A Phase 1 Study of Blinatumomab in Combination With Checkpoint Inhibitor(s) of PD-1 (Nivolumab) or Both PD-1 (Nivolumab) and CTLA-4 (Ipilimumab) in Patients With Poor-Risk, Relapsed or Refractory CD19+ Precursor B-Lymphoblastic Leukemia
Phase: PHASE1
Conditions: Recurrent B Acute Lymphoblastic Leukemia, Recurrent Mixed Phenotype Acute Leukemia, Refractory B Acute Lymphoblastic Leukemia, Refractory Mixed Phenotype Acute Leukemia
Sponsor: National Cancer Institute (NCI)

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
i 
 
DATE: 
January 3, 2023 
 
TO: 
CTEP Protocol and Information Office 
 
FROM: 
Ivana Gojo, MD 
 
SUBJECT: 
Amendment in response to Notice of FDA Partial Clinical Hold from Dr. Mooney, NCI, 
dated 12/12/2022 and general formatting throughout the document. 
 
 
I. 
SUMMARY OF CHANGES – Protocol 
 
# 
Section 
Comments 
1. 
Header,  
Title Page 
Updated version date.  
2. 
Title Page 
Added the ClinicalTrials.gov identifier. 
3. 
Title Page 
Updated LAO Protocol Contact’s address and phone number. 
4. 
4.2.2 
Updated who to contact for the SIV. 
5. 
5.3.1, 8.1.1 
Removed reference to 72- and 96-hour infusions as requested in the notice. 
6. 
Throughout 
General formatting and corrected typos throughout the document. 
 
II. 
SUMMARY OF CHANGES – Consent Form 
 
# 
Section 
Comments 
1. 
Header 
Updated version date. 
2. 
Throughout 
General formatting. 
3. 
How the study 
drugs are given 
in all groups 
Updated to specify the IV bag will be changed every 1-2 days instead of every 1-4 days. 
 
 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
1 
 
NCI Protocol #: 
10030 
Local Protocol #: 
ETCTN10030 
 
ClinicalTrials.gov Identifier:   NCT02879695 
 
TITLE:  A phase 1 study of blinatumomab in combination with checkpoint inhibitor(s) of PD-1 
(nivolumab) or both PD-1 (nivolumab) and CTLA-4 (ipilimumab) in patients with poor-risk, 
relapsed or refractory CD19+ precursor B-lymphoblastic leukemia 
 
 
Corresponding Organization: LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer 
Center LAO    
 
 
Principal Investigator: 
Ivana Gojo, M.D. 
 
Johns Hopkins University 
 
Sidney Kimmel Comprehensive Cancer Center 
 
1650 Orleans St, CRB-1 346 
 
Baltimore, MD 21287-0013 
 
410-502-8775 
 
410-614-1005 
 
Igojo1@jhmi.edu   
 
 
Participating Organizations: 
LAO-CT018 / Yale University Cancer Center LAO 
LAO-MD017 / JHU Sidney Kimmel Comprehensive Cancer Center LAO 
LAO-MA036 / Dana-Farber - Harvard Cancer Center LAO 
LAO-MN026 / Mayo Clinic Cancer Center LAO 
LAO-NC010 / Duke University - Duke Cancer Institute LAO 
LAO-OH007 / Ohio State University Comprehensive Cancer Center LAO 
LAO-PA015 / University of Pittsburgh Cancer Institute LAO 
 
 
Statistician: 
 
LAO Protocol Contact: 
Amanda Blackford, M.S. 
Judy Murray, CCRC 
550 N. Broadway, Rm 1111 
201 N. Broadway, Viragh 9120-46   Baltimore, 
MD 21205  
Baltimore, MD 21287 
410-614-0361 (phone) 
443-927-3568 (phone) 
410-955-0859 (fax) 
jmurra33@jhmi.edu (email) 
ablackf1@jhmi.edu (e-mail)                                  
 
 
 
 
 
 
 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
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NCI-Supplied Agent(s):   
Nivolumab (BMS-936558, MDX-1106, and ONO-4538) (NSC #748726) 
Ipilimumab (NSC #732442) 
Blinatumomab (AMG-103) (NSC #765986) 
IV Solution Stabilizer for Blinatumomab (AMG 103) (NSC #773150) 
 
 
IND Sponsor:  DCTD, NCI 
 
Protocol Type / Version # / Version Date: Original/ March 13, 2017 
 
 
 
 
Amendment/Version 5.0/September 5, 2017  
 
 
 
 
Amendment /Version 6.0/ January 26, 2018 
 
 
 
 
Amendment /Version 7.0/ May 1, 2018 
 
 
 
 
Amendment / Version 8.0/ May 25, 2018 
 
 
 
 
Amendment / Version 9.0/ July 27, 2018 
 
 
 
 
Amendment / Version 10.0/ December 21, 2018 
 
 
 
 
Amendