be evaluated using a multiplexed assay. 
 
Serial serum samples will be collected every 14 days before infusion of study drugs 
for the first 12 weeks of the study.  Samples will be subjected to multiplex ELISA 
(Invitrogen, Camarillo, CA) to measure 30 serum cytokines. Luminex-200 system 
version 1.7 will be used for reading plates and MasterPlex QT1.0 system (MiraiBio) 
will be used to analyze data.  Cytokines will include epidermal growth factor (EGF), 
eotaxin, basic fibroblast growth factor (FGF-b), granulocyte macrophage colony 
stimulating factor (GM-CSF), hepatocyte growth factor (HGF), IFN-α, IFN-ϒ, 
interleukin 1 receptor antagonist (IL-1RA), IL-1β,IL-2, IL-2R , IL-4, IL-5, IL-6, IL-7, 
IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IP10, MCP-1, MIG, MIP-1α (CCL3), MIP1β 
(CCL4), regulated on activation normal T-cell expressed and secreted (RANTES), 
TNF-α and vascular endothelial growth factor (VEGF).  Internal control serum will 
be included in all assays to control for inter-assay variation.  Analysis of the serum 
cytokine by multiplex ELISA will be largely exploratory and reported descriptively. 
 
 
 
Evaluation of Mutational Burden as a Biomarker for Response to Checkpoint 
Blockade Therapy 
 
As tumors accumulate mutations, they may become more prone to the generation of 

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neoantigens that can be recognized and targeted by the immune system.  Solid tumor 
groups with a higher mutational burden – such as melanoma or mismatch repair 
deficient colorectal cancer – have demonstrated higher response rates to checkpoint 
blockade therapy as compared to tumors with fewer genetic lesions.  Our study will 
therefore evaluate the mutational burden present in the tumor prior to initiation of 
therapy with the study drugs and describe their association with clinical outcomes. 
 
Genomic DNA will be extracted from formalin-fixed, paraffin-embedded (FFPE) 
tissue blocks.  Hematoxylin and eosin (H&E) stained sections from each case will be 
reviewed by an expert hematopathologist and representative blocks with at least 30% 
tumor cells will be selected.  Sections of 10 x 4-micron dimensions will be cut from 
blocks (based on tissue area of 25 mm2).  DNA will be extracted using the Qiagen 
FFPE DNA extraction kit.  DNA quantitation will be performed using a Qubit 
fluorometer prior to sequencing.  Whole exome analysis of paired tumor and normal 
tissue will be performed using Ion TorrentTM platform at the Molecular 
Characterization and Clinical Assay Development Laboratory, Leidos Biomedical 
Research Inc., Frederick National Laboratory for Cancer Research. The analysis of 
mutational burden by whole exome sequencing is largely exploratory and reported 
descriptively. 
 
2.5 
Rationale for Modification of the Dosage of Nivolumab After 4 Months 
 
Data obtained from manufacturer (Bristol-Myers Squibb) indicates that nivolumab 
administered as 480 mg Q4W over 30-minutes is expected to offer the same clinical 
benefit as 3 mg/kg Q2W in subjects with melanoma, squamous non-small cell lung 
cancer (SQ NSCLC), non-squamous NSCLC (NSQ, NSCLC), renal cell carcinoma 
(RCC), squamous cell carcinoma of the head and neck (SCCHN), urothelial carcinoma 
(UC), and classical Hodgkin’s lymphoma (cHL).  This information is based upon data 
gathered in the course of the extensive nivolumab development program across multiple 
tumor types as well as robust clinical pharmacology and quantitative systems 
pharmacology (QSP) analyses. 
 
The proposed dose modification is based on the comprehensive understanding of 
nivolumab pharmacology and mechanism of action taken together with the following 
data and analyses: 
 
• Comparison of nivolumab exposures achieved by 240 mg Q2W, 480 mg Q4W and 3 
mg/kg Q2W in subjects with melanoma, NSCLC, RCC, SCCHN, cHL, and UC 
 
• Efficacy bridging evaluation 
o Comparison of the efficacy of nivolumab 3 mg/kg Q2W, 240 mg Q2W, and 
480 mg Q4W in melanoma, NSCLC, and RCC with respect to the following 
endpoints: overall survival(OS), objective response (OR) 
o Comparison of predicted receptor occupancy (RO) with nivolumab 3 mg/kg 
Q2W, 240 mg Q2W, and 480 mg Q4W, including sensitivity of RO to 
parameters that may vary across solid tumor types 

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• Safety bridging evaluation 
o Assessment of safety margins, by comparison of predicted exposures with 240 
mg Q2W and 480 mg Q4W relative to the well-tolerated 10 mg/kg Q2W 
regimen 
o Comparison of the safety of nivolumab 3 mg/kg Q2W, 240 mg Q2W, and 480 
mg Q4W in subjects with melanoma, SQ and NSQ NSCLC, RCC, SCCHN, 
cHL, and UC with respect to the following 3 endpoints: Adverse events 
leading to discontinuation or death (AEDC/D), Grade 3+ adverse events (AE-
Grade 3+), and Grade 2+ immune-mediated adverse events (AE-IM Grade 2+) 
o Clinical safety data from subjects treated with nivolumab 480 mg Q4W 
administered over a 30-minute infusion 
 
The exposure-response efficacy analysis between the 3 mg/kg Q2W and the 480 mg 
Q4W regimens demonstrated that the hazard ratios for survival with the 480 mg Q4W 
regimen are very similar to the 3 mg/kg Q2W regimen, resulting in a similar hazard ratio 
relative to the standard of care treatment studied in each respective phase 3 clinical trial. 
In addition, these analyses indicated that similar outcomes would be achieved when using 
an early efficacy measure of response rate (objective response; OR) as well.  The 
exposure-efficacy response trends were consistent across different tumor types with 
varying tumor immunogenicity and mutational burdens.  Hence, in cases where 
nivolumab 3 mg/kg Q2W has been proven to be superior to standard of care, nivolumab 
480 mg Q4W is predicted to provide comparable benefit, irrespective of tumor type. 
 
This position is further supported by results of the analysis using a mechanistic 
quantitative systems pharmacology model incorporating transport to site of action, 
binding kinetics and varied physiological factors representing highly perfused or stromal 
tumors.  The median intratumoral RO predicted with this model is high for nivolumab 3 
mg/kg Q2W, 240 mg Q2W and 480 mg Q4W trough levels over a range of possible 
physiological parameter values.  It is postulated that high RO at the tumor site will 
initiate the immuno-stimulatory cascade resulting in similar efficacy with 3 mg/kg Q2W, 
240 mgQ2W, and 480 mg Q4W regimens. 
 
Safety bridging was conducted using robust clinical data for the 10 mg/kg Q2W regimen 
that had a similar safety profile to the 3 mg/kg Q2W regimen.  The nivolumab exposure 
parameters, including Cmax, resulting from 480 mg Q4W were well below Cmaxss 
values achieved with 10 mg/kg, providing a robust exposure safety margin. In addition, 
there were negligible differences in the probabilities of experiencing an adverse event 
irrespective of severity or adverse event type.  Moreover, key safety results from the 
interim safety analysis of CA209511 (Part 2) demonstrate that the safety profile of 
nivolumab 480 mg IV over 30 minutes Q4W is consistent with the established safety 
profile of nivolumab (240 mg Q2W or 3 mg/kg Q2W administered IV over 60 minutes) 
across multiple indications and Summary of Product Characteristics [SmPC].  Taken 
together, these findings indicated that the safety profile of nivolumab is expected to be 
unaltered by the proposed dosing regimen changes. 
 

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Based on extensive quantitative clinical pharmacology analyses and safety analyses 
summarized in this submission, the nivolumab 480 mg Q4W regimen administered over 
30 minutes is predicted to have similar efficacy and safety profiles to those established 
with the 3 mg/kg Q2W dosing regimen administered over 60 minutes. Thus, the provided 
analyses support the proposed nivolumab dosing regimen of 480 mg Q4W administered 
over 30 minutes as a convenient treatment option. 
 
Based on this information the dosage of Nivolumab will be 240 mg IV every 2 weeks for 
the first 4 months on the study.  After four months, Nivolumab will be administered at the 
dose of 480 mg IV every 4 weeks. Both dosage strengths will be infused over 30 minutes. 
 
3. PATIENT SELECTION 
 
3.1 
Eligibility Criteria  
 
3.1.1 Patients must have a histopathologically confirmed diagnosis of an aggressive B-cell 
non-Hodgkin lymphoma that is recurrent or refractory to standard therapy.  
 
For the purpose of this study, aggressive B-cell NHL will be deemed any lymphoma 
belonging to one of the following groups according to the 2016 revision of the World 
Health Organization (WHO) classification of lymphoid neoplasms (Swerdlow et al., 
2016). 
 
For the purposes of stratification, diagnoses are grouped into 2 categories: 
 
Category A 
• Burkitt lymphoma 
• Burkitt-like lymphoma with 11q aberration 
• High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements 
• High-grade B-cell lymphoma, NOS 
 
Category B 
• Diffuse large B-cell lymphoma (DLBCL), NOS 
• Diffuse large B-cell lymphoma (DLBCL), NOS; Germinal center B-cell type 
• Diffuse large B-cell lymphoma (DLBCL), NOS; Activated B-cell type 
• Large B-cell lymphoma with IRF4 rearrangement 
• T-cell/histiocyte-rich large B-cell lymphoma 
• Primary DLBCL of the central nervous system (CNS) 
• Primary cutaneous DLBCL, leg type 
• EBV+ DLBCL, NOS 
• EBV+  mucocutaneous ulcer 
• DLBCL associated with chronic inflammation 
• Lymphomatoid granulomatosis 
• Primary mediastinal (thymic) large B-cell lymphoma 
• Intravascular large B-cell lymphoma 

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• ALK+  large B-cell lymphoma 
• Plasmablastic lymphoma 
• Primary effusion lymphoma 
• HHV-8+  DLBCL, NOS 
• B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and 
classical Hodgkin lymphoma  
 
3.1.2 Patients must have measurable disease, defined as at least one lesion that is > 15 mm 
(1.5 cm) in the longest axis on cross-sectional imaging and measureable in two 
perpendicular dimensions per computed tomography (spiral CT), PET-CT or MRI. 
 
3.1.3 Patients must have disease that has relapsed after or is refractory to at least 2 lines of 
standard therapy.  The remaining standard treatment options are unlikely to be effective 
in the opinion of the treating physician, or patient is felt to be ineligible for such therapies 
or the patient refuses such therapies. Patients who have undergone autologous stem cell 
transplant are eligible as long as they meet all other criteria.  
 
3.1.4 Age ≥ 18 years.   
Because no dosing or adverse event data are currently available on the use of CDX-1127 
(varlilumab) in combination with nivolumab in patients <18 years of age, children are 
excluded from this study, but will be eligible for future pediatric trials. 
 
3.1.5 ECOG performance status of 0 or 1 (See Appendix A). 
 
3.1.6 Life expectancy of greater than 12 weeks 
 
3.1.7 Patients must have normal organ and marrow function as defined below within 14 days of 
registration: 
 
− 
White blood cell (WBC) ≥ 2000/mm3 
− 
Absolute neutrophil count (ANC) ≥ 1500/mm3 
− 
Platelet count  100,000/mm3 
− 
Hemoglobin > 9.0 g/dL 
− 
Total bilirubin ≤ 1.5 x upper limit of normal (ULN) (except patients with Gilbert 
Syndrome, who can have total bilirubin < 3.0 mg/dL) 
− 
Aspartate transaminase (AST) 2.5 x ULN 
− 
Calculated creatinine clearance (CrCl) ≥ 50 mL/min (if using the Cockcroft-Gault 
formula below): 
 
Female CrCl = (140 - age in years) x weight in kg x 0.85 
72 x serum creatinine in mg/dL 
Male CrCl = (140 - age in years) x weight in kg   
72 x serum creatinine in mg/dL  
 
 

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3.1.8 Females of child bearing potential per protocol section 3.3 must have a negative serum or 
urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG)  
 
3.1.9 Ability to understand and the willingness to sign a written informed consent document. 
 
 
3.2 
Exclusion Criteria 
 
3.2.1 Patient has received chemotherapy, targeted agent, or radiotherapy within 4 weeks or at 
least 5 half-lives, whichever is longer, prior to registration.   
 
Palliative (limited-field) radiation therapy is permitted, if all of the following criteria are 
met: 
1) Repeat imaging demonstrates no new sites of bone metastases. 
2) The lesion being considered for palliative radiation is not a target lesion. 
 
3.2.2 Patient has received immunotherapy (including monoclonal antibodies) within 4 weeks 
prior to registration. 
 
3.2.3 Patients who have not recovered to grade 1 or less from any adverse events due to agents 
administered more than 4 weeks earlier (excluding alopecia)  
 
3.2.4 Patients who are receiving any other investigational agents. 
 
3.2.5 Patients should be excluded if they have had prior treatment with an anti-PD-1, anti-PD-
L1, anti-PD-L2, anti-CTLA-4 antibody, or any other antibody or drug specifically 
targeting T-cell co-stimulation or immune checkpoint pathways.   
 
3.2.6 Patients who have received autologous stem cell transplant (ASCT) ≤ 12 weeks prior to 
the first dose of study drug. 
 
3.2.7 Patients with a prior history of allogeneic stem cell or solid organ transplantation. 
 
3.2.8 Patients with evidence of active disease in the central nervous system (CNS) defined as 
either the presence of active lesions on MRI obtained within 4 weeks of registration or 
progressive neurological decline. 
 
Patients with primary CNS lymphoma who develop systemic recurrence following 
standard therapy may be included as long as no active CNS disease is present at the time 
or enrollment. Similarly, patients with secondary involvement of the CNS from a 
systemic lymphoma may be included as long as the CNS disease has been optimally 
treated and they demonstrate no evidence of active CNS disease. 
 
3.2.9 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to CDX-1127 (varlilumab) and/or nivolumab. 
 

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3.2.10 History of severe hypersensitivity reaction to any monoclonal antibody. 
 
3.2.11 Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, 
symptomatic congestive heart failure, unstable angina pectoris, cardiac arrhythmia, or 
psychiatric illness/social situations that would limit compliance with study requirements. 
 
3.2.12 Pregnant women are excluded from this study because CDX-1127 (varlilumab) and 
nivolumab are agents with the potential for teratogenic or abortifacient effects.  Because 
there is an unknown but potential risk for adverse events in nursing infants secondary to 
treatment of the mother with CDX-1127 (varlilumab) or nivolumab, breastfeeding should 
be discontinued if the mother is treated with CDX-1127 (varlilumab) or nivolumab. 
 
3.2.13 Patients with  human immunodeficiency virus (HIV) are eligible for the study provided 
they meet the other protocol criteria in addition to the following:  
− 
Undetectable HIV load by standard PCR clinical assay within 60 days prior to 
registration 
− 
Absolute CD4 count of ≥ 200 mm3 within 60 days prior to registration 
− 
Willing to maintain adherence to combination antiretroviral therapy 
− 
No history of AIDS defining condition (other than lymphoma or CD4 cell count < 
200 mm3) 
− 
Likely to have near normal lifespan if not for the presence of relapsed/refractory 
lymphoma 
 
Patients with evidence of HBV are eligible provided there is minimal hepatic injury and 
the patient has undetectable HBV on suppressive HBV therapy.  Patient must be willing 
to maintain adherence to HBV therapy. 
 
Patients with previously treated and eradicated HCV who have minimal hepatic injury are 
eligible. 
 
 
 

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3.2.14 Patients with active autoimmune disease or history of autoimmune disease that might 
recur, which may affect vital organ function or require immune suppressive treatment 
including systemic corticosteroids, should be excluded.  These include but are not limited 
to patients with a history of immune related neurologic disease,  multiple sclerosis, 
autoimmune (demyelinating)  neuropathy, Guillain-Barre syndrome, myasthenia gravis; 
systemic autoimmune disease such as SLE, connective tissue diseases, scleroderma, 
inflammatory bowel disease (IBD), Crohn’s, ulcerative colitis, hepatitis; and patients 
with a history of toxic epidermal necrolysis (TEN), Stevens-Johnson syndrome, or 
phospholipid syndrome should be excluded because of the risk of recurrence or 
exacerbation of disease.  Patients with vitiligo, endocrine deficiencies including 
thyroiditis managed with replacement hormones including physiologic corticosteroids are 
eligible.  Patients with rheumatoid arthritis and other arthropathies, Sjögren’s syndrome 
and psoriasis controlled with topical medication and patients with positive serology, such 
as antinuclear antibodies (ANA), anti-thyroid antibodies should be evaluated for the 
presence of target organ involvement and potential need for systemic treatment but 
should otherwise be eligible.  
 
3.2.15 Patients are permitted to enroll if they have vitiligo, type I diabetes mellitus, residual 
hypothyroidism due to autoimmune condition only requiring hormone replacement, 
psoriasis not requiring systemic treatment, or conditions not expected to recur in the 
absence of an external trigger (precipitating event). 
 
3.2.16 Patients should be excluded if they have a condition requiring systemic treatment with 
either corticosteroids (> 10 mg daily prednisone equivalents) or other immunosuppressive 
medications within 14 days of study drug administration.  Inhaled or topical steroids and 
adrenal replacement doses < 10 mg daily prednisone equivalents are permitted in the 
absence of active autoimmune disease.  Patients are permitted to use topical, ocular, intra-
articular, intranasal, and inhalational corticosteroids (with minimal systemic absorption).  
Physiologic replacement doses of systemic corticosteroids are permitted, even if < 10 
mg/day prednisone equivalents.  A brief course of corticosteroids for prophylaxis (e.g., 
contrast dye allergy) or for treatment of non-autoimmune conditions (e.g., delayed-type 
hypersensitivity reaction caused by contact allergen) is permitted. 
 
3.2.17 Patients who have had evidence of active or acute diverticulitis, intra-abdominal abscess, 
GI obstruction and abdominal carcinomatosis which are known risk factors for bowel 
perforation should be evaluated for the potential need for additional treatment before 
coming on study. 
 
3.2.18 Patients with other active malignancy ≤ 3 years prior to registration for which active 
treatment is required must be excluded.  Patients with composite lymphomas that have a 
non-B-cell component must be excluded. 
EXCEPTIONS: Non-melanotic skin cancer or carcinoma-in-situ of the cervix 
 
3.3 
Females of Childbearing Potential 
 
A female of child-bearing potential is defined as any female who has experienced 

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menarche and who has not undergone surgical sterilization (hysterectomy or bilateral 
oophorectomy) or who is not postmenopausal.  Menopause is defined clinically as 12 
months of amenorrhea in a female over 45 in the absence of other biological or 
physiological causes.  In addition, females who meet clinical criteria for menopause but 
are under the age of 55 must have a documented serum follicle stimulating hormone 
(FSH) level higher than 40 mIU/mL.   
 
The effects of CDX-1127 (varlilumab) and nivolumab on the developing human fetus are 
unknown.  For this reason, and because the study drugs used in this trial are known to be 
teratogenic, females of child-bearing potential must agree to use adequate contraception 
(hormonal or barrier method of birth control; abstinence) prior to study entry, for the 
duration of study participation and for 23 weeks after the last dose of study drug.  Males 
who are the sexual partners of a female of child-bearing potential must use any 
contraceptive method with a failure rate of less than 1% per year for the duration of study 
participation and for a period of 31 weeks after the last dose of study drug.  These periods 
of required use of contraception have been calculated using the upper limit of the half-life 
for nivolumab (25 days) and are based on the protocol requirement that females of child-
bearing potential use contraception for 5 half-lives plus 30 days and males who are the 
sexual partners of females of child-bearing potential use contraception for 5 half-lives 
plus 90 days. 
 
Females who are not of childbearing potential (i.e., who are postmenopausal or surgically 
sterile) and azoospermic males do not require contraception.   
 
Should a female of child-bearing potential become pregnant or suspect she is pregnant 
while she or her partner is participating in this study, she (or the participating partner) 
should inform the treating physician immediately. 
 
3.4 
Inclusion of Women and Minorities 
 
NIH policy requires that women and members of minority groups and their subpopulations be 
included in all NIH-supported biomedical and behavioral research projects involving NIH-
defined clinical research unless a clear and compelling rationale and justification establishes to 
the satisfaction of the funding Institute & Center (IC) Director that inclusion is inappropriate 
with respect to the health of the subjects or the purpose of the research.  Exclusion under other 
circumstances must be designated by the Director, NIH, upon the recommendation of an IC 
Director based on a compelling rationale and justification.  Cost is not an acceptable reason for 
exclusion except when the study would duplicate data from other sources.  Women of 
childbearing potential should not be routinely excluded from participation in clinical research.  
Please see http://grants.nih.gov/grants/funding/phs398/phs398.pdf. 
 
Both males and females of all races and ethnic groups are eligible for this trial. 
 
 
4. 
REGISTRATION PROCEDURES 
 

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4.1 
Investigator and Research Associate Registration with CTEP 
Food and Drug Administration (FDA) regulations require IND sponsors to select qualified 
investigators.  NCI policy requires all persons participating in any NCI-sponsored clinical 
trial to register and renew their registration annually..  To register, all individuals must 
obtain a CTEP Identity and Access Management (IAM) account 
(https://ctepcore.nci.nih.gov/iam).  In addition, persons with a registration type of 
Investigator (IVR), Non-Physician Investigator (NPIVR), or Associate Plus (AP) (i.e., 
clinical site staff requiring write access to OPEN or RAVE or acting as a primary site 
contact) must complete their annual registration using CTEP’s web-based Registration 
and Credential Repository (RCR) (https://ctepcore.nci.nih.gov/rcr).  Documentation 
requirements per registration type are outlined in the table below. 
Documentation Required 
IVR 
NPIVR AP 
A 
FDA Form 1572 
 
 
Financial Disclosure Form 
 
 
 
NCI Biosketch (education, training, employment, 
license, and certification) 
 
 
 
HSP/GCP training 
 
 
 
Agent Shipment Form (if applicable) 
 
CV (optional) 
 
 
 
An active CTEP-IAM user account and appropriate RCR registration is required to access 
all CTEP and CTSU (Cancer Trials Support Unit) websites and applications.  In addition, 
IVRs and NPIVRs must list all clinical practice sites and IRBs covering their practice 
sites on the FDA Form 1572 in RCR to allow the following: 
• Added to a site roster 
• Assigned the treating, credit, consenting, or drug shipment (IVR only) tasks in 
OPEN 
• Act as the site-protocol PI on the IRB approval 
• Assigned the Clinical Investigator (CI) role on the Delegation of Tasks Log 
(DTL).     
Additional information can be found on the CTEP website at  
https://ctep.cancer.gov/investigatorResources/default.htm.  For questions, please contact 
the RCR Help Desk by email at RCRHelpDesk@nih.gov. 
 

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4.2 
Site Registration 
 
This study is supported by the NCI Cancer Trials Support Unit (CTSU). 
 
Each investigator or group of investigators at a clinical site must obtain IRB approval for 
this protocol and submit IRB approval and supporting documentation to the CTSU 
Regulatory Office before they can be approved to enroll patients.  Assignment of site 
registration status in the CTSU Regulatory Support System (RSS) uses extensive data to 
make a determination of whether a site has fulfilled all regulatory criteria including but 
not limited to the following:  
• An active Federal Wide Assurance (FWA) number 
• An active roster affiliation with the Lead Network or a participating organization 
• A valid IRB approval 
• Compliance with all protocol specific requirements. 
 
In addition, the site-protocol Principal Investigator (PI) must meet the following criteria: 
• Active registration status 
• The IRB number of the site IRB of record listed on their Form FDA 1572 
• An active status on a participating roster at the registering site 
 
Sites participating on the NCI CIRB initiative that are approved by the CIRB for the 
study are not required to submit separate IRB approval documentation to the CTSU 
Regulatory Office.  For sites using the CIRB, IRB approval information is received from 
the CIRB and applied to the RSS in an automated process.  Signatory institutions must 
submit a Study Specific Worksheet for Local Context (SSW) to the CIRB via 
IRBManager to indicate their intention to open the study locally.  The CIRB’s approval 
of the SSW is then communicated to the CTSU Regulatory Office.  In order for the SSW 
approval to be processed, the Signatory Institution must inform the CTSU which CIRB-
approved institutions aligned with the Signatory Institution are participating in the study. 
 
4.2.1 Downloading Regulatory Documents 
 
Site registration forms may be downloaded from the 10089 protocol page located on the 
CTSU Web site.  Permission to view and download this protocol is restricted and is based 
on person and site roster data housed in the CTSU RSS.  To participate, Investigators and 
Associates must be associated with the Corresponding or Participating protocol 
organization in the RSS.  
 
• Go to https://www.ctsu.org and log in using your CTEP-IAM username and 
password. 
• Click on the Protocols tab in the upper left of your screen.  
• Either enter the protocol # in the search field at the top of the protocol tree, or 

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• Click on the By Lead Organization folder to expand, then select LAO-MN026, 
and protocol # 10089. 
• Click on LPO Documents, select the Site Registration documents link, and 
download and complete the forms provided.  (Note: For sites under the CIRB 
initiative, IRB data will load to RSS as described above.) 
 
4.2.2 Requirements For Protocol 10089 Site Registration: 
 
• IRB approval (For sites not participating via the NCI CIRB; local IRB 
documentation, an IRB-signed CTSU IRB Certification Form, Protocol of Human 
Subjects Assurance Identification/IRB Certification/Declaration of Exemption 
Form, or combination is accepted) 
• Site Initiation Visit 
 
4.2.3  Submitting Regulatory Documents 
 
Submit required forms and documents to the CTSU Regulatory Office, where they will 
be entered and tracked in the CTSU RSS.   
Regulatory Submission Portal: www.ctsu.org  (members’ area) → Regulatory Tab 
→Regulatory Submission  
When applicable, original documents should be mailed to: 
CTSU Regulatory Office 
1818 Market Street, Suite 3000 
Philadelphia, PA 19103 
Institutions with patients waiting that are unable to use the Portal should alert the CTSU 
Regulatory Office immediately at 1-866-651-2878 in order to receive further instruction 
and support. 
 
4.2.4 Checking Site Registration Status 
 
You can verify your site registration status on the members’ section of the CTSU 
website.   
 
 
Go to https://www.ctsu.org and log into the members area using your CTEP-IAM 
username and password. 
Click on the Regulatory tab at the top of your screen. 
Click on the Site Registration subtab. 
Enter your 5-character CTEP Institution Code and click on Go. 
Note: The status given only reflects compliance with IRB documentation and institutional 
compliance with protocol-specific requirements as outlined by the Lead Network. It does 
not reflect compliance with protocol requirements for individuals participating on the 

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protocol or the enrolling investigator’s status with the NCI or their affiliated networks. 
 
 
4.3 
Patient Registration 
 
 
4.3.1 OPEN / IWRS 
 
Patient enrollment will be facilitated using the Oncology Patient Enrollment Network 
(OPEN).  OPEN is a web-based registration system available to users on a 24/7 basis.  It 
is integrated with the CTSU Enterprise System for regulatory and roster data interchange 
and with the Theradex Interactive Web Response System (IWRS) for retrieval of patient 
registration/randomization assignment.  Patient enrollment data entered by Registrars in 
OPEN / IWRS will automatically transfer to the NCI’s clinical data management system, 
Medidata Rave. 
 
The OPEN system will provide the site with a printable confirmation of registration and 
treatment information.  Please print this confirmation for your records.  
 
4.3.2 OPEN/IWRS User Requirements 
 
OPEN/IWRS users must meet the following requirements: 
• Have a valid CTEP-IAM account (i.e., CTEP username and password). 
• To enroll patients:  Be on an ETCTN Corresponding or Participating Organization 
roster with the role of Registrar. 
• To access cohort management:  Be identified to Theradex as the “Client Admin” 
for the study.  
• Have regulatory approval for the conduct of the study at their site. 
 
Prior to accessing OPEN/IWRS, site staff should verify the following: 
• All eligibility criteria have been met within the protocol stated timeframes.  
• If applicable, all patients have signed an appropriate consent form and HIPAA 
authorization form. 
 
4.3.3 OPEN/IWRS Questions? 
 
Further instructional information on OPEN is provided on the OPEN tab of the CTSU 
website at https://www.ctsu.org or at https://open.ctsu.org.  For any additional questions 
contact the CTSU Help Desk at 1-888-823-5923 or ctsucontact@westat.com.  
 
Theradex has developed a Slot Reservations and Cohort Management User Guide, which 
is available on the Theradex website 
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11.  . 
This link to the Theradex website is also on the CTSU website OPEN tab.  

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For questions about the use of IWRS for slot reservations, contact the Theradex Helpdesk 
at 609-619-7862 or Theradex main number 609-799-7580; 
CTMSSupport@theradex.com. 
 
4.4 
General Guidelines 
 
Following registration, patients should begin protocol treatment within 7 days.  Issues that would 
cause treatment delays should be discussed with the Principal Investigator.  If a patient does not 
receive protocol therapy following registration, the patient’s registration on the study may be 
canceled.  The Study Coordinator should be notified of cancellations as soon as possible. 
 
 
5. 
TREATMENT PLAN 
 
5.1 
Agent Administration 
 
Treatment will be administered on an outpatient basis.  The study drugs may be 
administered in sequence, without regard to order.  Do not administer study drugs 
concurrently.  For patients receiving both drugs, the intravenous catheter must be flushed 
with 0.9% sodium chloride between the two infusions.  Pre-medication is not needed 
unless a patient develops an infusion reaction. 
 
Patients will be randomly allocated for treatment in one of two groups (group 1 or group 
2).  Both groups will receive Nivolumab at the dose of 240 mg IV every 2 weeks for the 
first 4 months on the study.  After four months, Nivolumab will be administered at the 
dose of 480 mg IV every 4 weeks.  Patients allocated to group 2 will also receive CDX-
1127 (varlilumab) at the dose of 3 mg/kg IV every 4 weeks.  Response assessment will be 
performed every 12 weeks.  Patients in group 1 (nivolumab alone) who meet criteria for 
disease progression at any point in the study will be allowed to cross-over to group 2 
(nivolumab and CDX-1127 (varlilumab) and continue on the study.  A repeat biopsy is 
mandatory for patients who wish to cross-over from group 1 to group 2 at the time of 
disease progression.  
 
Reported adverse events and potential risks are described in Section 7.  Appropriate dose 
modifications are described in Section 6.  No investigational or commercial agents or 
therapies other than those described below may be administered with the intent to treat 
the patient's malignancy. 
 
5.1.1 CDX-1127 (Varlilumab) 
 
CDX-1127 (Varlilumab) will be given every four weeks ± 2 days at a dose of 3 mg/kg.  
Patients may be dosed no less than 26 days from the previous dose of drug.   
 
CDX-1127 (Varlilumab) is to be administered as a 90-minute intravenous (IV) infusion 

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using a 0.2 – 0.22 micron in-line filter connected to the infusion set.  CDX-1127 
(Varlilumab) should not be administered as a bolus injection.  All patients should be 
monitored for 4-6 hours following the first two doses and 2 hours following all 
subsequent doses; patients who experience any treatment-related adverse events during 
the observation period should be further monitored as clinically appropriate (e.g., for up 
to 24 hours post-dose). 
 
CDX-1127 (Varlilumab) cannot be mixed with any other drug in the infusion bag or the 
administration set. 
 
5.1.2 Nivolumab 
 
Nivolumab will be given every two weeks ± 2 days at a dose of 240 mg for 4 months 
followed by 480 mg every 4 weeks thereafter.  Patients may be dosed no less than 12 
days from the previous dose of drug during cycles 1 - 5 and no less than 26 days from the 
previous dose beginning with cycle 6.  
 
There will be no dose modifications allowed.   
 
Nivolumab is to be administered as a 30-minute IV infusion, using a volumetric pump 
with a 0.2-1.2 micron in-line filter at the protocol-specified dose.  The drug can be diluted 
with 0.9% normal saline for delivery but the total volume must not exceed 160 mL.  It is 
not to be administered as an IV push or bolus injection.  At the end of the infusion, flush 
the line with a sufficient quantity of normal saline.   
 
 
5.2 
General Concomitant Medication and Supportive Care Guidelines 
 
Because there is a potential for interaction of CDX-1127 (varlilumab) and nivolumab 
with other concomitantly administered drugs, the case report form must capture the 
concurrent use of all other drugs, over-the-counter medications, or alternative therapies.  
Appendix B, the Patient Wallet Card, will be given to patients to identify the study 
physician and provide a contact telephone number.  
 
5.3 
Duration of Therapy 
 
In the absence of treatment delays due to adverse event(s), treatment may continue for up 
to a maximum of 2 years or until one of the following criteria applies: 
 
• 
Disease progression (except patients on group 1 who wish to cross-over to group 
2), 
• 
Intercurrent illness that prevents further administration of treatment, 
• 
Adverse event(s) which require(s) permanently going off study treatment (see also 
section 6 and specific algorithms in Appendix E) 
• 
Any dosing interruption lasting > 6 weeks, with the following exceptions:  Dosing 

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interruptions > 6 weeks that occur for non-drug-related reasons may be allowed if 
approved by the Investigator.  Prior to re-initiating treatment in a subject with a 
dosing interruption lasting > 6 weeks, the Principal Investigator must be 
consulted. 
• 
Patient decides to withdraw from the study 
• 
General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator 
• 
Clinical deterioration as defined by acute or progressive decline in performance 
status, progressive debility or progressive increase in tumor-associated symptoms 
that negatively impact the patient’s quality of life as judged by the treating 
physician. 
• 
Patient non-compliance 
• 
Pregnancy 
o All women of child bearing potential should be instructed to contact the 
investigator immediately if they suspect they might be pregnant (e.g., 
missed or late menstrual period) at any time during study participation. 
o The investigator must immediately notify CTEP in the event of a 
confirmed pregnancy in a patient participating in the study. 
 
• 
Termination of the study by sponsor 
• 
The drug manufacturer can no longer provide the study agent 
 
The reason(s) for protocol therapy discontinuation must be documented in the Case Report Form 
(CRF). 
 
 
5.4 
Duration of Follow Up Following End of Therapy 
 
Patients will be followed for additional 100 days (based on 5 half-lives) after end of 
therapy or until death, whichever occurs first.  Patients removed from therapy for 
unacceptable adverse event(s) will be followed until resolution or stabilization of the 
adverse event. 
 
5.5 
Criteria for Removal from Study 
 
Patients treated in group 1 (Nivolumab alone) are allowed to cross-over to group 2 at the 
time of documented disease progression. A repeat biopsy is mandatory to confirm 
progressive disease.  Patients who cross-over from group 1 to group 2 may continue 
treatment for an additional 2 years (counting from the start of treatment on group 2) as 
long as he or she does not meet other criteria for removal from the study. 
 
Patients will be removed from study when any of the applicable criteria occur:  
completion of follow-up as described in Section 5.4 above, patient withdrawal, or 

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inability to follow study protocol as listed in Section 5.3.  The reason for study removal 
and the date the patient was removed must be documented in the Case Report Form. 
 
5.6 
Criteria to Resume Treatment Following a Drug-Related Adverse Event 
 
Some patients may continue to benefit from treatment, maintaining or improving 
responses after developing a drug-related adverse event that requires temporary 
discontinuation of the study drugs.  These may include patient who require treatment with 
steroids. 
 
Patients who develop drug-related adverse events may resume therapy only if he or she 
meets the dose modification criteria as described in the tables in Section 6. 
 
If the criteria to resume treatment are met, the patient should restart treatment no sooner 
than the next scheduled time point per protocol.  However, if the treatment is delayed 
past the next scheduled time point per protocol the treatment should resume at the earliest 
convenient point that is within the six week delay period.  
 
 For patients who develop immune-related adverse events, including those who require 
treatment with high dose steroids treatment may be resumed if all the following are met: 
 
• Must resolve to baseline within 6 weeks of treatment 
 
• Must be off steroids for at least 2 weeks with no recurrence or new events New 
immune related events or exacerbation of existing events during steroid treatment 
or taper suggest the presence of ongoing immune activation and should require 
permanent discontinuation of nivolumab.  
 
• Must have had no recurrence of symptoms or new symptoms during steroid taper. 
 
 
5.7 
Treatment of Study Drug Related Infusion Reactions 
 
Since nivolumab and CDX-1127 (varlilumab) contain only human immunoglobulin 
protein sequences, they are unlikely to be immunogenic and induce infusion or 
hypersensitivity reactions.  However, if such a reaction were to occur, it might manifest 
with fever, chills, rigors, headache, rash, urticaria, angioedema, pruritis, arthralgias, 
hypo- or hypertension, bronchospasm, or other symptoms.  
 
All Grade 3 or 4 infusion reactions should be reported as an SAE if criteria are met.  
Infusion reactions should be graded according to NCI CTCAE version 5.0 guidelines. 
 
Treatment recommendations are provided below and may be modified based on local 
treatment standards and guidelines as medically appropriate: 
 
Remain at bedside and monitor subject until recovery from symptoms.  

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For Grade 1 symptoms (Mild transient reaction; infusion interruption not indicated; 
intervention not indicated):   
 
Infusion rate may be slowed or interrupted and restarted at 50% of the original infusion 
rate when symptoms resolve; if no further complications ensue after 30 minutes, the rate 
may be increased to 100% of the original infusion rate.  Monitor patient closely.   
 
The following prophylactic premedications are recommended for future infusions:  
diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg 
(acetaminophen) at least 30 minutes before additional administrations of study drugs, 
slowing infusion rate as above. 
 
If the grade 1 event occurs during the infusion of the first drug in patients randomized to 
the combination therapy arm (group 2), the second drug may still be given as long as the 
patient is closely monitored and there is no evidence of increase in severity of reaction 
(beyond grade 1). 
 
 
For Grade 2 symptoms (Therapy or infusion interruption indicated but responds 
promptly to symptomatic treatment [e.g., antihistamines, NSAIDS, narcotics, IV fluids]; 
prophylactic medications indicated for ≤24 hrs):   
  
Stop the study drug infusion, begin an IV infusion of normal saline, and treat the subject 
with diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 1000 mg 
(acetaminophen); remain at bedside and monitor patient until resolution of symptoms.  
Corticosteroid or bronchodilator therapy may also be administered as appropriate.  If the 
infusion is interrupted, then restart the infusion at 50% of the original infusion rate when 
symptoms resolve; if no further complications ensue after 30 minutes, the rate may be 
increased to 100% of the original infusion rate.  Monitor patient closely.  If symptoms 
recur, re administer diphenhydramine 50 mg IV, and remain at bedside and monitor the 
patient until resolution of symptoms.  No further study drug will be administered in the 
setting of a recurrent infusion reaction and the amount of study drug infused must be 
recorded on the electronic case report form (eCRF). 
 
Close observation for resolution of symptoms and supportive care may need to be 
continued 24-48 hours. If the event (i.e. recurrent infusion reaction) occurs during the 
infusion of the first drug in patients randomized to the combination therapy arm (group 
2), the second drug will also be held for that day but may be administered the following 
day as long as infusion-related symptoms have resolved. Given the degree of clinical 
experience with nivolumab and its known low likelihood of infusion reaction we 
recommend that it be administered first for those patients in the combination therapy arm 
(Group 2). 
 
The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and (acetaminophen) (or paracetamol) 325 to 

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1000 mg should be administered at least 30 minutes before additional nivolumab 
administrations.  If necessary, corticosteroids (recommended dose: up to 25 mg of IV 
hydrocortisone or equivalent) may be used. 
 
For Grade 3 or Grade 4 symptoms:  
 
• Grade 3 symptoms: Prolonged (e.g., not rapidly responsive to symptomatic 
medication and/or brief interruption of infusion); recurrence of symptoms 
following initial improvement; hospitalization indicated for other clinical sequelae  
 
• Grade 4 symptoms: Life-threatening consequences; urgent intervention indicated  
 
Immediately discontinue infusion of the study drug.  Begin an IV infusion of normal 
saline, and bronchodilators, epinephrine 0.2 to 1 mg of a 1:1,000 solution for 
subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 solution injected slowly for 
IV administration, and/or diphenhydramine 50 mg IV with methylprednisolone 100 mg 
IV (or equivalent), as needed.  Patient should be monitored until the investigator is 
comfortable that the symptoms will not recur.   
 
Investigators should follow their institutional guidelines for the treatment of anaphylaxis.  
Remain at bedside and monitor patient until recovery from symptoms.  
 
For Grade 4 infusion reactions, study drug(s) will be permanently discontinued.  
 
Patients with Grade 3 infusion reactions who have not been pre-medicated may continue 
study treatment with appropriate pre-medication, at the discretion of the investigator. 
Recommended prophylactic pre-medications for all subsequent infusions as described in 
management of Grade 2 infusion reactions.  Study drug(s) should be permanently 
discontinued for recurrence of Grade 3 infusion reaction for patients who have received 
pre-medications.   
 
In the case of late-occurring hypersensitivity symptoms (e.g., appearance of a localized or 
generalized pruritis within 1 week after treatment), symptomatic treatment may be given 
(e.g., oral antihistamine, or corticosteroids).  Additional treatment prior to next dose as 
per guidelines above.  
 
Please note that late occurring events including isolated fever and fatigue may represent 
the presentation of systemic inflammation.  Please evaluate accordingly.  
 
 
 
 
6. 
DOSING DELAYS/DOSE MODIFICATIONS 
 

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6.1 
Dose Modifications for Group 1 (Nivolumab alone) and Group 2 (Nivolumab and 
CDX-1127 (Varlilumab)  
 
Below are DOSE MODIFICATION tables applicable to all patients participating in this study for 
the following adverse events.  This applies to all patients whether they have been assigned to 
Group 1 (nivolumab alone) or Group 2 (nivolumab and CDX-1127 (varlilumab)  
 
Patients who develop adverse events while being treated with combinatory therapy CDX-1127  
(varlilumab and nivolumab - Group 2 patients) must have both drugs held or discontinued 
according to the guidance provided in the tables below.  Treatment with single-agent will not be 
permitted at any time for patients who are randomized to Group 2 and develop adverse events. 
 
Please use as written and contact the drug monitor for any proposed changes.  Note that if a 
patient experiences several adverse events and there are conflicting recommendations, the 
investigator should use the recommended treatment modification for the most serious event that 
has a higher level of modification, i.e. going off study treatment versus holding drug. 
 
A patient who requires treatment to be held within the first 4 months on the study will continue 
to receive nivolumab at the dosage of 240 mg every 2 weeks if he meets criteria to resume 
treatment before the 4 months’ timepoint.  For this patient, the change in dosage and frequency 
of nivolumab (from 240 mg every 2 weeks to 480 mg every 4 weeks) should occur at the 4-
month mark regardless of the number of nivolumab infusions received prior to holding treatment. 
However, if the same patient only meets criteria to resume treatment after the 4-month mark he 
or she will resume treatment with nivolumab 480 mg every 4 weeks regardless of the total 
number of nivolumab infusions received up to that point.  
 
 
In several places there are differences between the protocol specific guidelines in Section 
6.1 and the toxicity management algorithms in Appendix D. In these instances, the protocol 
specific guidelines should be followed. These treatment guidelines and management 
algorithms should be followed unless there are specific clinical circumstances for which the 
treating physician decides an alternative treatment approach is clinically appropriate. 
Consultation with the study PI or drug monitor is recommended.   
  
Generally we strongly encourage early evaluation while withholding drug, and appropriate 
treatment as indicated in the management tables and event specific guidelines.   
 
Dose hold = All study drugs must be held.  Day 1 of the next cycle is given when the patient 
meets the protocol criteria to restart drugs.  The current cycle will include all days until the 
patient resumes treatment and may be longer than 28 days. 
 
 
 
ALL OTHER 
EVENTS 
Management/Next Dose  
≤ Grade 1 
No change in dose  

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ALL OTHER 
EVENTS 
Management/Next Dose  
Grade 2 
Hold until ≤ Grade 1 OR baseline (exceptions as noted below)     
Grade 3 
 Off protocol therapy (exceptions as noted below)   
Grade 4 
Off protocol therapy 
 
Recommended management:  As clinically indicated  
 
 
o Any grade 2 drug-related uveitis or eye pain or blurred vision that does not 
respond to topical therapy and does not improve to Grade 1 severity within the re-
treatment period OR requires systemic treatment should go off protocol treatment  
 
o Any adverse event, laboratory abnormality, or intercurrent illness which, in the 
judgment of the investigator, presents a substantial clinical risk to the subject with 
continued study drug dosing should go off protocol treatment.  
 
o Any grade 3 or 4 drug-related laboratory abnormality or electrolyte abnormality, 
that can be managed independently from  underlying organ pathology with 
electrolyte replacement, hormone replacement, insulin or  that does not require 
treatment does not require discontinuation.  
 
o Lymphopenia is an expected event for both study drugs.  Asymptomatic 
lymphopenia does not constitute reason to hold or discontinue the study drugs, 
regardless of the grade 
 
 
Skin Rash and Oral 
Lesions 
 
Management/Next Dose  
≤ Grade 1 
No change in dose * 
Grade 2 
Hold* until 1≤ Grade resolved.  Resume at same dose level.  
Grade 3 
Hold* until ≤ Grade 1.  Resume at same level at investigator discretion  
Grade 4 
Off protocol therapy 
*Patients with purpuric or bullous lesions must be evaluated for vasculitis, Steven-Johnson syndrome, 
TEN, and autoimmune bullous disease including oral lesions of bullous pemphigus/pemphigoid.  
Pruritus may occur with or without skin rash and should be treated symptomatically if there is no 
associated liver or GI toxicity.  Note skin rash typically occurs early and may be followed by additional 
events particularly during steroids tapering.   
Recommended management:  AE management guidelines 
 
 
Liver Function 
AST, ALT, 
Bilirubin   
Management/Next Dose  

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Liver Function 
AST, ALT, 
Bilirubin   
Management/Next Dose  
≤ Grade 1 
Hold until UNL or baseline.   Resume at same dose level. 
Grade 2 
Hold until UNL or baseline.  Resume at same dose level.  
Grade 3 
Off protocol therapy  
Grade 4 
Off protocol therapy 
Continued treatment of active immune mediated hepatitis may exacerbate ongoing inflammation.  
Holding drug to evaluate LFT changes and early treatment are recommended.   
LFT changes may occur during steroid tapers from other events and may occur together with other GI 
events including cholecystitis/pancreatitis.  
Recommended management:  see Hepatic AE management algorithm 
 
 
Diarrhea/ Colitis  
Management/Next Dose  
≤ Grade 1 
Hold until baseline.  No change in dose 
Grade 2 
Hold until baseline.  No change in dose 
Grade 3 
Off protocol therapy. 
Grade 4 
Off protocol therapy 
See GI AE Algorithm for management of symptomatic colitis.  
Patients with grade 2 symptoms but normal colonoscopy and biopsies may be retreated after resolution.  
Patients who require steroids should be taken off study treatment.  
 Please evaluate pituitary function prior to starting steroids if possible without compromising acute care.   
Evaluation for all patients for additional causes includes C. diff, acute and self-limited infectious and 
foodborne illness, ischemic bowel, diverticulitis, and IBD.  
Recommended management:  see GI AE management Algorithm 
 
Pancreatitis 
Amylase/Lipase  
Management/Next Dose  
≤ Grade 1 
Hold dose until baseline.  Resume at same dose level if asymptomatic 
Grade 2 
Hold until baseline.  Resume at same dose level if asymptomatic 
Grade 3 
Hold until baseline.  Resume at same dose level if asymptomatic. 
Patients who develop symptomatic pancreatitis or DM should be taken 
off treatment  
Grade 4 
Hold until baseline.  Resume at same dose level if asymptomatic. 
Patients who develop symptomatic pancreatitis or DM should be taken 
off treatment  
Patients may develop symptomatic and radiologic evidence of pancreatitis as well as DM and 
DKA.  Lipase elevation may occur during the period of steroid withdrawal and with other 
immune mediated events or associated with colitis, hepatitis, and patients who have 
asymptomatic lipase elevation typically have self-limited course and may be retreated.  
For treatment management of symptomatic pancreatitis please follow the Hepatic Adverse 
Event Management Algorithm  
 
 
Pneumonitis 
Management/Next Dose  

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Pneumonitis 
Management/Next Dose  
≤ Grade 1 
Hold dose pending evaluation and resolution to baseline including 
baseline pO2.  Resume no change in dose after pulmonary and/or ID 
consultation excludes lymphocytic pneumonitis.  
Grade 2 
Hold dose pending evaluation. Off protocol therapy if steroids are 
required.  
Grade 3 
Hold dose pending evaluation. Off protocol therapy  if steroids are 
required  
Grade 4 
Off protocol therapy 
Distinguishing inflammatory pneumonitis is often a diagnosis of exclusion for patients who do not 
respond to antibiotics and have no causal organism identified including influenza.  Most patients with 
respiratory failure or hypoxia will be treated with steroids.  Bronchoscopy may be required and analysis 
of lavage fluid for lymphocytic predominance may be helpful.  Patients with new lung nodules should 
be evaluated for sarcoid like granuloma.  Please consider recommending seasonal influenza killed 
vaccine for all patients. 
Recommended management:  See Pulmonary Adverse Event Management Algorithm  
 
 
Other GI  
(not Nausea and 
Vomiting)  
Management/Next Dose  
≤ Grade 1 
No change in dose.  
Grade 2 
Hold pending evaluation for gastritis duodenitis and other immune 
adverse events or other causes.  Resume at same dose level after 
resolution to ≤ Grade 1.   
Grade 3 
Hold pending evaluation   until ≤ Grade 1.  Resume at same dose level. 
If symptoms do not resolve within 7 days with symptomatic treatment  patients 
should go off protocol therapy 
Grade 4 
Off protocol therapy 
Patients with grade 2 or 3 N-V should be evaluated for upper GI inflammation and other immune related 
events.   
 
Fatigue  
Management/Next Dose  
≤ Grade 1 
No change in dose. 
Grade 2 
No change in dose 
Grade 3 
Hold until ≤ Grade 2.  Resume at same dose level 
Fatigue is the most common adverse event associated with immune checkpoint therapy.  Grade 
2 or greater fatigue should be evaluated for associated or underlying organ involvement 
including pituitary, thyroid, and hepatic, or muscle (CPK) inflammation  
 
Neurologic events  
 
Management/Next Dose  
≤ Grade 1 
Hold dose pending evaluation and observation. Resume with no change 
in dose when resolved to baseline. .  
Grade 2 
Hold dose pending evaluation and observation. Hold until ≤ Grade 1. 
Off protocol therapy if treatment with steroids is required.  Resume at 

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Neurologic events  
 
Management/Next Dose  
same dose level for peripheral isolated n. VII (Bell’s palsy)^  
Grade 3 
Off protocol therapy  
Grade 4 
Off protocol therapy  
Patients with any CNS events including aseptic meningitis, encephalitis, symptomatic 
hypophysitis, or myopathy, peripheral demyelinating neuropathy, cranial neuropathy (other 
than peripheral n. VII), GB syndrome and myasthenia gravis should be off study.   
Recommended management:  See Neurologic Adverse Event Management Algorithm  
 
 
Endocrine 
Hypophysitis 
Adrenal 
Insufficiency  
 
Management/Next Dose  
≤ Grade 1 
Asymptomatic TSH elevation *  Hold pending evaluation, endocrine 
consult  
Grade 2 
Hold until patients are on a stable replacement hormone regimen.  If 
treated with steroids patients must be stable off steroids for two weeks. 
Resume at same dose level.  
Grade 3 
Off study treatment. 
Grade 4 
Off protocol therapy 
Note all patients with symptomatic pituitary enlargement, exclusive of hormone deficiency, but 
including severe headache or enlarged pituitary on MRI should be considered grade 3 events.  Isolated 
thyroid or testosterone deficiency may be treated as grade 2 if there are no other associated deficiencies 
and adrenal function is monitored.  
Please evaluate pituitary function before beginning steroid therapy or replacement therapy of any kind.  
*Note patients with thyroiditis may be retreated on replacement therapy.  Patients must be evaluated to 
rule out pituitary disease prior to initiating thyroid replacement. 
Recommended management: See Endocrine Management Algorithm  
 
Creatinine 
Increased  
Management/Next Dose  
≤ Grade 1 
No change in dose.  Monitor toxicity weekly until returned to baseline. 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 4 
Off treatment 
Recommended management: See Renal Management Algorithm  
 
 
Infusion Reaction  
Management/Next Dose  
≤ Grade 1 
Infusion may be slowed or interrupted until symptoms resolve. See 
Section 5.7 for details on management and subsequent dosing.  
Grade 2 
Interrupt until symptoms resolve. See Section 5.7 for details on 

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Infusion Reaction  
Management/Next Dose  
management and subsequent dosing.  
Grade 3 
Immediately discontinue infusion. See Section 5.7 for details on 
management and subsequent dosing. 
Grade 4 
Immediately discontinue infusion. See Section 5.7 for details on 
management. Permanently discontinue study drug(s). 
Patients with fever should be evaluated as clinically appropriate.  Patients may experience 
isolated fever during infusion reactions or up to several days after infusion.  Evaluation over the 
course of 1-2 weeks should be done for other autoimmune events that may present as fever  
 
 
Fever  
Management/Next Dose  
≤ Grade 1 
Evaluate and continue at same dose level 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 4 
Off treatment 
Patients with fever should be evaluated as clinically appropriate.  Patients may experience 
isolated fever during infusion reactions or up to several days after infusion.  Evaluation over the 
course of 1-2 weeks should be done for other autoimmune events that may present as fever  
See section 5.    infusion reactions   
 
Cardiac *   
Management/Next Dose for  
Cardiac Toxicities  
≤ Grade 1  
Hold dose pending evaluation and observation.**  Evaluate for signs and 
symptoms of CHF, ischemia, arrhythmia or myositis.  Obtain history EKG, 
CK (for concomitant myositis), CK-MB.  Repeat troponin, CK and EKG 2-3 
days.  If troponin and labs normalize may resume therapy.   If labs worsen 
or symptoms develop then treat as below.  Hold pending evaluation  
Grade >2 with 
suspected 
myocarditis 
Hold dose.**  Admit to hospital.  Cardiology consult.  Rule out MI and 
other causes of cardiac disease.  Cardiac Monitoring.  Cardiac Echo.  
Consider cardiac MRI and cardiac biopsy.  Initiate high dose 
methylprednisolone.  If no improvement within 24 hours, add either 
infliximab, ATG or tacrolimus. Consult algorithm for more details.  Resume 
therapy if there is a return to baseline and myocarditis is excluded or 
considered unrelated. 
Grade >2 with 
confirmed 
myocarditis   
Off protocol therapy.  Admit to CCU (consider transfer to nearest Cardiac 
Transplant Unit).  Treat as above.  Consider high dose methylprednisolone   
Add ATG or tacrolimus if no improvement.   Off treatment. 
* Including CHF, LV systolic dysfunction, Myocarditis, CPK, and troponin  
**Patients with evidence of myositis without myocarditis may be treated according as “other 
event”   
Note:  The optimal treatment regimen for immune mediated myocarditis has not been 

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o Drug will be held for grade 2 cardiac dysfunction pending evaluation 
o Drug will be permanently discontinued for grade  3 or 4 cardiac dysfunction and 
grade 2 events that do not recover to baseline or that reoccur 
o Treatment with steroids as clinically indicated  
 
If treatment is delayed > 6 weeks for an adverse event, the patient must be permanently 
discontinued from study therapy.  
  
Patients requiring high dose steroid treatment for autoimmune or inflammatory events should go 
off study treatment except for a short course of tapering steroids for infusion reaction, skin rash 
or endocrine events.  
 
Patients with grade 3 thyroiditis and skin rash may continue therapy  with resolution and stable 
replacement treatment. 
 
Patients with thyroiditis or hypopituitarism who are stable as above may be restarted with 
replacement hormones including thyroid hormone and physiologic doses of corticosteroids.  
Please note that grading and for hypophysitis with symptoms of headache, visual or neurologic 
changes or radiologic evidence of pituitary enlargement and other CNS events such as aseptic 
meningitis or encephalitis should be considered grade 3 events.  
Any patients who require additional immune suppressive treatment beyond steroids should go off 
study treatment 
 
Patients requiring > two dose delays for the same event should go off protocol therapy. 
 
Prior to starting corticosteroids or hormone replacement for any reason, appropriate endocrine 
testing including cortisol, ACTH, TSH and T4 must be obtained to document baseline.  
 
Please note that in some cases the treatment algorithms recommend steroids if symptoms do not 
resolve in 7 days.  However, this recommendation is not meant to delay steroid treatment at any 
time it is clinically indicated.   
 
Patients may be dose-delayed for evaluation and restarted depending on results.  
Any patient started on corticosteroids initially who is determined to not require steroid treatment 
for an autoimmune adverse event may resume therapy after a 2 week observation period without 
further symptoms at the discretion of the PI or investigator. 
 
 
 
 
established.  Since this toxicity has caused patient deaths, an aggressive approach is 
recommended.   

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7. ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS  
 
Adverse event (AE) monitoring and reporting is a routine part of every clinical trial.  The 
following list of AEs (Section 7.1) and the characteristics of an observed AE (Sections 7.2 
and 7.3) will determine whether the event requires expedited reporting via the CTEP 
Adverse Event Reporting System (CTEP-AERS) in addition to routine reporting. 
 
7.1 
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs) 
 
7.1.1 CAEPRs for CTEP IND Agent(s) 
 
 
CAEPR for CDX-1127 (Varlilumab) 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
 for 
CDX-1127 (Varlilumab, NSC 778372) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for further clarification. Frequency is provided based on 343 patients. Below is the CAEPR for CDX-1127 
(varlilumab). 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
 
Version 2.1, September 14, 20191 
 
 Adverse Events with Possible  
 Relationship to CDX-1127 (varlilumab) 
 (CTCAE 5.0 Term) 
[n= 343] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia 
 
  
CARDIAC DISORDERS 
  
 
 
Pericardial effusion 
  
ENDOCRINE DISORDERS 
  
 
 
Hyperthyroidism 
  
 
Hypothyroidism 
 
  
EYE DISORDERS 
  
 
 
Blurred vision 
  
 
 
Dry eye 
  
 
 
Eye disorders - Other 
(transient central vision loss) 
  

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 Adverse Events with Possible  
 Relationship to CDX-1127 (varlilumab) 
 (CTCAE 5.0 Term) 
[n= 343] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
 
Eye disorders - Other (visual 
acuity reduced transiently) 
  
 
 
Floaters 
  
 
 
Watering eyes 
  
GASTROINTESTINAL DISORDERS 
  
 
 
Colitis 
  
 
Diarrhea 
 
 Diarrhea (Gr 2) 
 
Nausea 
 
 Nausea (Gr 2) 
 
 
Proctitis 
  
 
Vomiting 
 
  
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills 
 
  
Fatigue 
 
 
 Fatigue (Gr 2) 
 
Fever 
 
  
 
Flu like symptoms 
 
  
 
Malaise 
 
  
HEPATOBILIARY DISORDERS 
  
 
 
Hepatobiliary disorders - 
Other (hepatitis) 
  
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction 
  
 
 
Cytokine release syndrome2 
  
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
 
Infusion related reaction 
 
  
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased3 
 
  
 
Alkaline phosphatase increased3  
  
 
Aspartate aminotransferase 
increased 
 
  
 
Blood bilirubin increased3 
 
  
 
GGT increased3 
 
  
 
Lipase increased 
 
  
 
Lymphocyte count decreased 
 
 Lymphocyte count 
decreased (Gr 2) 
 
Neutrophil count decreased 
 
  
 
Serum amylase increased 
 
  
 
Thyroid stimulating hormone 
increased 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
  
 
 
Tumor lysis syndrome4 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
NERVOUS SYSTEM DISORDERS 
  
 
Headache 
 
  

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 Adverse Events with Possible  
 Relationship to CDX-1127 (varlilumab) 
 (CTCAE 5.0 Term) 
[n= 343] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
 
 
 
Nervous system disorders - 
Other (peripheral 
sensorimotor neuropathy) 
  
 
 
Paresthesia 
  
 
 
Peripheral sensory 
neuropathy 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
 
Pneumonitis 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
Pruritus 
 
 
 Pruritus (Gr 2) 
Rash maculo-papular 
 
 
 Rash maculo-papular (Gr 2) 
 
 
Skin hyperpigmentation 
  
 
 
Skin hypopigmentation 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2Symptoms of cytokine release syndrome (CRS) and/or allergic reaction may include chills, fever, fatigue, 
flushing, bronchospasm, and hypotension.  In some cases, disseminated intravascular coagulation (DIC), 
capillary leak syndrome (CLS), and hemophagocytic lymphohistiocytosis/macrophage activation 
syndrome (HLH/MAS) have been reported in the setting of CRS. 
 
3Symptoms of hepatic dysfunction may include Alanine aminotransferase increased, Alkaline 
phosphatase increased, Aspartate aminotransferase increased, Blood bilirubin increased, and GGT 
increased under the INVESTGATIONS SOC. 
 
4Tumor lysis syndrome is defined as a massive overload of potassium, phosphate, uric acid, plus 
hypocalcemia, potentially causing lethal cardiac arrhythmias and/or renal failure. 
 
 
 NOTE:  Adverse reactions generally low grade that may represent immune-mediated toxicity, such as 
rash, diarrhea, fever, and increased liver function tests, have been observed in patients receiving CDX-
1127 monotherapy and may be manifestations of immune-mediated adverse events. In clinical trials, 
most immune-mediated adverse reactions were reversible and managed with interruptions of CDX-1127, 
administration of corticosteroids and supportive care.  Immune-related adverse events which are 
expected with checkpoint inhibition, have been observed among the patients who have received CDX-
1127 (varlilumab) in combination with checkpoint inhibitors. 
 
Adverse events reported on CDX-1127 (varlilumab) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that CDX-1127 (varlilumab) caused the 
adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Leukocytosis; Lymph node pain 
CARDIAC DISORDERS - Sinus tachycardia 
GASTROINTESTINAL DISORDERS - Abdominal distension; Abdominal pain; Constipation; Dry mouth; 
Dyspepsia; Dysphagia; Flatulence; Gastroesophageal reflux disease; Gastrointestinal disorders - Other 

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(tongue discoloration); Gastrointestinal disorders - Other (tongue ulceration); Gastrointestinal pain; Lower 
gastrointestinal hemorrhage; Mucositis oral; Oral dysesthesia; Oral pain; Periodontal disease; Small 
intestinal obstruction 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema limbs; Gait disturbance; 
General disorders and administration site conditions - Other (temperature intolerance); Localized edema; 
Non-cardiac chest pain; Pain 
INFECTIONS AND INFESTATIONS - Appendicitis; Infections and infestations - Other (candida infection); 
Infections and infestations - Other (epididymitis); Infections and infestations - Other (Herpes zoster); 
Mucosal infection; Sepsis; Sinusitis; Thrush 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Fall; Injury, poisoning and procedural 
complications - Other (procedural pain) 
INVESTIGATIONS - Creatinine increased; Investigations - Other (haptoglobin increased); Investigations - 
Other (urobilinogen urine increased); Platelet count decreased; Weight loss; White blood cell decreased 
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hyperglycemia; Hyperuricemia; 
Hypocalcemia; Hypoglycemia; Hypokalemia; Hypomagnesemia; Hyponatremia; Hypophosphatemia; 
Metabolism and nutrition disorders - Other (cachexia); Metabolism and nutrition disorders - Other 
(hyperalbuminemia); Metabolism and nutrition disorders - Other (malnutrition) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Back pain; Flank pain; Generalized 
muscle weakness; Muscle cramp; Musculoskeletal and connective tissue disorder - Other (axillary pain); 
Musculoskeletal and connective tissue disorder - Other (groin pain); Musculoskeletal and connective 
tissue disorder - Other (osteolysis); Musculoskeletal and connective tissue disorder - Other (pain in jaw); 
Myalgia; Neck pain; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Tumor pain 
NERVOUS SYSTEM DISORDERS - Dizziness; Dysgeusia; Lethargy 
PSYCHIATRIC DISORDERS - Insomnia; Irritability; Personality change 
RENAL AND URINARY DISORDERS - Acute kidney injury; Chronic kidney disease; Hematuria; Renal 
and urinary disorders - Other (urine odor abnormal); Urinary frequency 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis; Bronchopulmonary 
hemorrhage; Bronchospasm; Cough; Dyspnea; Nasal congestion; Oropharyngeal pain; Respiratory 
failure; Sinus pain; Sneezing; Voice alteration; Wheezing 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Bullous dermatitis; Dry skin; 
Erythroderma; Hyperhidrosis; Pain of skin; Palmar-plantar erythrodysesthesia syndrome; Rash acneiform; 
Skin and subcutaneous tissue disorders - Other (pemphigoid); Skin and subcutaneous tissue disorders - 
Other (skin hemorrhage) 
VASCULAR DISORDERS - Flushing; Hot flashes; Hypertension; Hypotension 
 
 
Note: CDX-1127 (varlilumab) in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the combination may result in events 
never previously associated with either agent.  
 
7.1.1.2 
CAEPR for Nivolumab 
 
Comprehensive Adverse Events and Potential Risks list (CAEPR) 
for  
Nivolumab (NSC 748726) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below).  Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 

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for further clarification. Frequency is provided based on 2069 patients. Below is the CAEPR for 
Nivolumab. 
 
NOTE: Report AEs on the SPEER ONLY IF they exceed the grade noted in parentheses next to the 
AE in the SPEER.  If this CAEPR is part of a combination protocol using multiple investigational 
agents and has an AE listed on different SPEERs, use the lower of the grades to determine if 
expedited reporting is required. 
 
     Version 2.4, December 2, 20201 
 
 Adverse Events with Possible  
 Relationship to Nivolumab 
 (CTCAE 5.0 Term) 
[n= 2069] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
Anemia 
 
 Anemia (Gr 3) 
CARDIAC DISORDERS 
  
 
 
Cardiac disorders - Other 
(cardiomyopathy) 
  
 
 
Myocarditis 
  
 
 
Pericardial tamponade2 
  
 
 
Pericarditis 
  
ENDOCRINE DISORDERS 
  
 
Adrenal insufficiency3 
 
  
 
Hyperthyroidism3 
 
  
 
Hypophysitis3 
 
  
 
Hypothyroidism3 
 
  
EYE DISORDERS 
  
 
 
Blurred vision 
  
 
 
Dry eye 
  
 
 
Eye disorders - Other (diplopia)3   
 
 
Eye disorders - Other (Graves 
ophthalmopathy)3 
  
 
 
Eye disorders - Other (optic 
neuritis retrobulbar)3 
  
 
 
Eye disorders - Other (Vogt-
Koyanagi-Harada) 
  
 
Uveitis 
 
  
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
Colitis3 
 
  
 
 
Colonic perforation3 
  
 
Diarrhea 
 
 Diarrhea (Gr 3) 
 
Dry mouth 
 
 Dry mouth (Gr 2) 
 
 
Enterocolitis 
  
 
 
Gastritis 
  
 
 
Mucositis oral 
  
 
Nausea 
 
 Nausea (Gr 2) 
 
Pancreatitis4 
 
  
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever 
 
 Fever (Gr 2) 
 
Injection site reaction 
 
 Injection site reaction (Gr 2) 

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 Adverse Events with Possible  
 Relationship to Nivolumab 
 (CTCAE 5.0 Term) 
[n= 2069] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
HEPATOBILIARY DISORDERS 
  
 
 
Hepatobiliary disorders - Other 
(immune-mediated hepatitis) 
  
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction3 
  
 
 
Autoimmune disorder3 
  
 
 
Cytokine release syndrome5 
  
 
 
Immune system disorders - 
Other (GVHD in the setting of 
allotransplant)3,6 
  
 
 
Immune system disorders - 
Other (sarcoidosis)3 
  
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
 
Infusion related reaction7 
 
  
INVESTIGATIONS 
  
 
Alanine aminotransferase 
increased3 
 
 Alanine aminotransferase 
increased3 (Gr 3) 
 
Aspartate aminotransferase 
increased3 
 
 Aspartate aminotransferase 
increased3 (Gr 3) 
 
Blood bilirubin increased3 
 
 Blood bilirubin increased3 
(Gr 2) 
 
CD4 lymphocytes decreased 
 
 CD4 lymphocyte decreased 
(Gr 4) 
 
Creatinine increased 
 
  
 
Lipase increased 
 
  
 
Lymphocyte count decreased 
 
 Lymphocyte count 
decreased (Gr 4) 
 
Neutrophil count decreased 
 
  
 
Platelet count decreased 
 
  
 
Serum amylase increased 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
  
 
 
Hyperglycemia 
 Hyperglycemia (Gr 2) 
 
 
Metabolism and nutrition 
disorders - Other (diabetes 
mellitus with ketoacidosis)3 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
 
 
Musculoskeletal and connective 
tissue disorder - Other 
(polymyositis) 
  
 
 
Myositis 
  
 
 
Rhabdomyolysis 
  
NERVOUS SYSTEM DISORDERS 
  
 
 
Encephalopathy3 
  
 
 
Facial nerve disorder3 
  
 
 
Guillain-Barre syndrome3 
  
 
 
Myasthenia gravis3 
  

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 Adverse Events with Possible  
 Relationship to Nivolumab 
 (CTCAE 5.0 Term) 
[n= 2069] 
 
 
 Specific Protocol 
Exceptions to Expedited 
Reporting (SPEER)  
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
 
 
Nervous system disorders - 
Other (demyelination 
myasthenic syndrome) 
  
 
 
Nervous system disorders - 
Other (encephalitis)3 
  
 
 
Nervous system disorders - 
Other (meningoencephalitis) 
  
 
 
Nervous system disorders - 
Other (meningoradiculitis)3 
  
 
 
Nervous system disorders - 
Other (myasthenic syndrome) 
  
 
 
Peripheral motor neuropathy 
  
 
 
Peripheral sensory neuropathy   
 
 
Reversible posterior 
leukoencephalopathy 
syndrome3 
  
RENAL AND URINARY DISORDERS 
  
 
 
Acute kidney injury3 
  
 
 
Renal and urinary disorders - 
Other (immune-mediated 
nephritis) 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Pleural effusion3 
 
  
 
Pneumonitis3 
 
  
 
 
Respiratory, thoracic and 
mediastinal disorders - Other 
(bronchiolitis obliterans with 
organizing pneumonia)3 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
 
Erythema multiforme3 
  
 
Pruritus3 
 
 Pruritus3 (Gr 2) 
 
Rash maculo-papular3 
 
 Rash maculo-papular3 (Gr 2) 
 
 
Skin and subcutaneous tissue 
disorders - Other (bullous 
pemphigoid) 
  
 
Skin and subcutaneous tissue 
disorders - Other (Sweet's 
Syndrome)3 
 
  
 
Skin hypopigmentation3 
 
  
 
 
Stevens-Johnson syndrome 
  
 
 
Toxic epidermal necrolysis 
  
 
1This table will be updated as the toxicity profile of the agent is revised.  Updates will be distributed to all 
Principal Investigators at the time of revision.  The current version can be obtained by contacting 
PIO@CTEP.NCI.NIH.GOV.  Your name, the name of the investigator, the protocol and the agent should 
be included in the e-mail. 
 
2Pericardial tamponade may be related to possible inflammatory reaction at tumor site. 
 

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3Nivolumab being a member of class of agents involved in the inhibition of “immune checkpoints”, may 
result in severe and possibly fatal immune-mediated adverse events probably due to T-cell activation and 
proliferation.  This may result in autoimmune disorders that can include (but are not limited to) 
autoimmune hemolytic anemia, acquired anti-factor VIII immune response, autoimmune aseptic 
meningitis, autoimmune hepatitis, autoimmune nephritis, autoimmune neuropathy, autoimmune 
thyroiditis, bullous pemphigoid, exacerbation of Churg-Strauss Syndrome, drug rash with eosinophilia 
systemic symptoms [DRESS] syndrome, facial nerve disorder (facial nerve paralysis), limbic encephalitis, 
hepatic failure, pure red cell aplasia, pancreatitis, ulcerative and hemorrhagic colitis, endocrine disorders 
(e.g., autoimmune thyroiditis, hyperthyroidism, hypothyroidism, autoimmune hypophysitis/hypopituitarism, 
thyrotoxicosis, and adrenal insufficiency), sarcoid granuloma, myasthenia gravis, polymyositis, and 
Guillain-Barre syndrome. 
 
4Pancreatitis may result in increased serum amylase and/or more frequently lipase. 
 
5Cytokine release syndrome may manifest as hemophagocytic lymphohistiocytosis with accompanying 
fever and pancytopenia. 
 
6Complications including hyperacute graft-versus-host disease (GVHD), some fatal, have occurred in 
patients receiving allo stem cell transplant (SCT) after receiving Nivolumab.  These complications may 
occur despite intervening therapy between receiving Nivolumab and allo-SCT. 
 
7Infusion reactions, including high-grade hypersensitivity reactions which have been observed following 
administration of nivolumab, may manifest as fever, chills, shakes, itching, rash, hypertension or 
hypotension, or difficulty breathing during and immediately after administration of nivolumab. 
 
 
Adverse events reported on Nivolumab trials, but for which there is insufficient evidence to 
suggest that there was a reasonable possibility that Nivolumab caused the adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Leukocytosis 
CARDIAC DISORDERS - Atrial fibrillation; Atrioventricular block complete; Heart failure; Ventricular 
arrhythmia 
EAR AND LABYRINTH DISORDERS - Vestibular disorder 
EYE DISORDERS - Eye disorders - Other (iridocyclitis); Optic nerve disorder; Periorbital edema 
GASTROINTESTINAL DISORDERS - Constipation; Duodenal ulcer; Flatulence; Gastrointestinal 
disorders - Other (mouth sores); Vomiting 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Chills; Edema limbs; Malaise; 
Pain 
HEPATOBILIARY DISORDERS - Bile duct stenosis 
IMMUNE SYSTEM DISORDERS - Anaphylaxis; Immune system disorders - Other (autoimmune 
thrombotic microangiopathy); Immune system disorders - Other (limbic encephalitis) 
INFECTIONS AND INFESTATIONS - Bronchial infection; Lung infection; Sepsis; Upper respiratory 
infection 
INVESTIGATIONS - Blood lactate dehydrogenase increased; GGT increased; Investigations - Other 
(protein total decreased); Lymphocyte count increased; Weight loss 
METABOLISM AND NUTRITION DISORDERS - Dehydration; Hyperuricemia; Hypoalbuminemia; 
Hypocalcemia; Hyponatremia; Hypophosphatemia 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Back pain; Musculoskeletal and 
connective tissue disorder - Other (musculoskeletal pain); Musculoskeletal and connective tissue disorder 
- Other (polymyalgia rheumatica); Myalgia; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Neoplasms 
benign, malignant and unspecified (incl cysts and polyps) - Other (Histiocytic necrotizing lymphadenitis) 
NERVOUS SYSTEM DISORDERS - Dizziness; Headache; Intracranial hemorrhage 
PSYCHIATRIC DISORDERS - Insomnia 
RENAL AND URINARY DISORDERS - Hematuria; Renal and urinary disorders - Other (tubulointerstitial 

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nephritis) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchospasm; Cough; Dyspnea; 
Hypoxia 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Dry skin; Hyperhidrosis; Pain of skin; 
Photosensitivity; Rash acneiform; Skin and subcutaneous tissue disorders - Other (rosacea) 
VASCULAR DISORDERS - Flushing; Hypertension; Hypotension; Vasculitis 
 
 
Note: Nivolumab in combination with other agents could cause an exacerbation of any adverse event 
currently known to be caused by the other agent, or the combination may result in events never 
previously associated with either agent. 
 
7.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales 
found in the revised NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 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. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in 
the SPEER column, Section 7.1.1) should be reported through CTEP-AERS only 
if the grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined in 
section 7.3.4. 
 
• Attribution of the AE: 
- 
Definite – The AE is clearly related to the study treatment. 
- 
Probable – The AE is likely related to the study treatment. 
- 
Possible – The AE may be related to the study treatment. 
- 
Unlikely – The AE is doubtfully related to the study treatment. 
- 
Unrelated – The AE is clearly NOT related to the study treatment. 
 
Although standard AE attributions will be collected and recorded as part of this study all 
adverse events will be considered relevant to study treatment unless clearly determined to 
be unrelated to the drugs and therefore classified as unrelated. 
 
 
 

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7.3 
Expedited Adverse Event Reporting 
 
7.3.1 Expedited AE reporting for this study must use CTEP-AERS (CTEP Adverse Event 
Reporting System), accessed via the CTEP Web site (https://eapps-
ctep.nci.nih.gov/ctepaers).  The reporting procedures to be followed are presented in the 
“NCI Guidelines for Investigators: Adverse Event Reporting Requirements for DCTD 
(CTEP and CIP) and DCP INDs and IDEs” which can be downloaded from the CTEP 
Web site 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm
).  These requirements are briefly outlined in the tables below (Section 7.3.3). 
 
In the rare occurrence when Internet connectivity is lost, a 24-hour notification is to be 
made to CTEP by telephone at 301-897-7497.  Once Internet connectivity is restored, the 
24-hour notification phoned in must be entered electronically into CTEP-AERS by the 
original submitter at the site. 
 
7.3.2 Distribution of Adverse Event Reports 
 
CTEP-AERS is programmed for automatic electronic distribution of reports to the 
following individuals:  Principal Investigator and Adverse Event Coordinator(s) (if 
applicable) of the Corresponding Organization or Lead Organization, the local treating 
physician, and the Reporter and Submitter.  CTEP-AERS provides a copy feature for 
other e-mail recipients.  
 
7.3.3 Expedited Reporting Guidelines 
 
Use the NCI protocol number and the protocol-specific patient ID assigned during trial 
registration on all reports. 
 
Note:  A death on study requires both routine and expedited reporting, regardless of 
causality.  Attribution to treatment or other cause must be provided. 
 
  “Death due to progressive disease should be reported as Grade 5 “Disease progression” 
in the system organ class (SOC) “General disorders and administration site conditions.” 
Evidence that the death was a manifestation of underlying disease (e.g., radiological 
changes suggesting tumor growth or progression: clinical deterioration associated with a 
disease process) should be submitted.  
 
 

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Phase 1 and Early Phase 2 Studies:  Expedited Reporting Requirements for Adverse 
Events that Occur on Studies under an IND/IDE within 30 Days of the Last Administration 
of the Investigational Agent/Intervention 1, 2 
FDA REPORTING REQUIREMENTS FOR SERIOUS ADVERSE EVENTS (21 CFR Part 312) 
NOTE:  Investigators MUST immediately report to the sponsor (NCI) ANY Serious Adverse Events, whether or not 
they are considered related to the investigational agent(s)/intervention (21 CFR 312.64) 
An adverse event is considered serious if it results in ANY of the following outcomes:   
1) 
Death 
2) 
A life-threatening adverse event  
3) 
An adverse event that results in inpatient hospitalization or prolongation of existing hospitalization for ≥ 24 
hours  
4) 
A persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions  
5) 
A congenital anomaly/birth defect.  
6) 
Important Medical Events (IME) that may not result in death, be life threatening, or require hospitalization 
may be considered serious when, based upon medical judgment, they may jeopardize the patient or 
subject and may require medical or surgical intervention to prevent one of the outcomes listed in this 
definition. (FDA, 21 CFR 312.32; ICH E2A and ICH E6). 
 
ALL SERIOUS adverse events that meet the above criteria MUST be immediately reported to the NCI via electronic 
submission within the timeframes detailed in the table below. 
Hospitalization 
Grade 1 and Grade 2 Timeframes 
Grade 3-5 
Timeframes 
Resulting in 
Hospitalization  
≥ 24 hrs 
10 Calendar Days 
24-Hour 5 Calendar 
Days 
Not resulting in 
Hospitalization  
≥ 24 hrs 
Not required 
NOTE:  Protocol specific exceptions to expedited reporting of serious adverse events are found in the Specific 
Protocol Exceptions to Expedited Reporting (SPEER) portion of the CAEPR. 
Expedited AE reporting timelines are defined as: 
o 
“24-Hour; 5 Calendar Days” - The AE must initially be submitted electronically within 24 hours of learning 
of the AE, followed by a complete expedited report within 5 calendar days of the initial 24-hour report. 
o 
“10 Calendar Days” - A complete expedited report on the AE must be submitted electronically within 10 
calendar days of learning of the AE. 
1Serious adverse events that occur more than 30 days after the last administration of investigational 
agent/intervention and have an attribution of unlikely, possible, probable, or definite require reporting as follows:  
Expedited 24-hour notification followed by complete report within 5 calendar days for: 
• 
All Grade 3, 4, and Grade 5 AEs 
Expedited 10 calendar day reports for: 
• 
Grade 2 AEs resulting in hospitalization or prolongation of hospitalization 
2For studies using PET or SPECT IND agents, the AE reporting period is limited to 10 radioactive half-lives, 
rounded UP to the nearest whole day, after the agent/intervention was last administered.  Footnote “1” above 
applies after this reporting period. 
Effective Date:  May 5, 2011 
 
 
 
 
 

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7.3.4 Additional Protocol-Specific Expedited Adverse Event Reporting Exclusions 
 
For this protocol only, the AEs/grades listed below do not require expedited reporting 
via CTEP-AERS.  However, they still must be reported through the routine reporting 
mechanism (Section 7.4): 
 
CTCAE SOC 
Adverse Event 
CTCAE Grade at 
which the event will 
not require 
expedited reporting1 
Investigations 
Neutrophil count decreased 
≤ Grade 4 
Platelet count decreased 
≤ Grade 4 
White blood count  
≤ Grade 4 
Lymphocyte count decreased 
≤ Grade 4 
Blood and lymphatic system 
disorders 
Anemia 
≤ Grade 4 
1 These exceptions only apply if the adverse event does not result in hospitalization. If the 
adverse event results in hospitalization, then the standard expedited adverse events reporting 
requirements must be followed.  
Specific protocol exceptions to expedited reporting should be reported expeditiously by 
investigators ONLY if they exceed the expected grade of the event. 
The following hospitalizations are not considered to be SAEs because there is no “adverse 
event” (i.e., there is no untoward medical occurrence) associated with the hospitalization: 
• Hospitalizations for respite care 
• Planned hospitalizations required by the protocol 
• Hospitalization planned before informed consent (where the condition requiring the 
hospitalization has not changed post study drug administration) 
• Hospitalization for elective procedures unrelated to the current disease and/or treatment 
on this trial 
• Hospitalization for administration of study drug or insertion of access for administration 
of study drug 
• Hospitalization for routine maintenance of a device (e.g., battery replacement) that was in 
place before study entry 
• Hospitalization, or other serious outcomes, for signs and symptoms of progression of the 
cancer. 
 
 
7.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 

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Adverse event data collection and reporting, which are required as part of every clinical 
trial, are done to ensure the safety of patients enrolled in the studies as well as those who 
will enroll in future studies using similar agents.  AEs are reported in a routine manner at 
scheduled times during the trial using Medidata Rave.  For this trial the Adverse Event 
CRF is used for routine AE reporting in Rave. 
 
7.5 
Secondary Malignancy 
 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (e.g., 
treatment with investigational agent/intervention, radiation or chemotherapy). A 
secondary malignancy is not considered a metastasis of the initial neoplasm. 
 
CTEP requires all secondary malignancies that occur following treatment with an agent 
under an NCI IND/IDE be reported expeditiously via CTEP-AERS.  Three options are 
available to describe the event:  
 
• Leukemia secondary to oncology chemotherapy (e.g., acute myelocytic leukemia 
[AML])  
• Myelodysplastic syndrome (MDS)  
• Treatment-related secondary malignancy  
 
Any malignancy possibly related to cancer treatment (including AML/MDS) should also 
be reported via the routine reporting mechanisms outlined in each protocol.  
 
 
7.6 
Second Malignancy 
 
A second malignancy is one unrelated to the treatment of a prior malignancy (and is 
NOT a metastasis from the initial malignancy).  Second malignancies require ONLY 
routine AE reporting unless otherwise specified. 
 
 
8. PHARMACEUTICAL INFORMATION 
 
A list of the adverse events and potential risks associated with the investigational agents 
administered in this study can be found in Section 7.1. 
 
8.1 
CTEP IND Agent(s) 
 
8.1.1 CDX-1127 (Varlilumab;  NSC 778372) 
 
Other Names: CDX-1127 (Varlilumab) 
 
Classification: monoclonal antibody of the IgG1κ isotope 
 

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M.W.:  146,076 Dalton 
 
Mode of Action:  CDX-1127 (Varlilumab) binds to human CD27 and acts as an agonist of 
CD27, reacting with the ligand binding site of CD27 as demonstrated by inhibition of 
CD70 binding to CD27.  CDX-1127 (Varlilumab) does not bind other tumor necrosis 
factor receptor (TNFR) family members. CDX-1127 (Varlilumab) does not lead to direct 
activation of lymphocytes in the absence of signaling through the T cell receptor (TCR). 
 
Description: CDX-1127 (Varlilumab) is a recombinant, fully human monoclonal 
antibody (mAb) of the IgG1κ isotype that specifically binds human CD27.  The amino 
acid sequence of CDX-1127 (varlilumab) has been determined and its structure is 
comprised of two IgG1 heavy chains and two kappa light chains which are disulfide-
linked as expected for a mAb. 
 
How Supplied: CDX-1127 (Varlilumab) is formulated as a clear, colorless, sterile 
solution intended for single-use parenteral administration. Each vial contains a nominal 
50 mg CDX-1127 (varlilumab) protein in a 10.0 mL volume of buffered solution 
composed of Sodium Phosphate, Potassium Phosphate, Potassium Chloride, Sodium 
Chloride, and Polysorbate 80 with a pH of 7.0. 
 
Preparation:  Withdraw the prescribed dose of CDX-1127 (varlilumab) from the 
required number of vials. CDX-1127 (varlilumab) may be added to empty non-PVC/non-
DEHP or PVC IV bags and administered undiluted or further diluted with 0.9% sodium 
chloride in a non-PVC/non-DEHP IV bag to a concentration between 0.27 mg/mL and 5 
mg/mL or a PVC IV bag to a concentration between 0.1 mg/mL and 5 mg/mL.  Gently 
invert the infusion bag 5 times to thoroughly mix the CDX-1127 (varlilumab) and 0.9% 
sodium chloride.    
 
Storage: Store at 2 - 8°C (36 - 46°F).  CDX-1127 (Varlilumab) should be protected from 
light. However, sufficient light protection is provided by the secondary container 
(carton); no specific light protection is needed during preparation of the dosing solution 
and infusion.  
 
If a storage temperature excursion is identified, promptly return CDX-1127 (varlilumab) 
to 2 - 8°C (36 - 46°F) and quarantine the supplies.  Provide a detailed report of the 
excursion (including documentation of temperature monitoring and duration of the 
excursion) to PMBAfterHours@mail.nih.gov for determination of suitability. 
 
Stability:  Stability studies are ongoing. 
 
CAUTION:  Once the sterile vials are entered (i.e., once CDX-1127 (varlilumab) is 
drawn into a syringe), the drug should be used as soon as possible (typically within 3 
hours if kept at room temperature or within 6 hours if refrigerated; or in accordance with 
any applicable institutional guidance). 
  
Route(s) of Administration: IV 

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Method of Administration: Infuse CDX-1127 (varlilumab) intravenously over 90 
minutes using a polyethylene- or polypropylene-lined, non-DEHP-containing, low-
protein binding/low-sorbing administration set with a 0.2 or 0.22 micron polyethersulfone 
(PES) in-line filter.   
 
Patient Care Implications:  It is possible that CDX-1127 (varlilumab) may exacerbate 
autoimmune diseases. Therefore, with the exception of vitiligo, CDX-1127 (varlilumab) 
should not be administered to patients with autoimmune diseases. 
 
Management of CDX-1127(varlilumab) induced irAEs, should they occur, should be 
based on the extensive experience with treatment of toxicities related to ipilimumab and 
other checkpoint blockers. Guidelines and algorithms have been published for treatment 
of ipilimumab related toxicity (see ipilimumab package insert) and investigators should 
be familiar with these recommendations in the event of CDX-1127 induced irAEs (Di 
Giacomo, Biagioli et al. 2010; Kaehler, Piel et al. 2010). 
 
Availability: Varlilumab is an investigational agent supplied to investigators by the 
Division of Cancer Treatment and Diagnosis (DCTD), NCI. 
 
Varlilumab is provided to the NCI under a Collaborative Agreement between the 
Pharmaceutical Collaborator and the DCTD, NCI (see Section 12.4). 
 
 
 
8.1.2 Nivolumab (NSC 748726) 
 
Amino Acid Sequence:  4 polypeptide chains, which include 2 identical heavy chains 
with 440 amino acids and 2 identical light chains. 
 
Other Names:  BMS-936558, MDX1106 
 
Classification:  Anti-PD-1MAb 
 
M.W.:  146,221 Daltons 
 
Mode of Action:  Nivolumab targets the programmed death–1 (PD-1, cluster of 
differentiation 279 [CD279]) cell surface membrane receptor.  PD-1 is a negative 
regulatory receptor expressed by activated T and B lymphocytes.  Binding of PD-1 to its 
ligands, programmed death–ligand 1 (PD-L1) and 2 (PD-L2), results in the down-
regulation of lymphocyte activation.  Nivolumab inhibits the binding of PD-1 to PD-L1 
and PD-L2.  Inhibition of the interaction between PD-1 and its ligands promotes immune 
responses and antigen-specific T-cell responses to both foreign antigens as well as self-
antigens. 
 
Description:  Nivolumab Injection is a clear to opalescent, colorless to pale yellow 

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liquid; light (few) particulates may be present.  The drug product is a sterile, 
nonpyrogenic, single-use, isotonic aqueous solution formulated in sodium citrate 
dihydrate, sodium chloride, mannitol, diethylenetriamine pentacetic acid (pentetic acid) 
and polysorbate 80 (Tween® 80), and water for injection.  Dilute solutions of 
hydrochloric acid and/or sodium hydroxide may be used for pH adjustment (pH 5.5-6.5).. 
 
How Supplied:  Nivolumab is supplied by Bristol-Myers Squibb and distributed by the 
Pharmaceutical Management Branch, CTEP/DCTD/NCI as 100 mg vials (10 mg/mL) 
with a 0.7 mL overfill.  It is supplied in 10 mL type I flint glass vials, with fluoropolymer 
film-laminated rubber stoppers and aluminum seals. 
 
Preparation:  Nivolumab injection can be infused undiluted (10 mg/mL) or diluted with 
0.9% Sodium Chloride Injection, USP or 5% Dextrose, USP. When the dose is based on 
patient weight (i.e., mg/kg), nivolumab injection can be infused undiluted or diluted to 
protein concentrations as low as 0.35 mg/mL. When the dose is fixed (eg, 240 mg, 360 
mg, or 480 mg flat dose), nivolumab injection can be infused undiluted or diluted so as 
not to exceed a total infusion volume of 160 mL.  For patients weighing less than 40 
kilograms (kg), the total 
volume of infusion must not exceed 4 mL per kg of patient weight. During drug product 
preparation and handling, vigorous mixing or shaking is to be avoided. 
 
Nivolumab infusions are compatible with polyvinyl chloride (PVC) or polyolefin 
containers and infusion sets, and glass bottles. 
 
Storage:  Vials of Nivolumab injection must be stored at 2°-8°C (36°-46°F) and 
protected from light, freezing, and shaking.  The unopened vials can be stored at room 
temperature (up to 25°C, 77°F) and room light for up to 48 hours. If a storage temperature 
excursion is identified, promptly return Nivolumab to 2°C-8°C and quarantine the supplies.  
Provide a detailed report of the excursion (including documentation of temperature 
monitoring and duration of the excursion) to PMBAfterHours@mail.nih.gov for 
determination of suitability. 
 
Stability:  Shelf-life surveillance of the intact vials is ongoing. 
 
The administration of undiluted and diluted solutions of Nivolumab must be completed 
within 24 hours of preparation.  If not used immediately, the infusion solution may be 
stored up to 24 hours in a refrigerator at 2°-8°C (36°-46°F) and a maximum of 8 hours of 
the total 24 hours can be at room temperature (20°-25°C, 68°-77°F) and room light.  The 
maximum -8 hour period under room temperature and room light conditions includes the 
product administration period. 
 
CAUTION:  The single-use dosage form contains no antibacterial preservative or 
bacteriostatic agent.  Therefore, it is advised that the product be discarded 8 hours after 
initial entry.  
 
Route of Administration:  Intravenous infusion over 30 minutes.  Do not administer as 

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an IV push or bolus injection.   
 
Method of Administration:  Administer through a 0.2 micron to 1.2 micron pore size, 
low-protein binding polyethersulfone membrane in-line filter.  Nivolumab infusions are 
compatible with polyvinyl chloride (PVC) or polyolefin containers and infusion sets, and 
glass bottles. 
 
Potential Drug Interactions:  None have been reported. 
 
Potential Drug Interactions: The indirect drug-drug interaction potential of nivolumab 
was assessed using systemic cytokine modulation data for cytokines known to modulate 
CYP enzymes.  There were no meaningful changes in cytokines known to have indirect 
effects on CYP enzymes across all dose levels of nivolumab. This lack of cytokine 
modulation suggests that nivolumab has no or low potential for modulating CYP 
enzymes, thereby indicating a low risk of therapeutic protein-drug interaction. 
 
Patient Care Implications: Women of childbearing potential (WOCBP) receiving 
nivolumab must continue contraception for a period of 5 months after the last dose of 
nivolumab. Men receiving nivolumab and who are sexually active with WOCBP must 
continue contraception for a period of 7 months after the last dose of nivolumab. 
 
Availability: Nivolumab is an investigational agent supplied to investigators by the 
Division of Cancer Treatment and Diagnosis (DCTD), NCI. 
 
Nivolumab is provided to the NCI under a Collaborative Agreement between the 
Pharmaceutical Collaborator and the DCTD, NCI (see Section 12.4). 
 
 
8.1.3 Agent Ordering and Agent Accountability 
 
 
NCI-supplied agents may be requested by the Principal Investigator (or their 
authorized designee) at each participating institution.  Pharmaceutical Management 
Branch (PMB) policy requires that agent be shipped directly to the institution where 
the patient is to be treated.  PMB does not permit the transfer of agents between 
institutions (unless prior approval from PMB is obtained).  The CTEP-assigned 
protocol number must be used for ordering all CTEP-supplied investigational agents.  
The responsible investigator at each participating institution must be registered with 
CTEP, DCTD through an annual submission of FDA Form 1572 (Statement of 
Investigator), Curriculum Vitae, Supplemental Investigator Data Form (IDF), and 
Financial Disclosure Form (FDF).  If there are several participating investigators at 
one institution, CTEP-supplied investigational agents for the study should be ordered 
under the name of one lead investigator at that institution. 
 
Supplies may be ordered once a patient has been enrolled to the study; starter supplies 
of investigational agents are not available.  
 

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Active CTEP-registered investigators and investigator-designated shipping designees 
and ordering designees can submit agent requests through the PMB Online Agent 
Order Processing (OAOP) application.  Access to OAOP requires the establishment 
of a CTEP Identity and Access Management (IAM) account and the maintenance of 
an “active” account status and a “current” password.  For questions about drug orders, 
transfers, returns, or accountability, call or email PMB any time.  Refer to the PMB’s 
website for specific policies and guidelines related to agent management.   
 
 
Agent Inventory Records – The investigator, or a responsible party designated by the 
investigator, must maintain a careful record of the receipt, dispensing and final 
disposition of all agents received from the PMB using the appropriate NCI 
Investigational Agent (Drug) Accountability Record (DARF) available on the CTEP 
forms page.  Store and maintain separate NCI Investigational Agent Accountability 
Records for each agent, strength, formulation and ordering investigator on this 
protocol. 
 
 
Investigator Brochures - The current versions of the IBs for PMB-supplied agents will 
be accessible to site investigators and research staff through the PMB Online Agent 
Order Processing (OAOP) application.  Access to OAOP requires the establishment 
of a CTEP Identity and Access Management (IAM) account and the maintenance of 
an “active” account status and a “current” password.  Questions about IB access may 
be directed to the PMB IB coordinator via email. 
 
 
Useful Links and Contacts 
• CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
• NCI CTEP Investigator Registration:  PMBRegPend@ctep.nci.nih.gov 
• PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent_management.htm  
• PMB Online Agent Order Processing (OAOP) application: https://eapps-
ctep.nci.nih.gov/OAOP/pages/login.jspx  
• CTEP Identity and Access Management (IAM) account: https://eapps-
ctep.nci.nih.gov/iam/ 
• CTEP Associate Registration and IAM account help:  
ctepreghelp@ctep.nci.nih.gov  
• PMB email:  PMBAfterHours@mail.nih.gov 
• PMB phone and hours of service: (240) 276-6575 Monday through Friday 
between 8:30 am and 4:30 pm (ET) 
• IB Coordinator: ibcoordinator@mail.nih.gov 
 
 
9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Specimen Requirements for Correlative Studies 
 
In this study, we propose several correlative studies, as detailed below.   These assays are 

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specifically chosen to provide information on the status of the immune system in general 
as well as specific information related to the mechanism of action of the study drugs.  
One integrated biomarker study (CD27 by IHC) has been included which has been 
approved by the Biomarker Review Committee (BRC) of the Cancer Therapy Evaluation 
Program (CTEP).  All other correlative studies will be exploratory in nature.  Although 
exploratory, the proposed studies will be done on specimens obtained at time points 
relevant to standard clinical practice (prior to treatment, and at the time of suspected 
progression) in order to avoid unnecessary risks.  The scientific information obtained 
from these studies is intended to be hypothesis-generating and will help us advance our 
understanding of the anti-tumoral immune system in the context of simultaneous 
manipulations using immunomodulatory drugs in lymphoma. 
 
Submission of tumor tissue obtained from a biopsy performed within 60 days of 
registration is a mandatory part of this protocol.  This tissue will be used to confirm the 
diagnosis and correctly stratify patients between categories A or B (Section 3.1.1).  
Submission of tumor tissue obtained from a biopsy performed to at the time of suspected 
disease progression is optional, except for Group 1 patients who cross over to Group 2, 
for these patients, the biopsy is mandatory. The importance of a repeat biopsy for patients 
in Group 1 who are suspected to have progressive disease is explained by the fact that 
responses to immunotherapy drugs may differ from those of standard cytotoxic 
treatments.  Before proceeding with additional therapy we must exclude pseudo-
progression and delayed responses by obtaining a repeat biopsy. 
 
The biopsies obtained at the time of progression for patients in Group 2 or for those in 
Group 1 not wishing to cross-over to Group 2 are exploratory in nature.  We anticipate 
that these biopsies will be done in approximately 25% of patients (some for this study 
and some also for eligibility in subsequent trials).  Even though the cohort may be small, 
we may potentially gain insights into whether patients progress despite increased immune 
cell infiltration into the tumor. 
 
All tumor biopsy tissue will be submitted in formalin-fixed paraffin-embedded (FFPE) 
format to the Mayo Clinic where biomarker specimen processing will be centralized. 
Once the quality of the specimen is verified by expert hematopathologist, ten 4 micron 
unstained slides will be forwarded to Mosaic Laboratories (Lake Forest, CA) for CD27 
IHC assay (integrated biomarker).  The remaining tissue block or slides will be used to 
generate specimens for exploratory biomarker studies including (1) additional unstained 
slides for IHC evaluation of intra-tumoral immune cells, (2) extraction of tumor DNA for 
whole-exome sequencing, (3) evaluation of 9p24.1 locus by FISH and (4) mass 
cytometry analysis of intra-tumoral immune cells all of which will be performed centrally 
at Mayo Clinic. 
 
Serial collection of peripheral blood is also mandatory for patients participating in this 
study.  Peripheral blood will be collected at baseline and every 14 days (prior to 
administration of study drugs) for the first 12 weeks on study.  Submission of peripheral 
blood obtained at the time of disease progression is optional.  Peripheral blood will be 
used to generate serum for cytokine profiling, isolation of peripheral blood mononuclear 

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cells for immunophenotyping, immunogenicity assays and pharmacokinetic studies. 
 
Any surplus of tissue, DNA, cells or serum will be banked at Mayo Clinic for additional 
studies for the patients who provide additional consent for tissue banking.  If consent for 
banking was not provided by the patient, the remaining blocks or slides will be returned 
to the original institution after minimum specimens are generated.  Surplus of blood, 
plasma, serum, DNA and cells will be discarded once the minimum specimens are 
generated if the patient did not provide consent for banking of specimens. 
 
 
Integrated Correlative Study 
Correlative Study 
Optional 
or 
Mandatory 
Required  
Specimen 
Collection 
Timepoints 
Quantification/ 
Characterization 
of CD27+ cells 
by IHC  
Mandatory 
FFPE blocks (preferred) 
or 3 unstained glass slides 
with 4-micron-thick 
sections from FFPE 
blocks 
For all patients: 
Baseline  
(Within 60 days of 
registration) 
Mandatory 
FFPE blocks (preferred) 
or 3 unstained glass slides 
with 4-micron-thick 
sections from FFPE 
 For patients who cross 
over from Group 1 to 
Group 2 only:  
At the time of progression 
Optional 
FFPE blocks (preferred) 
or 3 unstained glass slides 
with 4-micron-thick 
sections from FFPE 
At the end of study  
(for all patients) 
 
Exploratory Correlative Studies 
Correlative Study 
Optional  
or  
Mandatory 
Required  
Specimen 
Collection 
Timepoints 
Analysis of Peripheral 
Blood Immune Cells by 
Mass Cytometry 
(CyTOF)1 
Mandatory 
Peripheral blood 
12 mL collected in 
yellow top tubes 
(ACD) 
Baseline and every 14 
days for the first 12 
weeks  of treatment  

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Identification/ 
Characterization of 
Intratumoral Immune 
Cells by IHC and CyTOF 
Mandatory 
FFPE blocks 
(preferred) or 7 
unstained glass 
slides with 4-
micron-thick 
sections from FFPE 
 
For all patients: 
Baseline  
(Within 60 days of 
registration) 
Mandatory 
FFPE blocks 
(preferred) or 7 
unstained glass 
slides with 4-
micron-thick 
sections from FFPE 
For patients who 
cross over from 
Group 1 to Group 2 
only:  
At the time of 
progression  
Optional 
FFPE blocks 
(preferred) or 7 
unstained glass 
slides with 4-
micron-thick 
sections from FFPE 
For all patients: 
At the end of study 
Evaluation of Genetic 
Alterations of 
Chromosome 9p24.1 by 
FISH 
Mandatory 
FFPE blocks 
(preferred) or 1 
unstained glass 
slide with 4-
micron-thick 
section from FFPE 
 
For all patients: 
Baseline  
(Within 60 days of 
registration) 
Mandatory 
FFPE blocks 
(preferred) or 1 
unstained glass 
slides with 4-
micron-thick 
section from FFPE 
For patients who 
cross over from 
Group 1 to Group 2 
only:  
At the time of 
progression  
Optional 
FFPE blocks 
(preferred) or 1 
unstained glass 
slide with 4-
micron-thick  
sections from FFPE 
For all patients: 
At the time of disease 
progression 
Evaluation of Serum 
Cytokine Profile by 
ELISA1 
Mandatory 
10 mL peripheral 
blood collected in 
red top tubes (no 
anticoagulant) 
Baseline and every 
14 days for the first 
12 weeks  of 
treatment  

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Evaluation of 
pharmacokinetics and 
immunogenicity to CDX-
1127 (Varlilumab)1 
Mandatory 
10 mL peripheral 
blood collected in 
red top tubes (no 
anticoagulant) 
Group 2: Baseline, 
pre-dose every 4 
weeks for the first 4 
cycles, at the end of 
treatment, and at 
safety follow-up (if 
available). 
 
Group 1: Baseline 
for all patients. 
 
Group 1 at cross-
over: pre-dose every 
4 weeks prior to the 
first 4 doses of CDX-
1127 (varlilumab), at 
the end of treatment, 
and at safety follow-
up (if available). 
 
Evaluation of 
pharmacokinetics and 
immunogenicity to 
nivolumab1 
Mandatory 
10 mL peripheral 
blood collected in 
red top tubes (no 
anticoagulant) 
For all patients: 
Baseline, pre-dose 
every 4 weeks for the 
first 4 cycles, at the 
end of treatment, and 
at safety follow-up (if 
available). 
Evaluation of Mutation 
Burden by WES 
Mandatory 
FFPE blocks 
(preferred) or 2 
unstained glass 
slides with 4-
micron-thick 
sections from 
FFPE 
For all patients: 
Baseline  
(Within 60 days of 
registration) 
Mandatory 
FFPE blocks 
(preferred) or 2 
unstained glass slides 
with 4-micron-thick 
sections from FFPE 
For patients who 
cross over from 
Group 1 to Group 2 
only:  
At the time of  
disease progression 

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Optional 
FFPE blocks 
(preferred) or 2 
unstained glass slides 
with 4-micron-thick 
sections from FFPE 
For all patients: 
At the time of  
disease progression 
1. Kits will be provided by Mayo Clinic.  To request kits, refer to Appendix E. 
 
9.2 
Integrated Correlative Studies 
 
9.2.1 Quantification/Characterization of CD27+ cells in the Tumor Microenvironment by 
Immunohistochemistry (IHC) 
 
 
Collection of Specimen(s): FFPE tumor tissue 
 
 
Handling and Shipping of Specimen(s):  FFPE tumor blocks are preferred. 
Alternatively, a minimum of 13 unstained glass slides with 4-micron thick sections 
from FFPE per collection timepoint are acceptable. Please include a copy of the de-
identified surgical pathology report, as well as study, site and patient study numbers. 
All FFPE specimens for correlative studies may be shipped together. 
 
Shipping Procedure: 
1. Place the block or slides in small zip-lock bag and seal.  
2. Insert the bag containing the block or the slides in a bubble wrap bag. 
3. Place wrapped samples inside the largest compartment of specimen biohazard bag 
and seal. 
4. Insert a copy of the de-identified surgical pathology report in the outer pocket of 
the specimen biohazard bag. 
5. Include a refrigerated cold pack (not frozen) if shipping in the summer months. 
6. Place the specimen biohazard bag into the box and close. 
7. Complete the transport documents and place into waybill pouch; affix to box.  
8. Ship package to Mayo Clinic at the address below. 
9. Please send email on the day of the shipment.  
 
Please send FFPE tissue to: 
Predolin Biobank  
Attn: Kim Henderson 
Mayo Clinic 
613 Stabile Building  
221 4th Avenue SW  
Rochester, MN 55905 
 
 

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Methodology: The integrated biomarker (CD27 IHC) assay will be performed on 
formalin-fixed paraffin-embedded (FFPE) tissue.  Biopsies should be obtained under 
radiologic or other guidance, as appropriate, per institutional procedures.  Tissues 
should be placed in preservative no later than 30 minutes following removal from the 
body (ideally with 5-10 minutes).  If tissue is obtained via core biopsy, a minimum of 
3 and up to 6 cores are requested; however, less than the goal amount of tissue is 
acceptable, and should be based upon the clinical judgment of the clinician 
performing the procedure.  Based upon prior studies, it is feasible for up to 6 to 8 core 
biopsies to be obtained depending on the site being sampled, the size of the mass, and 
the safety of the procedure.  Specimens should then be fixed using 10% Neutral 
Buffered formalin for 20 +/- 4 hours and then processed into FFPEs.  If fixed 
specimens cannot be processed into FFPE within the period specified above, transfer 
the specimen to a container of 70% histology-grade alcohol where the specimen can 
be stable for up to 2 weeks.  If the site cannot process tissue into FFPE, then ship 
specimens in 70% alcohol.  Tissue blocks should be ideally released for the 
biomarker study.  In the event this is not possible, serial 4 μm sections should be 
obtained from each core and mounted on positively-charged unstained glass slides.  A 
total of 3 slides created from biopsy obtained at the time of registration should be 
forwarded from the Predolin Biobank to Mosaic Laboratories.  A repeat biopsy is 
mandatory for patients who wish to cross-over from Group 1 to Group 2 in the event 
of progression.  Three additional slides obtained at the time of progression should be 
forwarded from the Predolin Biobank to Mosaic Laboratories for these patients.  
Additional glass slides will be created for exploratory correlative studies as specified 
on section 9.1 (Specimen Requirements for Correlative Studies). 
 
 
Statistical Analysis: We will use the “marker-by-treatment predictiveness curves” in 
Janes et al. to explore CD27 as a potential predictive biomarker for the benefit of 
Varlilumab.  Specifically, we will display the response rate as a function of the 
percentiles of CD27 for each treatment arm: Varlilumab plus Nivolumab and 
Nivolumab alone.  We will use logistic regression to model the response rate as a 
function of treatment and CD27 (as a continuous variable).  The distribution of CD27 
will be estimated empirically in the entire trial population and used to calculate CD27 
values corresponding to each fixed percentile.  If the two predictiveness curves cross 
(suggesting predictive potential of CD27), the point where the two curves cross 
would be a possible choice of threshold for dichotomizing CD27 into “low” versus 
“high”.  Threshold levels shown to be best predictors of clinical outcomes will be 
considered as reference for later pivotal trials. 
 
9.3 
Exploratory/Ancillary Correlative Studies 
 
9.3.1 Comprehensive Analysis of Peripheral Blood  Immune Cells by Mass Cytometry 
(CyTOF) 
 
 
Collection of Specimen(s): 12 mL peripheral blood collected in yellow top tubes 
(ACD). 
 

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Handling and Shipping of Specimens(s): Kits will be provided for the collection of 
blood samples.  The kit contains supplies and instructions for collecting, processing, 
and shipping specimens. Refer to Appendix E for kit ordering, sample collection, and 
sample shipping instructions. 
 
 
 
 
Methodology: CyTOF (cytometry at time-of-flight) or mass cytometry is a new 
platform that uses mass spectrometry to allow evaluation of at over 35 simultaneous 
parameters on a single-cell level.  This technology uses nonradioactive non-biological 
metal isotopes as reporters tagged to monoclonal antibodies.  Measurements are made 
based on mass spectrometry, which largely avoids the hurdles of interference and 
spectral overlap experienced with fluorochrome-based flow cytometry.  This 
constitutes an ideal platform for the study of the tumor microenvironment or immune 
monitoring given its ability to assess a large number of parameters and resolve small 
differences in a heterogeneous population of cells. 
 
Mononuclear cells will be isolated from patient’s peripheral blood via gradient 
separation using a Ficoll sodium diatrizoate solution (Ficoll-PaqueTM PLUS, GE 
Healthcare).  The resulting mononuclear single-cell suspension will be suspended in 
freezing media containing 10% dimethyl sulfoxide and stored in liquid nitrogen or -
150oC freezer for analysis.  Specimens will be stained in batches of 3-4 patients. 
Unstimulated live single-cell suspensions will be stained with a cocktail of metal-
tagged antibodies designed to recognize 34 surface proteins (Appendix F).  Nucleated 
cellular events will be identified using a DNA intercalator conjugated to natural 
abundance iridium (191Ir and 193Ir). Cisplatin (195Pt) will be used for dead-live cell 
discrimination and calibration beads containing natural abundance cerium (140/142Ce), 
europium (151/153Eu), holmium (165Ho), and lutetium (175/176Lu) will be used for 
normalization of acquired data.  Our panel will be constructed using commercially 
available metal-conjugated antibodies (Fluidigm Corporation) and stained cells will 
acquired on the CyTOF2 (Fluidigm Corporation). 
 
We will stain a minimum of 3 x 106 cells per specimen and acquire a minimum of 1 x 
106 events on the CyTOF.  We will initially perform high-level manual gating to 
exclude dead or apoptotic cells, debris, beads and doublets.  Additional 
multiparametric analysis will be done using platforms such as Spanning-tree 
Progression Analysis of Density-normalized Events (SPADE) and visualization of 
unbiased clustering of events using the t-SNE (t-Distributed Stochastic Neighbor 
Embedding) algorithm or viSNE. 
 
 
9.3.2 Identification/Characterization of Intratumoral Immune Cells by Immunohistochemistry 
(IHC) and CyTOF 
 
 
Collection of Specimen(s): FFPE tumor tissue 
 

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Handling and Shipping of Specimens(s): FFPE tumor block(s) are preferred. 
Alternatively, a minimum of 13 unstained glass slides with 4-micron thick sections 
from FFPE per collection timepoint are acceptable. Please include a copy of the de-
identified surgical pathology report, as well as study, site and patient study numbers. 
All FFPE specimens for correlative studies may be shipped together. 
 
Shipping Procedure: 
1. Place the block or slides in small zip-lock bag and seal.  
2. Insert the bag containing the block or the slides in a bubble wrap bag. 
3. Place wrapped samples inside the largest compartment of specimen biohazard bag 
and seal. 
4. Insert a copy of the de-identified surgical pathology report in the outer pocket of 
the specimen biohazard bag. 
5. Include a refrigerated cold pack (not frozen) if shipping in the summer months. 
6. Place the specimen biohazard bag into the box and close. 
7. Complete the transport documents and place into waybill pouch; affix to box.  
8. Ship package to Mayo Clinic at the address below. 
9. Please send email on the day of the shipment.  
 
Please send FFPE tissue to: 
Predolin Biobank  
Attn: Kim Henderson 
Mayo Clinic 
613 Stabile Building  
221 4th Avenue SW  
Rochester, MN 55905 
 
 
Methodology: Serial 4-μm paraffin-embedded sections will be used for IHC.  The 
tissue will be deparaffinized with three changes of xylene and cleared through graded 
series of ethanol.  Endogenous peroxidase will be quenched by incubation in 50% 
methanol/H2O2 and after rinsing with tap water; all sections will be pretreated for 30 
minutes with 50 mmol/L EDTA using a steamer and cooled for additional 5 minutes. 
All staining will be done automatically on DAKO Autostainer using the following 
antibodies to CD11c (Leica Microsystems 5D11), CD14 (Cell Marque EPR 3653), 
CD163 (DAKO 1F8), CD68 (DAKO PG-M1), CXCL13 (R&D Systems 53610), 
FOXP3 (Abcam 236AE/7), CD3 (R&D Systems), PD-L1 (405.9A11), PD-L2 
(366C.9E5), CD8a (Dako M7103) and PD-1 (Abcam NAT).  The sections will be 
viewed with an Olympus BXFA51 microscope and pictures taken with an Olympus 
DP71 camera. Stained slides will be scored by expert hematopathologist.  Internal 
control (reactive lymph node, tonsil) will be used to verify staining quality.  Analysis 
of intra-tumoral immune cell subsets by IHC will be largely exploratory and reported 
descriptively. 
 
For CyTOF analysis of intra-tumoral immune cells, we will perform multiparametric 
staining of single-cell suspensions obtained from FFPE blocks using the FFPE-

NCI Protocol #: 10089                                                     72 
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DISSECT (disaggregation for intracellular signaling in single epithelial cells from 
tissue) method.  Single cells will be stained with the same 34-parameter surface 
protein panel (Appendix F).  Nucleated cellular events will be identified using a DNA 
intercalator conjugated to natural abundance iridium (191Ir and 193Ir). Cisplatin (195Pt) 
will be used for dead-live cell discrimination and calibration beads containing natural 
abundance cerium (140/142Ce), europium (151/153Eu), holmium (165Ho), and lutetium 
(175/176Lu) will be used for normalization of acquired data.  Our panel will be 
constructed using commercially available metal-conjugated antibodies (Fluidigm 
Corporation) and stained cells will acquired on the CyTOF2 (Fluidigm Corporation). 
 
We will stain a minimum of 3 x 106 cells per specimen and acquire a minimum of 1 x 
106 events on the CyTOF.  We will initially perform high-level manual gating to 
exclude dead or apoptotic cells, debris, beads and doublets.  Additional 
multiparametric analysis will be done using platforms such as Spanning-tree 
Progression Analysis of Density-normalized Events (SPADE) and visualization of 
unbiased clustering of events using the t-SNE (t-Distributed Stochastic Neighbor 
Embedding) algorithm or viSNE. 
 
 
9.3.3 Evaluation of Genetic Alterations in Chromosome 9p24.1 by FISH  
 
 
Collection of Specimen(s): FFPE tumor tissue 
 
 
Handling and Shipping of Specimens(s): FFPE tumor blocks are preferred. 
Alternatively, a minimum of 13 unstained glass slides with 4-micron thick sections 
from FFPE per collection timepoint are acceptable.  Please include a copy of the de-
identified surgical pathology report, as well as study, site and patient study numbers. 
All FFPE tissue for correlative studies may be shipped together. 
 
Shipping Procedure: 
1. Place the block or slides in small zip-lock bag and seal.  
2. Insert the bag containing the block or the slides in a bubble wrap bag. 
3. Place wrapped samples inside the largest compartment of specimen biohazard bag 
and seal. 
4. Insert a copy of the de-identified surgical pathology report in the outer pocket of 
the specimen biohazard bag. 
5. Include a refrigerated cold pack (not frozen) if shipping in the summer months. 
6. Place the specimen biohazard bag into the box and close. 
7. Complete the transport documents and place into waybill pouch; affix to box.  
8. Ship package to Mayo Clinic at the address below. 
9. Please send email on the day of the shipment.  
 
Please send FFPE tissue to: 
Predolin Biobank  
Attn: Kim Henderson 

NCI Protocol #: 10089                                                     73 
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Mayo Clinic 
613 Stabile Building  
221 4th Avenue SW  
Rochester, MN 55905 
 
 
Methodology: The bacterial artificial chromosome probes (CHORI; www.chori.org) 
RP11-599H2O, which maps to 9p24.1 and includes CD274 (encoding PD-L1, labeled 
with Spectrum Orange), and RP11-635N21, which also maps to 9p24.1 and includes 
PDCD1LG2 (encoding PD-L2, labeled with Spectrum Green), will be cohybridized.  
A control centromeric probe, Spectrum Aqua–labeled CEP9 (Abbott Molecular) that 
maps to 9p11-q11, will be hybridized according to the manufacturer's 
recommendations. Nuclei with a target:control probe ratio of at least 3:1 will be 
classified as amplified, those with a probe ratio of more than 1:1 but less than 3:1 will 
be classified as relative copy gain, and those with a probe ratio of 1:1 but with more 
than two copies of each probe will be classified as polysomic for chromosome 9p.  
Analysis of genetic alterations Involving chromosome 9p24.1 by FISH will be largely 
exploratory and reported descriptively. 
 
 
9.3.4 Evaluation of Serum Cytokine Profile by ELISA  
 
 
Collection of Specimen(s): 10 mL of peripheral blood collected in red top tubes (No 
anticoagulant) 
 
 
Handling and Shipping of Specimens(s): Kits will be provided for the collection of 
blood samples.  The kit contains supplies and instructions for collecting, processing, 
and shipping specimens. Refer to Appendix E for kit ordering, sample collection, and 
sample shipping instructions. 
 
 
 
 Methodology: Serial serum samples will be collected every 14 days before infusion of 
study drugs for the first 12 weeks of the study.  Samples will be subjected to 
multiplex ELISA (Invitrogen, Camarillo, CA) to measure 30 serum cytokines.  
Luminex-200 system version 1.7 will be used for reading plates and MasterPlex 
QT1.0 system (MiraiBio) will be used to analyze data.  Cytokines will include 
epidermal growth factor (EGF), eotaxin, basic fibroblast growth factor (FGF-b), 
granulocyte macrophage colony stimulating factor (GM-CSF), hepatocyte growth 
factor (HGF), IFN-α, IFN-ϒ, interleukin 1 receptor antagonist (IL-1RA), IL-1β,IL-2, 
IL-2R , IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-15, IL-17, IP10, MCP-1, 
MIG, MIP-1α (CCL3), MIP1β (CCL4), regulated on activation normal T-cell 
expressed and secreted (RANTES), TNF-α and vascular endothelial growth factor 
(VEGF). Internal control serum will be included in all assays to control for inter-
assay variation. Analysis of the serum cytokine by multiplex ELISA will be largely 
exploratory and reported descriptively. 
 

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9.3.5 Evaluation of Pharmacokinetics and Immunogenicity of CDX-1127 (varlilumab) and 
Nivolumab 
 
 
Collection of Specimen(s): 20 mL of peripheral blood collected in red top tubes (No 
anticoagulant) 
 
 
Handling and Shipping of Specimens(s): Kits will be provided for the collection of 
blood samples.  The kit contains supplies and instructions for collecting, processing, 
and shipping specimens. Refer to Appendix E for kit ordering, sample collection, and 
sample shipping instructions. 
 
 
 
 
Methodology: The pharmacokinetic properties and the ability of the study drugs to 
elicit an immunogenic response will be evaluated using standardized assays 
performed at their respective companies for the two study drugs. Blood draws will be 
obtained at baseline, pre-dose prior to the administration of drugs for the first 4 
cycles, at end of treatment, and at the time of safety follow-up (if available) for all 
patients. Patients randomized to Group 1 who cross-over to Group 2 will need 4 
additional blood draws to evaluate for immunogenicity to CDX-1127 (varlilumab) 
obtained pre-dose prior to the administration of the 4 initial doses of that medication. 
 
 
9.3.6 Evaluation of Mutational Burden as a Biomarker for Response to Checkpoint Blockade 
Therapy  
 
 
Collection of Specimen(s): FFPE tumor tissue 
 
 
Handling and Shipping of Specimens(s): FFPE tumor blocks are preferred. 
Alternatively, a minimum of 13 unstained glass slides with 4-micron thick sections 
from FFPE per collection timepoint are acceptable. Please include a copy of the de-
identified surgical pathology report, as well as study, site and patient study numbers. 
All FFPE tissue for correlative studies may be shipped together. 
 
Shipping Procedure: 
1. Place the block or slides in small zip-lock bag and seal.  
2. Insert the bag containing the block or the slides in a bubble wrap bag. 
3. Place wrapped samples inside the largest compartment of specimen biohazard bag 
and seal. 
4. Insert a copy of the de-identified surgical pathology report in the outer pocket of 
the specimen biohazard bag. 
5. Include a refrigerated cold pack (not frozen) if shipping in the summer months. 
6. Place the specimen biohazard bag into the box and close. 
7. Complete the transport documents and place into waybill pouch; affix to box.  
8. Ship package to Mayo Clinic at the address below. 

NCI Protocol #: 10089                                                     75 
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9. Please send email on the day of the shipment.  
 
Please send FFPE tissue to: 
Predolin Biobank  
Attn: Kim Henderson 
Mayo Clinic 
613 Stabile Building  
221 4th Avenue SW  
Rochester, MN 55905 
 
 
Methodology: Genomic DNA will be extracted from formalin-fixed, paraffin-
embedded (FFPE) tissue blocks or slides. Hematoxylin and eosin (H&E) stained 
sections from each case will be reviewed by an expert hematopathologist and 
representative blocks with at least 30% tumor cells will be selected. Sections of 10 x 
4-micron dimensions will be cut from blocks (based on tissue area of 25 mm2).  DNA 
will be extracted using the Qiagen FFPE DNA extraction kit. DNA quantitation will 
be performed using a Qubit fluorometer prior to sequencing. Whole exome analysis 
of paired tumor and normal tissue will be performed using Ion TorrentTM platform at 
the Molecular Characterization and Clinical Assay Development Laboratory, Leidos 
Biomedical Research Inc., Frederick National Laboratory for Cancer Research. The 
analysis of mutational burden by whole exome sequencing is largely exploratory and 
reported descriptively 
 
 

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10. 
STUDY CALENDAR 
 
Baseline evaluations are to be conducted within 14 days prior to registration unless stated otherwise. Biopsy for FFPE may be 
obtained within 60 days prior to registration.  Scans and x-rays must be done < 4 weeks prior to the start of therapy.  In the event that 
the patient’s condition is deteriorating, laboratory evaluations should be repeated within 48 hours prior to initiation of the next cycle of 
therapy.  The frequency of routine evaluations (physical, vital signs, routine laboratory tests) changes from every 2 weeks to every 4 
weeks after 4 months to accommodate the change in administration schedule of nivolumab. 
 
 
 
Cycle 1 
Cycle 2 
Cycle 3 
Cycle 4 
Cycles 5 
and 
beyond* 
 
 
Pre-
Study 
Week 
1 
Week 
3 
Week 
5 
Week 
7 
Week 
9 
Week 
11 
Week 
13 
Week 
15 
Week 17 
and 
beyond 
Off  
Studyd 
CDX-1127 
(Varlilumab) 
 
V 
 
V 
 
V 
 
V 
 
V 
 
Nivolumab 
 
N 
N 
N 
N 
N 
N 
N 
N 
N 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
Concurrent meds 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital signs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Height 
X 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Oxygen saturation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Performance 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 

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status 
Lab tests a 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Evaluation of 
Cardiac Function 
e  
X 
 
 
 
 
 
 
 
 
 
 
Adverse event 
evaluation 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Radiologic 
evaluation 
X 
 
Radiologic measurements should be performed every 12 weeks 
from C1D1 (+/- 3 days).  Documentation (radiologic) should must 
be provided for patients removed from study for progressive disease 
B-HCG 
Xb 
Xg 
 
 
 
 
 
 
 
 
 
FFPE for 
correlatives 
Xc 
 
 
 
 
 
 
 
 
 
Xc 
Blood for 
correlativesf 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
V: CDX-1127 (Varlilumab):  Group 2 Patients only: 3 mg/kg every 4 weeks ± 2 days  
 
N: Nivolumab:  All patients: 240 mg every 2 weeks ± 2 days for 4 months followed by 480 
mg every 4 weeks thereafter 
 
a: Lab tests to be performed at baseline and within 72 hours prior to each study drug 
administration include complete blood count (CBC) with differential; albumin, alkaline 
phosphatase, total bilirubin, bicarbonate, BUN/urea, calcium, magnesium, chloride, 
creatinine, fasting glucose, LDH, phosphorus, potassium, total protein, SGOT [AST], 
SGPT [ALT], sodium, amylase, lipase, TSH (with reflexive Free T4 and Free T3).  
Laboratory test monitoring will continue as long as patient continues to receive study 
treatment. 
 
b: Serum or urine pregnancy test for females of childbearing potential.   

NCI Protocol #: 10089                                                     78 
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c.    A pre-study biopsy is mandatory for all groups and must be obtained within 60 days prior 
to registration.  For Group 1 patients who elect to cross over to Group 2, a biopsy is 
mandatory at that time.  An off-study biopsy is optional for all groups. 
 
d: Off-study evaluation to be performed 30 days (+/- 14 days) after the last dose of study drug.  
Patients are followed for at least 100 days for AE assessment. 
 
e:   As clinically indicated, perform an evaluation of cardiac function including ECG and 
echocardiogram for any patients with a history of CHF or at risk because of underlying 
cardiovascular disease or exposure to cardiotoxic drugs.  Also perform an evaluation for 
patients with evidence of CHF, MI, cardiomyopathy, or myositis including lab tests and 
cardiology consultations including ECG, echocardiogram, CPK and troponin. 
 
f:    Blood draw for correlative studies will be obtained at baseline (within 14 days prior to start 
of protocol therapy) and within 72 hours prior to the administration of any of the study 
drugs on dosing days.  These blood draws may be performed at the same occasion as other 
laboratory tests obtained for the purpose of clinical monitoring of the patient.  Patients who 
cross-over from Group 1 to Group 2 will need 4 additional blood draws pre-dose prior to 
their first 4 infusions of CDX-1127 (varlilumab) for immunogenicity and PK studies. 
 
g:   A serum or urine pregnancy test is required within 24 hours of starting study treatment. If 
the pre-study assessment was performed within 24 hours prior to start of study treatment, a 
pregnancy test does not need to be repeated. 
 
*:    Starting with Cycle 5 (Week 17), the dosage and administration schedule of nivolumab is 
changed to 480 mg every 4 weeks.  The dosage and administration schedule of CDX-1127 
(varlilumab) remains unchanged.  Once the schedule of administration of nivolumab 
changes, the frequency of routine evaluations also changes accordingly to every 4 weeks as 
well. 

NCI Protocol #: 10089                                                       79 
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11. MEASUREMENT OF EFFECT 
 
 
11.1 
Antitumor Effect – Hematological Tumors 
 
11.1.1 Definitions 
 
Evaluable for toxicity:  All patients will be evaluable for toxicity from the time of their 
first treatment with CDX-1127 (varlilumab) and/or nivolumab 
 
Evaluable for objective response:  All patients fulfilling eligibility criteria that have 
signed a consent form and have begun treatment will be considered evaluable for 
response.  These patients will have their response classified according to the definitions 
stated below.  (Note:  Patients who exhibit objective disease progression prior to the end 
of cycle 1 will also be considered evaluable.) 
 
 
11.1.2 Response Criteria   
Patients will be evaluated for efficacy based on the lymphoma response to 
immunomodulatory therapy criteria or LYRIC (Cheson et al., 2016). 
 
11.1.3 Schedule of Evaluations  
PET/CT scans are required at baseline for all patients.  Repeat PET-CT scans should be 
obtained every 12 weeks unless otherwise clinically indicated. 
 
Definitions for clinical response for patients with lymphoma are based on the lymphoma 
response to immunomodulatory therapy criteria or LYRIC (Cheson et al., 2016).  Lymph 
node measurements should be taken from the CT portion of the PET/CT, or other 
dedicated CT scans where applicable.  Measurement of lymphadenopathy for purposes of 
assessing for PR will be determined by adding the sum of the products of the maximal 
perpendicular diameters of measured lesions (SPD). The perpendicular diameter of a 
single node is sufficient to evaluate for PD (see Table 11.1.4).  Measurable extranodal 
disease should be assessed in a manner similar to that for nodal disease.  For these 
recommendations, the spleen is considered nodal disease. Disease that is only assessable 
(e.g., pleural effusions, bone lesions) will be recorded as present or absent only, unless, 
while an abnormality is still noted by imaging studies or physical examination, it is found 
to be histologically and pathologically negative. 
 
For response assessment, PET-CT is preferred for staging of FDG-avid lymphomas and 
CT scan is preferred in the other lymphomas 
 
Progressive disease is based on either PET-CT based (PMD) or CT based (PD) response 
criteria.  Definition of progressive disease according to LYRIC is same as the Lugano 
classification except that a new category of indeterminate response (IR) is added. Patients 
whose disease fall in the IR category may continue treatment for additional 12 weeks if 
the patient remains clinically stable as judged by the treating physician. A repeat imaging 

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study  in 12 weeks (or earlier if clinically indicated) is mandatory to confirm or refute 
disease progression.  PET confirmation of progressive disease is per physician discretion. 
 
 
 
11.1.4 Lymphoma Response to Immunomodulatory Therapy Criteria [ LYRIC] (adapted from 
Cheson et al., 2016)  
 
 
PET-CT Based Response 
CT-Based Response 
Complete 
Response 
(CR) 
Complete metabolic response (CMR) 
Complete radiologic response (CR) 
(all of the following) 
Lymph nodes 
and extra 
lymphatic sites  
Score 1, 2, or 3a with or without a residual 
mass on 5PS† 
It is recognized that in Waldeyer’s ring or 
extranodal sites with high physiologic 
uptake or with activation within spleen or 
marrow (e.g., with chemotherapy or 
myeloid colony-stimulating factors), 
uptake may be greater than normal 
mediastinum and/or liver. In this 
circumstance, complete metabolic 
response may be inferred if uptake at sites 
of initial involvement is no greater than 
surrounding normal tissue even if the 
tissue has high physiologic uptake 
Target nodes/nodal masses must 
regress to ≤ 1.5 cm in LDi 
No extra lymphatic sites of disease 
Non-measured 
lesion 
Not applicable 
Absent 
Organ 
enlargement 
Not applicable 
Regress to normal 
New lesions 
None 
None 
Bone marrow 
No evidence of FDG-avid disease in 
marrow 
Normal by morphology; if 
indeterminate, IHC negative 
Partial 
Response 
(PR) 
Partial metabolic response (PMR) 
Partial remission (PR) 
(all of the following) 
 Lymph nodes 
and extra 
lymphatic sites  
Score 4 or 5† with reduced uptake 
compared with baseline and residual 
mass(es) of any size 
At interim, these findings suggest 
responding disease 
At end of treatment, these findings 
indicate residual disease 
≥ 50% decrease in SPD of up to 
6 target measurable nodes and 
extranodal sites 
When a lesion is too small to measure 
on CT, assign 5 mm X 5 mm as the 
default value 
When no longer visible, 0 X 0 mm 
For a node > 5 mm X 5 mm, but 

NCI Protocol #: 10089                                                     81 
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PET-CT Based Response 
CT-Based Response 
smaller than normal, use actual 
measurement for calculation 
Non-measured 
lesions 
Not applicable 
Absent/normal, regressed, but no 
increase 
Organ 
enlargement 
Not applicable 
Spleen must have regressed by > 50% 
in length beyond normal 
New lesions 
None 
None 
Bone marrow  
Residual uptake higher than uptake in 
normal marrow but reduced compared 
with baseline (diffuse uptake compatible 
with reactive changes from chemotherapy 
allowed). If there are persistent focal 
changes in the marrow in the context of a 
nodal response, consideration should be 
given to further evaluation with MRI or 
biopsy or an interval scan 
Not Applicable  
No Response 
or Stable 
Disease 
No metabolic response (NMR) 
Stable disease (SD) 
Target 
nodes/nodal 
masses, 
extranodal 
lesions 
Score 4 or 5 with no significant change in 
FDG uptake from baseline at interim or 
end of treatment 
< 50% decrease from baseline in SPD 
of up to 6 dominant, measurable 
nodes and extranodal sites; no criteria 
for progressive disease are met 
Non-measured 
lesions 
Not applicable 
No increase consistent with 
progression  
Organ 
enlargement 
Not applicable 
No increase consistent with 
progression  
New lesions 
None 
None 
Bone marrow  
No change from baseline 
Not Applicable 
Indeterminate 
Response (IR)  
 
IR(1)b 
 
≥ 50% increase in SPD of up to 6 
measurable lesions in first 12 weeks 
without clinical deterioration. 
 
Note: The measurements from the 
first IR (1) time point becomes the 
reference against which future 
assessment will be compared.  An 
increase of ≥ 10% (in addition to an 
increase of ≥ 5 mm in either 
dimension of ≥ 1 lesion for lesions ≤ 

NCI Protocol #: 10089                                                     82 
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PET-CT Based Response 
CT-Based Response 
2cm and 10 mm for lesions > 2 cm) 
constitutes PD 
IR(2) 
 
< 50% increase in SPD of up to 6 
measurable lesions with: 
a. new lesion(s), or 
b. ≥ 50% increase in PPD of a lesion 
or set of lesions at any time during 
treatment. 
 
Note: The new or growing lesion(s) 
(unless biopsy proven to be benign) 
should be added to the target 
lesion(s), up to a total of no more than 
6 total lesions. In future assessments, 
if the SPD of the newly defined set of 
target lesions has increased ≥ 50% 
from their nadir value (which may 
precede the IR time point), the patient 
should be considered to have PD. 
IR(3) 
Increase in FDG uptake of 1 or more 
lesion(s) without a concomitant increase 
in lesion size or number. 
 
Note: Because inflammatory responses 
may result in an increase in the 
standardized uptake value of a lesion, the 
patient will not be considered to have PD 
unless there is evidence of PD by an 
increase in lesion size or the development 
of new lesions, as noted below. 
 
Progressive 
disease (PD) 
*** Excludes patients who meet criteria for Indeterminate Response (IR) *** 
Progressive metabolic disease (PMD) 
Progressive disease (PD) 
requires at least 1 of the following 
Individual 
target 
nodes/nodal 
masses 
Score 4 or 5 with an increase in intensity 
of uptake from baseline and/or 
 
New FDG-avid foci consistent with 
lymphoma at interim or end-of-treatment 
assessment 
An individual node/lesion must be 
abnormal with:  
LDi > 1.5 cm and 
Increase by ≥ 50% from PPD nadir 
and 
An increase in LDi or SDi from nadir 
0.5 cm for lesions ≤2 cm 
1.0 cm for lesions >2 cm 
In the setting of splenomegaly, the 
splenic length must increase by > 
Extranodal 
lesions 

NCI Protocol #: 10089                                                     83 
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PET-CT Based Response 
CT-Based Response 
50% of the extent of its prior increase 
beyond baseline (e.g., a 15 cm spleen 
must increase to >16 cm).  
If no prior splenomegaly, must 
increase by at least 2 cm from 
baseline 
New or recurrent splenomegaly 
Non-measured 
lesions 
None 
New or clear progression of 
preexisting non-measured lesions 
New lesions 
New FDG-avid foci consistent with 
lymphoma rather than another etiology 
(e.g., infection, inflammation). If 
uncertain regarding etiology of new 
lesions, biopsy or interval scan may be 
considered 
Regrowth of previously resolved 
lesions 
A new node >1.5 cm in any axis 
A new extranodal site >1.0 cm in any 
axis; if <1.0 cm in any axis, its 
presence must be unequivocal and 
must be attributable to lymphoma 
Assessable disease of any size 
unequivocally attributable to 
lymphoma 
Bone marrow 
New or recurrent FDG-avid foci 
New or recurrent involvement 
Abbreviations: 5PS, 5-point scale; CT, computed tomography; FDG, fluorodeoxyglucose; IHC, 
immunohistochemistry; LDi, longest transverse diameter of a lesion; MRI, magnetic resonance 
imaging; PET, positron emission tomography; PPD, cross product of the LDi and perpendicular 
diameter; SDi, shortest axis perpendicular to the LDi; SPD, sum of the product of the perpendicular 
diameters for multiple lesions. 
a.   A score of 3 in many patients indicates a good prognosis with standard treatment, especially if at 
the time of an interim scan. However, in trials involving PET where de-escalation is 
investigated, it may be preferable to consider a score of 3 as inadequate response (to avoid under 
treatment). Measured dominant lesions: Up to six of the largest dominant nodes, nodal masses, 
and extranodal lesions selected to be clearly measurable in two diameters. Nodes should 
preferably be from disparate regions of the body and should include, where applicable, 
mediastinal and retroperitoneal areas. Non-nodal lesions include those in solid organs (e.g., liver, 
spleen, kidneys, and lungs), GI involvement, cutaneous lesions, or those noted on palpation. 
Non-measured lesions: Any disease not selected as measured, dominant disease and truly 
assessable disease should be considered not measured. These sites include any nodes, nodal 
masses, and extranodal sites not selected as dominant or measurable or that do not meet the 
requirements for measurability but are still considered abnormal, as well as truly assessable 
disease, which is any site of suspected disease that would be difficult to follow quantitatively 
with measurement, including pleural effusions, ascites, bone lesions, leptomeningeal disease, 
abdominal masses, and other lesions that cannot be confirmed and followed by imaging. In 
Waldeyer’s ring or in extranodal sites (e.g.,, GI tract, liver, bone marrow), FDG uptake may be 
greater than in the mediastinum with complete metabolic response, but should be no higher than 
surrounding normal physiologic uptake (e.g., with marrow activation as a result of chemotherapy 

NCI Protocol #: 10089                                                     84 
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PET-CT Based Response 
CT-Based Response 
or myeloid growth factors). 
†   PET Deauville 5PS: 1, no uptake above background; 2, uptake ≤  mediastinum; 3, uptake > 
mediastinum but ≤ liver; 4, uptake moderately > liver; 5, uptake markedly higher than liver 
and/or new lesions; X, new areas of uptake unlikely to be related to lymphoma. 
b.   If a patient is assessed as having IR and then “true” PD at a subsequent time point (without an 
intervening objective response between IR and PD), the IR assessment should subsequently be 
corrected to PD for reporting purposes to the date of the prior designation of IR. We recognize 
that these lesions may remain stable during the time of observation, but, even if this is the case, 
the initial designation of IR should be changed to PD. 
 
 
 
12. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS 
 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 7.0 
(Adverse Events: List and Reporting Requirements). 
 
12.1 
Study Oversight 
 
This protocol is monitored at several levels, as described in this section.  The Protocol 
Principal Investigator is responsible for monitoring the conduct and progress of the 
clinical trial, including the ongoing review of accrual, patient-specific clinical and 
laboratory data, and routine and serious adverse events; reporting of expedited adverse 
events; and accumulation of reported adverse events from other trials testing the same 
drug(s).  The Protocol Principal Investigator and statistician have access to the data at all 
times through the CTMS web-based reporting portal.   
 
During the initial phase of the study (before the interim futility analysis), the Protocol 
Principal Investigator will have, at a minimum, quarterly conference calls with the Study 
Investigators to review accrual, progress, and pharmacovigilance.  Decisions to proceed 
with the study beyond the interim analysis will require sign-off by the Protocol Principal 
Investigator and the Protocol Statistician.  
 
All Study Investigators at participating sites who register/enroll patients on a given 
protocol are responsible for timely submission of data via Medidata Rave and timely 
reporting of adverse events for that particular study.  This includes timely review of data 
collected on the electronic CRFs submitted via Medidata Rave. 
 
All studies are also reviewed in accordance with the enrolling institution’s data safety 
monitoring plan. 
 

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12.2 
Data Reporting 
 
Data collection for this study will be done exclusively through Medidata Rave.  Access to 
the trial in Rave is granted through the iMedidata application to all persons with the 
appropriate roles assigned in the Regulatory Support System (RSS).  To access Rave via 
iMedidata, the site user must have an active CTEP IAM account (check at 
https://ctepcore.nci.nih.gov/iam) and the appropriate Rave role (Rave CRA, Rave Read-
Only, Rave CRA (Lab Admin), Rave SLA, or Rave Investigator) on either the LPO or 
participating organization roster at the enrolling site. To the hold Rave CRA role or Rave 
CRA (Lab Admin)  role, the user must hold a minimum of an AP registration type.  To 
hold the Rave Investigator role, the individual must be registered as an NPIVR or IVR.  
Associates can hold read-only roles in Rave.  
 
Upon initial site registration approval for the study in RSS, all persons with Rave roles 
assigned on the appropriate roster will be sent a study invitation e-mail from iMedidata.  
To accept the invitation, site users must log into the Select Login 
(https://login.imedidata.com/selectlogin) using their CTEP-IAM user name and 
password, and click on the “accept” link in the upper right-corner of the iMedidata page.  
Please note, site users will not be able to access the study in Rave until all required 
Medidata and study specific trainings are completed.  Trainings will be in the form of 
electronic learnings (eLearnings), and can be accessed by clicking on the link in the upper 
right pane of the iMedidata screen.   
 
Users that have not previously activated their iMedidata/Rave account at the time of 
initial site registration approval for the study in RSS will also receive a separate invitation 
from iMedidata to activate their account. Account activation instructions are located on 
the CTSU website, Rave tab under the Rave resource materials (Medidata Account 
Activation and Study Invitation Acceptance).  Additional information on iMedidata/Rave 
is available on the CTSU members’ website under the Rave tab or by contacting the 
CTSU Help Desk at 1-888-823-5923 or by e-mail at ctsucontact@westat.com. 
 
12.2.1 Method 
 
This study will be monitored by the Clinical Trials Monitoring Service (CTMS).  Data 
will be submitted to CTMS at least once every two weeks via Medidata Rave (or other 
modality if approved by CTEP).  Information on CTMS reporting is available at: 
http://www.theradex.com/clinicalTechnologies/?National-Cancer-Institute-NCI-11.  On-
site audits will be conducted on an 18-36 month basis as part of routine cancer center site 
visits. More frequent audits may be conducted if warranted by accrual or due to concerns 
regarding data quality or timely submission.  For CTMS monitored studies, after users 
have activated their accounts, please contact the Theradex Help Desk at (609) 799-7580 
or by email at CTMSSupport@theradex.com for additional support with Rave and 
completion of CRFs. 
 
 

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12.2.2 Responsibility for Data Submission 
 
For ETCTN trials, it is the responsibility of the PI(s) at the site to ensure that all 
investigators at the ETCTN Sites understand the procedures for data submission for each 
ETCTN protocol and that protocol specified data are submitted accurately and in a timely 
manner to the CTMS via the electronic data capture system, Medidata Rave.   
 
Data are to be submitted via Medidata Rave to CTMS on a real-time basis, but no less 
than once every 2 weeks.  The timeliness of data submissions and timeliness in resolving 
data queries will be tracked by CTMS.  Metrics for timeliness will be followed and 
assessed on a quarterly basis.  For the purpose of Institutional Performance Monitoring, 
data will be considered delinquent if it is greater than 4 weeks past due. 
 
Data from Medidata Rave and CTEP-AERS is reviewed by the CTMS on an ongoing 
basis as data is received.  Queries will be issued by CTMS directly within Rave.  The 
queries will appear on the Task Summary Tab within Rave for the CRA at the ETCTN to 
resolve.  Monthly web-based reports are posted for review by the Drug Monitors in the 
IDB, CTEP.  Onsite audits will be conducted by the CTMS to ensure compliance with 
regulatory requirements, GCP, and NCI policies and procedures with the overarching 
goal of ensuring the integrity of data generated from NCI-sponsored clinical trials, as 
described in the ETCTN Program Guidelines, which may be found on the CTEP 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm
)  and CTSU websites. 
 
An End of Study CRF is to be completed by the PI, and is to include a summary of study 
endpoints not otherwise captured in the database, such as (for phase 1 trials) the 
recommended phase 2 dose (RP2D), and a description of any dose-limiting toxicities 
(DLTs).  CTMS will utilize a core set of eCRFs that are Cancer Data Standards Registry 
and Repository (caDSR) compliant (http://cbiit.nci.nih.gov/ncip/biomedical-informatics-
resources/interoperability-and-semantics/metadata-and-models).  Customized eCRFs will 
be included when appropriate to meet unique study requirements.  The PI is encouraged 
to review the eCRFs, working closely with CTMS to ensure prospectively that all 
required items are appropriately captured in the eCRFs prior to study activation.  CTMS 
will prepare the eCRFs with built-in edit checks to the extent possible to promote data 
integrity. 
 
CDUS data submissions for ETCTN trials activated after March 1, 2014, will be carried 
out by the CTMS contractor, Theradex.  CDUS submissions are performed by Theradex 
on a monthly basis.  The trial’s lead institution is responsible for timely submission to 
CTMS via Rave, as above. 
 
Further information on data submission procedures can be found in the ETCTN Program 
Guidelines 
(http://ctep.cancer.gov/protocolDevelopment/electronic_applications/adverse_events.htm
). 
 

NCI Protocol #: 10089                                                     87 
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12.3 
CTEP Multicenter Guidelines 
Not Applicable. 
 
 
12.4 
Collaborative Agreements Language 
 
The agent(s) supplied by CTEP, DCTD, NCI used in this protocol is/are provided to the 
NCI under a Collaborative Agreement (CRADA, CTA, CSA) between the 
Pharmaceutical Company(ies) (hereinafter referred to as “Collaborator(s)”) and the NCI 
Division of Cancer Treatment and Diagnosis.  Therefore, the following 
obligations/guidelines, in addition to the provisions in the “Intellectual Property Option to 
Collaborator”  
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm) contained 
within the terms of award, apply to the use of the Agent(s) in this study: 
 
1. Agent(s) may not be used for any purpose outside the scope of this protocol, nor 
can Agent(s) be transferred or licensed to any party not participating in the 
clinical study.  Collaborator(s) data for Agent(s) are confidential and proprietary 
to Collaborator(s) and shall be maintained as such by the investigators.  The 
protocol documents for studies utilizing Agents contain confidential information 
and should not be shared or distributed without the permission of the NCI.  If a 
copy of this protocol is requested by a patient or patient’s family member 
participating on the study, the individual should sign a confidentiality agreement.  
A suitable model agreement can be downloaded from: http://ctep.cancer.gov. 
 
2. For a clinical protocol where there is an investigational Agent used in 
combination with (an)other Agent(s), each the subject of different Collaborative 
Agreements, the access to and use of data by each Collaborator shall be as follows 
(data pertaining to such combination use shall hereinafter be referred to as "Multi-
Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the 
existence and nature of any agreements governing their collaboration with 
NCI, the design of the proposed combination protocol, and the existence 
of any obligations that would tend to restrict NCI's participation in the 
proposed combination protocol. 
 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from 
the clinical trial by any other Collaborator solely to the extent necessary to 
allow said other Collaborator to develop, obtain regulatory approval or 
commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these 

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trials must agree in writing prior to the commencement of the trials that it 
will use the Multi-Party Data solely for development, regulatory approval, 
and commercialization of its own Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative 
Agreement will be made available to Collaborator(s), the NCI, and the FDA, as 
appropriate and unless additional disclosure is required by law or court order as 
described in the IP Option to Collaborator 
(http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used 
and disclosed consistent with all applicable federal statutes and regulations for the 
protection of human subjects, including, if applicable, the Standards for Privacy 
of Individually Identifiable Health Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be 
sent to the NCI, who will then notify the appropriate investigators (Group Chair 
for Cooperative Group studies, or PI for other studies) of Collaborator's wish to 
contact them. 
 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance 
with the guidelines and policies of the responsible Data Monitoring Committee 
(DMC), if there is a DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to 
CTEP by the Group office for Cooperative Group studies or by the principal 
investigator for non-Cooperative Group studies for immediate delivery to 
Collaborator(s) for advisory review and comment prior to submission for 
publication.  Collaborator(s) will have 30 days from the date of receipt for review.  
Collaborator shall have the right to request that publication be delayed for up to 
an additional 30 days in order to ensure that Collaborator’s confidential and 
proprietary data, in addition to Collaborator(s)’s intellectual property rights, are 
protected.  Copies of abstracts must be provided to CTEP for forwarding to 
Collaborator(s) for courtesy review as soon as possible and preferably at least 
three (3) days prior to submission, but in any case, prior to presentation at the 
meeting or publication in the proceedings.  Press releases and other media 
presentations must also be forwarded to CTEP prior to release.  Copies of any 
manuscript, abstract and/or press release/ media presentation should be sent to: 
 
Email: ncicteppubs@mail.nih.gov 
 
The Regulatory Affairs Branch will then distribute them to Collaborator(s).  No 
publication, manuscript or other form of public disclosure shall contain any of 
Collaborator’s confidential/ proprietary information. 
 
 

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13. 
STATISTICAL CONSIDERATIONS 
 
13.1 
Study Design/Endpoints 
 
13.1.1 
Overview  
This is a phase 2 study designed to evaluate the safety and efficacy of the addition of 
nivolumab to CDX-1127 (varlilumab) for patients with advanced high-grade B-cell 
NHL.  The study will utilize a randomized phase 2 study design to determine the anti-
tumor activity of combination therapy with CDX-1127 (varlilumab) and nivolumab 
(Group 2; experimental group) as compared to nivolumab alone (Group 1; control 
group), where response will be evaluated based on the LYRIC response criteria. 
 
13.1.2 
Primary Endpoint 
The primary endpoint of this trial is the overall response rate, which will be compared 
between the two groups.  A response will be defined as an objective status of PR or 
CR for patients evaluated by CT-based criteria and CMR or PMR for patients 
evaluated by PET-CT based criteria.  All patients meeting the eligibility criteria who 
have signed a consent form and have begun treatment will be evaluable for overall 
response. 
 
13.1.3 
Statistical Design 
Decision Rule: A randomized trial comparing combination therapy with CDX-1127 
(varlilumab) and nivolumab as compared to nivolumab alone will be conducted as 
described by Rubinstein.  We will enter 48 evaluable patients on each group of the 
study using a 1:1 randomization scheme  where patients are stratified based on age (< 
65 vs. ≥ 65 years), previous autologous stem cell transplant (yes vs. no), and 
diagnosis category per Section 3.1.1 (A vs. B).  Randomization will be done using a 
(stratified) permuted block design with randomly varying block sizes.  A sample size 
of 48 patients per group provides 80% power to detect an improvement in response 
rate from 25% to 45%, using a one-sided test at a significance level of 0.15 (nQuery 
7.0).   
 
This estimated response rate is based on the clinical efficacy demonstrated by 
Nivolumab in the phase II trial (Lesokhin et al, JCO 2016). In that study 11 patients 
with DLBCL were treated with Nivolumab, of which 4 (36%) achieved an objective 
response. Nonetheless, at the time of publication only 1 of those maintained a 
response while 2 were still being followed (3 of 11 or 27%).  Unpublished data from 
a larger phase 2 trial appears to have a low response rate for nivolumab alone with an 
overall response rate that appears to be < 20%. We therefore selected 25% as our best 
estimate of response for nivolumab alone. 
 
Interim Analysis Decision Rule: An interim analysis with a futility rule will be 
performed after half of the patients (24 patients in each group) have completed their 
first radiologic scan after 3 cycles (12 weeks of treatment or up to 20 weeks if 
treatment delays occurred).  At the time of the interim analysis, we will compare the 
response rate of Group 2 the experimental group to Group 1 the control group.   If the 

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response rate in Group 2 the experimental group is less than the response rate in 
Group 1 the control group, we will consider this early evidence that the Group 2 the 
experimental group does not have a higher overall response rate and accrual will be 
terminated.  Otherwise, we will continue accrual (Wieand et al., 1994) 
 
Final Decision Rule: The final analysis will take place after all 48 evaluable patients 
in each group have been followed for at least 6 months.  The response rates will be 
compared between the two groups using Fisher’s exact test.  If the response rate is 
higher in Group 2 the experimental group, where the p-value < 0.15, this will be 
considered sufficient evidence that Group 2 the experimental group may be 
recommended for further testing in subsequent studies.  Otherwise, we will conclude 
that there is not statistical evidence of superiority of the experimental regimen. 
 
Over Accrual: If more than the target number of patients are accrued, the additional 
patients will not be used to evaluate the stopping rule or used in any decision making 
process however, they will be included in final point estimates and confidence 
intervals.   
 
NOTE:  The trial will not be halted while the first 24 patients in each group are 
evaluated for the interim analysis.  However, if the accrual is especially rapid, we 
may temporarily suspend accrual to prevent missing important acute toxicity patterns. 
 
Other Considerations: Toxicity, quality/duration of response, and patterns of 
treatment failure observed in this study, as well as scientific discoveries or changes in 
standard care will be taken into account in any decision to terminate the study. 
 
13.1.4 
Analysis Plan 
The analysis for this trial will commence at planned time points and at the time the 
patients have become evaluable for the primary endpoint.  Such a decision will be 
made by the Statistician and Study Chair, in accord with ETCTN Standard Operating 
Procedures, availability of data for secondary endpoints (eg, laboratory correlates), 
and the level of data maturity.  It is anticipated that the earliest date in which the 
results will be made available via manuscript, abstract, or presentation format is when 
the last patient has been followed for at least 6 months. 
 
13.1.5 
Primary Endpoint 
Definition: The primary endpoint of this trial is the overall response rate, which will 
be compared between the two arms. A response will be defined as an objective status 
of PR or CR for patients evaluated by CT-based criteria and CMR or PMR for 
patients evaluated by PET-CT based criteria.  All patients meeting the eligibility 
criteria who have signed a consent form and have begun treatment will be evaluable 
for overall response. 
 
Estimation:  The proportion of successes will be estimated in each arm by the number 
of successes divided by the total number of evaluable patients. Exact binomial ninety-
five percent confidence intervals for the true success proportion will be calculated in 

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each arm.  Comparison of overall response rates between the two treatment groups 
will be performed using a one-sided Fisher’s exact test at significance level 0.15.   
 
13.2 
Sample Size/Accrual Rate 
 
13.2.1 
Sample Size 
A maximum of 96 evaluable patients (48 in each group) will be accrued unless undue 
toxicity is encountered.  We anticipate accruing an additional 10 patients to account 
for ineligibility, cancellation, major treatment violation, or other reasons.  Maximum 
projected accrual is 106 patients. 
 
13.2.2 
Accrual Rate and Study Duration 
The anticipated accrual rate is approximately 5-6 patients per month.  Therefore, the 
accrual period for this phase 2 study is expected to be about 20 months.  The final 
analysis can begin approximately 26 months after the trial begins, i.e. as soon as the 
final patient accrued to this trial has been followed for at least 6 months.  
 
13.2.3 
Inclusion of Women and Minorities 
This study will be available to all eligible patients, regardless of race, gender or ethnic 
origin. 
 
There is no information currently available regarding differential effects of this 
regimen in subsets defined by race or gender, and there is no reason to expect such 
differences to exist.  Therefore, although the planned analysis will, as always, look 
for differences in treatment effect based on racial and gender groupings, the sample 
size is not increased in order to provide additional power for subset analyses. 
 
Based on prior studies involving similar disease sites, we expect about 30-35% of 
patients will be classified as minorities by race and about 40% of patients will be 
women.  Expected sizes of racial by gender subsets are shown in the following table: 
 
 
PLANNED ENROLLMENT REPORT 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
 
Female 
Male 
Female 
Male 
 
American Indian/ 
Alaska Native 
0 
1 
0 
0 
1 
Asian 
2 
3 
0 
0 
5 
Native Hawaiian or 
Other Pacific Islander 
0 
1 
0 
0 
1 

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Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
 
Female 
Male 
Female 
Male 
 
Black or African 
American 
5 
8 
0 
0 
13 
White 
30 
44 
4 
5 
83 
More Than One Race 
1 
1 
0 
1 
3 
Total 
38 
58 
4 
6 
106 
 
 
13.3 
Stratification Factors 
 
13.3.1 
Age group: < 65 years or ≥ 65 years 
 
13.3.2 
Previous autologous stem cell transplant: yes vs. no 
 
13.3.3 
Diagnosis category (per section 3.1.1): Category A vs. Category B 
 
 
13.4 
Analysis of Secondary Endpoints 
 
13.4.1 
Duration of Response 
Duration of response is defined for all evaluable patients who have achieved a 
response as the date at which the patient’s objective status is first noted to be a PR or 
CR for patients evaluated by CT-based criteria or CMR or PMR for patients 
evaluated by PET-CT based criteria to the earliest date progression (PMD or PD) is 
documented.  If a patient has not had disease progression, they will be censored on 
the date of their last disease assessment.  The distribution of duration of response will 
be estimated using the method of Kaplan-Meier.  The comparison of duration of 
response between two treatment arms will be based on the log-rank test. 
 
13.4.2 
Survival Time 
Survival time is defined as the time from randomization to death due to any cause. 
The distribution of survival time will be estimated using the method of Kaplan-Meier. 
The comparison of overall survival between two treatment arms will be based on the 
log-rank test. 
 
13.4.3 
Progression Free Survival 
Progression free survival is defined as the time from randomization to the earliest 

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date of documentation of disease progression (PMD or PD) or death due to any cause.  
The distribution of progression-free survival will be estimated using the method of 
Kaplan-Meier.  The comparison of progression-free survival between two treatment 
arms will be based on the log-rank test. 
 
 
Adverse Events 
All patients that have initiated treatment will be considered evaluable for assessing 
adverse event rate(s).  The maximum grade for each type of adverse event will be 
recorded for each patient, and frequency tables will be reviewed for each arm to 
determine patterns.  Additionally, the relationship of the adverse event(s) to the study 
treatment will be taken into consideration.  The overall adverse event rates for Grade 
3 or higher hematologic and non-hematologic adverse events at least possibly related 
to treatment will be compared between the two treatment groups using the Chi-square 
test (or Fisher’s exact test if the data in the contingency table is sparse). 
 
13.5 
Analysis of Exploratory Endpoints 
To determine the effect of combination therapy with CDX-1127 (varlilumab) and 
nivolumab on the immune system as assessed by immunohistochemistry (IHC), mass 
cytometry (CyTOF) and changes in serum cytokine profile, multiple measures will be 
evaluated.   For each measure below, baseline values and changes in these parameters 
over time will be both graphically and quantitatively summarized and explored.  Standard 
paired comparisons methodologies (Wilcoxon signed rank and McNemar’s tests) will be 
used to assess changes in these variables before and after therapy.  In addition, baseline 
values and changes over time in each measure will be explored in relation to clinical 
outcome.  Differences between responders and non-responders will be assessed using 
Wilcoxon’s rank sum (continuous data) or Fisher’s exact (categorical data) test.   The 
relationship between each measure and time to event measures (PFS, OS) will be 
evaluated using Cox’s proportional hazards models and log-rank tests. 
 
• CD27 IHC: CD27 expression will be evaluated in terms of level (an ordinal 
variable such as low, medium, high), % of cells expressing, and location 
(expression in tumor cells vs. expression in normal immune cells).  The 
expression level can be gathered continuously and may also be evaluated as a 
categorical variable (low, medium, high expression for example).  These values 
will be evaluated as predictors of response.  This is the only integrated biomarker. 
The expression level of CD27 will be analyzed using the “marker-by-treatment 
predictiveness curves” in Janes et al. to explore CD27 as a potential predictive 
biomarker for the benefit of Varlilumab. Specifically, we will display the 
response rate as a function of the percentiles of CD27 for each treatment arm: 
Varlilumab plus Nivolumab and Nivolumab alone. We will use logistic regression 
to model the response rate as a function of treatment and CD27 (as a continuous 
variable). The distribution of CD27 will be estimated empirically in the entire trial 
population and used to calculate CD27 values corresponding to each fixed 
percentile. If the two predictiveness curves cross (suggesting predictive potential 
of CD27), the point where the two curves cross would be a possible choice of 
threshold for dichotomizing CD27 into “low” versus “high”. Threshold levels 

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shown to be best predictors of clinical outcomes will be considered as reference 
for later pivotal trials. 
 
• Analysis of Peripheral Blood Immune cells by Mass Cytometry (CyTOF): The 
patient’s peripheral blood will be evaluated serially (at baseline and every 14 days 
for the first 12 weeks on study).  The assay will detect and quantify the presence 
of specific subpopulations of immune cells (expressed as % of parent).  In this 
exploratory analysis the relationship between presence/absence of a particular 
subtype of cell and association with outcomes will be evaluated. Evaluation of 
particular combinations of immune cells (immune signature) and whether they are 
predictive of outcome will also be evaluated. 
 
• Identification/Characterization of Intratumoral Immune cells by IHC and CyTOF: 
Immune cell subpopulations in the neighborhood around the tumor will be 
evaluated with this assay.  This is similar to above (CyTOF on peripheral blood) 
but in this case the assessment is made on the tumor biopsy specimen.  The 
presence/absence of different subsets will be identified and quantified and the 
association with clinical outcomes will be evaluated as specified above.  This is 
another exploratory biomarker. 
 
• Evaluation of Genetic Alterations of Chromosome 9p24.1 by FISH: This 
chromosomal region will be evaluated and patients will be categorized in 4 
groups: normal, amplified, relative copy gain or polysomy.  The proportion of 
patients in each of these groups who achieve a response will be evaluated. This is 
another exploratory biomarker. 
 
• Evaluation of Serum Cytokine Profile by ELISA: Serially collected peripheral 
blood (at baseline and every 14 days for the first 12 weeks on study) will be 
analyzed. The levels (continuous variable) of 30 different cytokines will be 
assessed at each of those time points. The elevation or decrease in any individual 
cytokine or a combination of them will be explored, as well as the association 
with outcomes. This is another exploratory biomarker. 
 
• Evaluation of Mutation Burden by WES: Tumor tissue will undergo whole-exome 
sequencing to determine if the amount of mutations (continuous) is associated 
with outcome. This is another exploratory biomarker. 
 
13.6 
Reporting and Exclusions 
 
13.6.1  Evaluable for Toxicity 
All patients will be evaluable for toxicity from the time they start treatment. 
 
13.6.2 Evaluation of Response 
Ineligible patients who have signed a consent form, enrolled, and initiated treatment, will 
be considered evaluable for adverse events.   

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13.6.2.1 
Ineligible 
A patient is deemed ineligible if after registration, it is determined that at the time of 
registration, the patient did not satisfy each and every eligibility criteria for study 
entry.  The patient may continue treatment at the discretion of the physician as long as 
there are no safety concerns and the patient was properly registered.  Sites should 
send a dated report and all relevant source documents to Mayo Clinic to the attention 
of the QAS at the address in Section 4.3.1. 
 
Protocol stipulations, including follow-up, safety reporting, dose modification, off 
treatment criteria should be followed as for other patients on protocol.  
 
13.6.2.2 
Major Violation 
A patient is deemed a major violation, if protocol requirements regarding treatment 
are severely violated that evaluability for primary end point is questionable.  All data 
up until the point of confirmation of a major violation must be submitted.  The patient 
may continue treatment at the discretion of the physician as long as there are no 
safety concerns and the patient was properly registered.  Sites should send a dated 
report and all relevant source documents to Mayo Clinic to the attention of the QAS 
at the address in Section 4.3.1. 
 
Protocol stipulations, including follow-up, safety reporting, dose modification, off 
treatment criteria should be followed as for other patients on protocol.  
 
13.6.2.3 
Cancel 
 
A patient is deemed a cancel if he/she is removed from the study for any reason 
before any study treatment is given.  Sites should send a dated report and all relevant 
source documents to Mayo Clinic to the attention of the QAS at the address in  
Section 4.3.1. 
 
Data is to be submitted for all patients who cancel, including query resolution, for all 
data required to be submitted through the date the patient cancelled.  No further 
follow-up is required. 
 
 
13.7 
Adverse Event Stopping Rule 
The stopping rule applies to each group independently. 
 
The stopping rule specified below is based on the knowledge available at study 
development.  We note that the rule may be adjusted in the event of either (1) the study 
re-opening to accrual or (2) at any time during the conduct of the trial and in 
consideration of newly acquired information regarding the adverse event profile of the 
treatments under investigation.  The study team may choose to suspend accrual because 
of unexpected adverse event profiles that have not crossed the specified rule below. 
 

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Accrual will be temporarily suspended to both groups if at any time we observe events 
considered relevant to the study treatment (defined as any adverse events except those 
receiving the “unrelated” attribution) that satisfy one of the following in either of the 
groups (evaluated in each group separately): 
 
• if 4 or more patients in the first 20 treated patients in the  group experience a 
grade 4 or higher non-hematologic adverse event relevant to treatment. 
 
• if after the first 20 patients have been treated, 20% of all patients in the group 
experience a grade 4 or higher non-hematologic adverse event relevant to 
treatment. 
 
We note that we will review grade 4 and 5 adverse events deemed “unrelated”  to verify 
their attribution and to monitor the emergence of a previously unrecognized treatment-
related adverse event. 
 
 
 
 
 
 
 
 
 

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Ansell, S. M. et al. (2014). PD-1 Blockade with Nivolumab in Relapsed or Refractory Hodgkin’s 
Lymphoma. N Engl J Med 372, 311–319. 
 
Ansell, S. M. et al. (2014). Phase I evaluation of an agonist anti-CD27 human antibody (CDX-
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Bendall SC, Nolan GP, Roederer M, Chattopadhyay PK. (2014). A deep profiler’s guide to 
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Brahmer, J.R., L. Horn, S.J. Antonia, et al.  (2013).  Survival and long-term follow-up of the 
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Campesato, L. F. et al. (2015). Comprehensive cancer-gene panels can be used to estimate 
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Chen, B. J. et al. (2013). PD-L1 expression is characteristic of a subset of aggressive B-cell 
lymphomas and virus-associated malignancies. Clin. Cancer Res. 19, 3462–3473. 
 
Cheson, B. D. et al. (2014). Recommendations for initial evaluation, staging, and response 
assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J. Clin. Oncol. 
32, 3059–68.  Available from: http://www.ncbi.nlm.nih.gov/pubmed/25113753 
 
Cheson, B.D. et al. (2016). Refinement of the Lugano Classification lymphoma response criteria 
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Curran, M.A., W.Montalvo, H. Yagita, et al.  (2010).  PD-1 and CTLA-4 combination blockade 
expands infiltrating T cells and reduces regulatory T and myeloid cells within B16 melanoma 
tumors.  Proc Natl Acad Sci U S A.  107: 4275-80. 
 
Dong, H. et al. (2002). Tumor-associated B7-H1 promotes T-cell apoptosis: a potential 
mechanism of immune evasion. Nat. Med. 8, 793–800 (2002). 
 
Dong, H. Y., Shahsafaei, A. & Dorfman, D. M. (2002). CD148 and CD27 are expressed in B cell 
lymphomas derived from both memory and naïve B cells. Leuk. Lymphoma 43, 1855–8. 
 
Dong, H., and L. Chen.  (2003).  B7-H1 pathway and its role in the evasion of tumor immunity.  

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J Mol Med (Berl).  81:281-287. 
 
Drake, C.G., D.F. McDermott, M. Sznol, et al.  (2013).  Survival, safety, and response duration 
results of nivolumab (Anti-PD-1; BMS-936558; ONO-4538) in a phase I trial in patients with 
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Oncol.  31:A4514. 
 
Elsawa, S. F. et al. (2011). Comprehensive analysis of tumor microenvironment cytokines in 
Waldenstrom macroglobulinemia identifies CCL5 as a novel modulator of IL-6 activity. Blood 
118, 5540–9. 
 
Francisco, L. M., Sage, P. T. & Sharpe, A. H.  (2010). The PD-1 pathway in tolerance and 
autoimmunity. Immunological Reviews 236, 219–242. 
 
Green, M. R. et al. (2010).  Integrative analysis reveals selective 9p24.1 amplification, increased 
PD-1 ligand expression, and further induction via JAK2 in nodular sclerosing Hodgkin 
lymphoma and primary mediastinal large B-cell lymphoma. Blood 116, 3268–77. 
 
Hammers, H.J., E.R. Plimack, J.R. Infante, et al.  (2014).  Phase I study of nivolumab in 
combination with ipilimumab in metastatic renal cell carcinoma (mRCC).  J Clin Oncol.  
32:A4504. 
 
He, L.-Z. et al. (2013). Agonist anti-human CD27 monoclonal antibody induces T cell activation 
and tumor immunity in human CD27-transgenic mice. J. Immunol. 191, 4174–83. 
 
Hilchey, S. P., De, A., Rimsza, L. M., Bankert, R. B. & Bernstein, S. H. (2007). Follicular 
lymphoma intratumoral CD4+CD25+GITR+ regulatory T cells potently suppress CD3/CD28-
costimulated autologous and allogeneic CD8+CD25- and CD4+CD25- T cells. J. Immunol. 178, 
4051–4061. 
 
Investigator Brochure.  (2014).  Nivolumab, BMS-936558, MDX1106.  Version 13, 21 July 
2014. Bristol-Myers Squibb.  Lawrenceville, NJ.   
 
Ipilimumab Investigator Brochure.  (2014).  BMS-734016, MDX010.  Version 17, 10 March 
2014. Bristol-Myers Squibb.  Wallingford, CT.   
 
Janes, H., Pepe, M.S., Bossuyt, P.M. and Barlowe, W.E.  (2011). Measuring the performance of 
markers for guiding treatment decisions.  Annals Internal Medicine.  154(4);253-9.  doi: 
10.7326/0003-4819-154-4-201102150-00006. 
 
Jung, S.-H. (2008). Randomized phase II trials with a prospective control. Stat. Med. 27, 568–83. 
 
Kaplan E. and P. Meier. (1958).   Nonparametric estimation from incomplete observations. J Am 
Stat Assoc. 53:457-481. 
 
Keir, M. E., Butte, M. J., Freeman, G. J. & Sharpe, A. H. (2008). PD-1 and its ligands in 

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tolerance and immunity. Annu. Rev. Immunol. 26, 677–704. 
 
Lesokhin, A. M. et al. (2016). Nivolumab in Patients With Relapsed or Refractory Hematologic 
Malignancy: Preliminary Results of a Phase Ib Study. J. Clin. Oncol. 20. 
 
Nomi, T., M. Sho, T. Akahori, et al.  (2007).  Clinical significance and therapeutic potential of 
the programmed death-1 ligand/programmed death-1 pathway in human pancreatic cancer.  Clin 
Cancer Res.  13:2151-2157. 
 
Ohigashi, Y., M. Sho, Y. Yamada, et al.  (2005).  Clinical significance of programmed death-1 
ligand-1 and programmed death-1 ligand-2 expression in human esophageal cancer.  Clin Cancer 
Res.  11:2947-2953. 
 
Opdivo Package Insert. (2014). Bristol-Myers Squibb.  Lawrenceville, NJ.   
 
Pocock, S. and J. Simon. (1975). Sequential treatment assignment with balancing for prognostic 
factors in the controlled clinical trial. Biometrics 31:103-115. 
 
Rizvi, N.A., S.J. Antonia, L.Q.M. Chow, et al.  (2013).  A phase I study of nivolumab (anti-PD-
1; BMS-936558, ONO-4538) plus platinum-based doublet chemotherapy (PT-doublet) in 
chemotherapy-naive non-small cell lung cancer (NSCLC) patients (pts).  J Clin Oncol.  
31:A8072. 
 
Rizvi, N. A. et al. (2015). Cancer immunology. Mutational landscape determines sensitivity to 
PD blockade in non-small cell lung cancer. Science 348, 124–8. 
 
Rubenstein, L.V. et al. (2005).  Design issues of randomized phase II trials and a proposal for 
phase II screening trials. Journal of clinical oncology: official journal of the American Society of 
Clinical Oncology. 2005; 23(28):7199-7206. Prepublished on 2005/09/30 as DOI 
10.1200/JCO.2005.01.149. 
 
Sanborn, R. et al. (2016) Phase I results from the combination of an immune-activating anti-
CD27 antibody (varlilumab) in combination with PD-1 blockade (nivolumab): activation across 
multiple immune pathways without untoward immune-related adverse events. in Proceedings of 
the 107th Annual Meeting of the American Association for Cancer Research Abstract #CT023 
(AACR, 2016). 
 
Sznol, M., H.M. Kluger, F.S. Hodi, et al.  (2013).  Survival and long-term follow-up of safety 
and response in patients (pts) with advanced melanoma (MEL) in a phase I trial of nivolumab 
(anti-PD-1; BMS-936558; ONO-4538).  J Clin Oncol.  31:ACRA9006. 
 
Taube, J.M., R.A. Anders, G.D. Young, et al.  (2012).  Colocalization of inflammatory response 
with B7-H1 expression in human melanocytic lesions supports an adaptive resistance mechanism 
of immune escape.  Sci Transl Med.  4:127ra137. 
 
Taube, J. M. et al. (2014). Association of PD-1, PD-1 ligands, and other features of the tumor 

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immune microenvironment with response to anti-PD-1 therapy. Clin. Cancer Res. 20, 5064–
5075. 
 
Thomas, L. J., He, L.-Z., Marsh, H. & Keler, T. (2014). Targeting human CD27 with an agonist 
antibody stimulates T-cell activation and antitumor immunity. Oncoimmunology 3, e27255. 
 
Thompson, R.H., M.D. Gillett, J.C. Cheville, et al.  (2004).  Costimulatory B7-H1 in renal cell 
carcinoma patients: Indicator of tumor aggressiveness and potential therapeutic target.  Proc Natl 
Acad Sci U S A.  101:17174-17179. 
 
Thompson, R.H., M.D. Gillett, J.C. Cheville, et al.  (2005).  Costimulatory molecule B7-H1 in 
primary and metastatic clear cell renal cell carcinoma.  Cancer.  104:2084-2091. 
 
Thompson, R.H., S.M. Kuntz, B.C. Leibovich, et al.  (2006).  Tumor B7-H1 is associated with 
poor prognosis in renal cell carcinoma patients with long-term follow-up.  Cancer Res.  66:3381-
3385. 
 
Topalian, S.L., F.S. Hodi, J.R. Brahmer, et al.  (2012).  Safety, activity, and immune correlates 
of anti-PD-1 antibody in cancer.  N Engl J Med.  366:2443-2454. 
 
van de Ven, K. and Borst, J. (2015). Targeting the T-cell co-stimulatory CD27/CD70 pathway in 
cancer immunotherapy: rationale and potential. Immunotherapy 7, 655–67. 
 
Vitale, L. A. et al. (2012). Development of a human monoclonal antibody for potential therapy 
of CD27-expressing lymphoma and leukemia. Clin. Cancer Res. 18, 3812–21. 
 
Villasboas Bisneto, J. and Ansell, S. M. (2015). Multiparametric Analysis of Intra-Tumoral T-
Cells in Hodgkin’s Lymphoma Using Mass Cytometry (CyTOF). Blood 126, 1438. 
 
Wieand et al. (1994) Statistics in Medicine.  13:1453-1458. 
 
Wilcox, R. A. et al. (2009). B7-H1 (PD-L1, CD274) suppresses host immunity in T-cell 
lymphoproliferative disorders. Blood 114, 2149–2158. 
 
Wilcox, R. A. et al. (2009). Monocytes promote tumor cell survival in T-cell lymphoproliferative 
disorders and are impaired in their ability to differentiate into mature dendritic cells. Blood 114, 
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Wolchok, J.D., H. Kluger, M.K. Callahan, et al.  (2013).  Nivolumab plus ipilimumab in 
advanced melanoma.  N Engl J Med.  369:122-133. 
 
Woo, S.R., M.E. Turnis, M.V. Goldberg, et al.  (2012).  Immune inhibitory molecules LAG-3 
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Res.  72:917-927. 
 
Wu, C., Y. Zhu, J. Jiang, et al.  (2006).  Immunohistochemical localization of programmed 

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death-1 ligand-1 (PD-L1) in gastric carcinoma and its clinical significance.  Acta Histochem.  
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immunoselection and immunosubversion.  Nat Rev Immunol.  6:715-727. 
 
 
 
 

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

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APPENDIX B: PATIENT WALLET CARD 
 
Information for Patients, Their Caregivers and Non-Study Healthcare Team  
 
The patient ____________________________ is enrolled on a clinical trial using the 
experimental study drugs, CDX-1127 (varlilumab) and nivolumab.  This clinical trial is 
sponsored by the National Cancer Institute.  This form is addressed to the patient, but includes 
important information for others who care for this patient.  
 
To the patient: Take this paper with you to your medical appointments and keep the 
attached information card in your wallet.   
 
It is very important to tell your study doctors of any medicines you are taking before you enroll 
onto this clinical trial.  It is also very important to tell your doctors if you stop taking any regular 
medicines, or if you start taking a new medicine while you take part in this study.  When you talk 
about your current medications with your doctors, include medicine you buy without a 
prescription (over-the-counter remedy), or any herbal supplements such as St. John’s Wort.  It is 
helpful to bring your medication bottles or an updated medication list with you. 
 
Many health care providers can write prescriptions.  You must tell all of your health care 
providers (doctors, physician assistants, nurse practitioners, pharmacists) you are taking part in a 
clinical trial.  
 
These are the things that you and they need to know:  
 
Before you enroll onto the clinical trial, your study doctor will work with your regular health 
care providers to review any medicines and herbal supplements   
 
• Please be very careful!  Over-the-counter drugs (including herbal supplements) may 
contain ingredients that could interact with your study drug.  Speak to your doctors or 
pharmacist to determine if there could be any side effects.  
• Your regular health care provider should check a frequently updated medical reference or 
call your study doctor before prescribing any new medicine or discontinuing any 
medicine.  Your study doctor’s name is  
_____________________________________ and he or she can be contacted at  
 
_____________________________________. 
 

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STUDY DRUG INFORMATION WALLET CARD 
You are enrolled on a clinical trial using the experimental study  
drugs CDX-1127 (varlilumab) and nivolumab.  This clinical trial is 
sponsored by the NCI.   
It is very important to: 
➢ Tell your doctors if you stop taking any medicines or if you start 
taking any new medicines. 
➢ Tell all of your health care providers (doctors, physician assistants, 
nurse practitioners, or pharmacists) that you are taking part in a 
clinical trial. 
➢ Check with your doctor or pharmacist whenever you need to use 
an over-the-counter medicine or herbal supplement. 
 
 
 
➢ Before you enroll onto the clinical trial, your study doctor will 
work with your regular health care providers to review any 
medicines  and herbal supplements . 
➢ Before prescribing new medicines, your regular health care 
providers should go to a frequently-updated medical reference for 
a list of drugs to avoid, or contact your study doctor.   
 
➢ Your study doctor’s name is _____________________________ 
and can be contacted at _________________________________.  

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APPENDIX C: BIOASSAY TEMPLATES 
 
The CD27 assay is commercially available from Mosaic Laboratories, LLC.  CD27 expression 
and localization on tumor biopsies will be assessed by immunohistochemistry using analytically 
validated assay performed according to the vendor protocols and SOPs.  This assay has been 
approved by the Biomarker Review Committee (BRC) of the Cancer Therapy Evaluation 
Program (CTEP) 
 

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APPENDIX D: MANAGEMENT ALGORITHMS FOR ENDOCRINOPATHY, 
GASTROINTESTINAL, HEPATIC, NEUROLOGICAL, PULMONARY, RENAL, AND 
SKIN ADVERSE EVENTS 
 
 

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APPENDIX E: SPECIMEN CHECKLIST AND SHIPPING INSTRUCTIONS 
 
** PLEASE AVOID DRAWING OR SENDING SPECIMENS ON FRIDAYS AND HOLIDAYS** 
 
Kit Contents: 
• Small Styrofoam box and cardboard mailing sleeve 
• Patient Information Form 
• FedEx Airbill with pre-printed return address 
• 6ml ACD (yellow top) collection tubes 
• 10ml Red Top collection tubes 
• Absorbent tube holder 
• Zip lock specimen bag 
 
To Order Kits: 
Participating sites may obtain kits by e-mailing Kim Henderson at Henderson.Kimberly@mayo.edu.  
E-mail requests should include the site address, contact information and number of kits being 
requested.  Kits will be sent via FedEx® Ground at no additional cost to the participating 
institutions. Allow 3 to 4 business days to receive the kits. 
 
Packing and Shipping Instructions: 
1. Collect Peripheral blood as below (NOTE: All kits will contain two 6ml ACD tubes and 
three 10ml Red top tubes. Each site will determine the appropriate tubes to  collect per time 
point): 
Group 1 (without crossover): 
➢ Baseline: 
• 12 ml in two (2) ACD tubes 
• 30 ml in three (3) Red Top tubes 
➢ C1D1, C2D1, C3D1: 
• 12 ml in two (2) ACD tubes 
• 20 ml in two (2) Red Top tubes 
➢ C1D15, C2D15, C3D15: 
• 12 ml in two (2) ACD tubes 
• 10 ml in one (1) Red Top tube 
➢ C4D1, EOT, Safety Follow-Up: 
• 10 ml in one (1) Red Top tube 
 
Group 1 (with crossover): 
➢ Baseline: same as Group 1 without crossover 
➢ C1D1, C2D1, C3D1: same as Group 1 without crossover 
➢ C1D15, C2D15, C3D15: same as Group 1 without crossover 
➢ C4D1: same as Group 1 without crossover 

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➢ Before first 4 doses of CDX-1127 (varlilumab): 
• 10 ml in one (1) Red Top tube 
➢ EOT, Safety Follow-Up: 
• 20 ml in two (2) Red Top tubes 
 
Group 2: 
➢ Baseline, C1D1, C2D1, C3D1: 
• 12 ml in two (2) ACD tubes 
• 30 ml in three (3) Red Top tubes 
➢ C1D15, C2D15, C3D15: 
• 12 ml in two (2) ACD tubes 
• 10 ml in one (1) Red Top tube 
➢ C4D1, EOT, Safety Follow-Up: 
▪ 20 ml in two (2) Red Top tubes 
 
2.  All specimens are to be clearly labeled with the protocol MC168D, the patient’s initials (last, 
first, middle), study patient ID number (if available) and date of collection. 
3. Place the tubes in the absorbent holder and seal in the zip lock specimen bag. 
4. Place the filled specimen bag in the Styrofoam container. 
5. Loosely pack with paper toweling. 
6. Place the Styrofoam container and Patient Information form within the cardboard mailing sleeve. 
7. Prepare the package for shipping, applying packing tape as needed. Adhere the Fed Ex Airbill to 
the exterior of the box.  Ship specimens via priority overnight delivery (next day delivery by 
10am) the same day collected. 
8. Notify Federal Express for pick-up and/or leave package at the designated FedEx drop-off 
location. 
 
Please e-mail Kim Henderson at Henderson.kimberly@mayo.edu to notify the laboratory when 
samples are being shipped.  Indicate the protocol number MC168D, the Fed Ex tracking number, 
name and phone number of the contact person. The samples should be shipped to the following: 
Mayo Clinic 
Attn: Kim Henderson 
221 4th Avenue SW 
613 Stabile 
Rochester, MN 55905 
 
 

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Patient Information Form 
 
Specimen Date:      /        /           
Patient Initials (last name, first 
name):                 
Mayo Clinic Number:  
Protocol #: MC168D                                                                                   
Contact Person:                                                                                                   
Institution:                                                                                                   
Address:  
 City                                           State                  Zip 
Phone #:                                                                                                   
Please indicate which peripheral blood samples are being shipped at this time: 
1. Baseline 
2. Cycle 1 Day 1 
3. Cycle 1 Day 15 
4. Cycle 2 Day 1 
5. Cycle 2 Day 15 
6. Cycle 3 Day 1 
7. Cycle 3 Day 15 
8. Cycle 4 Day 1 
9. End of Treatment 
10. Safety Follow-up  
11. Before first 4 doses of CDX-1127 (Group 1 crossover ONLY) 
For any questions concerning these samples or to obtain blood collection kits for the MC168D study, 
please contact: 
 
Kim Henderson 
Mayo Clinic 
(507)284-3805 
Henderson.kimberly@mayo.edu 
 
 

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APPENDIX F: PANEL FOR CYTOF ANALYSIS 
 
Target 
Clone 
Metal Tag 
1. 
CD45 
HI30 
89Y 
2. 
CD196 (CCR6) 
G034E3 
141Pr 
3. 
CD11a 
HI111 
142Nd 
4. 
CD5 
UCHT2 
143Nd 
5. 
CD195 (CCR5) 
NP-6G4 
144Nd 
6. 
CD4 
RPA-T4 
145Nd 
7. 
CD8a 
RPA-T8 
146Nd 
8. 
CD7 
CD7-6B7 
147Sm 
9. 
CD16 
3G8 
148Nd 
10. 
CD25 (IL-2R) 
2A3 
149Sm 
11. 
CD223 (LAG3) 
874501 
150Nd 
12. 
CD278, ICOS 
DX29 
151Eu 
13. 
TCRgd 
11F2 
152Sm 
14. 
CD45RA 
HI100 
153Eu 
15. 
TIM-3 
F38-2E2 
154Sm 
16. 
CD183 (CXCR3) 
G025H7 
156Gd 
17. 
CD194 (CCR4) 
205410 
158Gd 
18. 
CD197 (CCR7) 
G043H7 
159Tb 
19. 
CD28 
CD28.2 
160Gd 
20. 
CD274 (PD-L1) 
29E.2A3 
161DY 
21. 
CD69 
FN50 
162Dy 
22. 
CD56 (NCAM) 
NCAM16.2 
163Dy 
23. 
CD161 
HP-3G10 
164Dy 
24. 
CD45RO 
UCHL1 
165Ho 
25. 
CD44 
BJ18 
166Er 
26. 
CD27 
O323 
167Er 
27. 
CD30 
BerH8 
168Er 
28. 
CD19 
HIB19 
169Tm 
29. 
CD3 
UCHT1 
170Er 
30. 
CD185 (CXCR5) 
51505 
171Yb 
31. 
CD273 (PDL2) 
24F.10C12 
172Yb 
32. 
HLA-DR 
L243 
174Yb 
33. 
CD279 (PD-1) 
EH12.2H7 
175Lu 
34. 
CD127 (IL-7R) 
A019D5 
176Yb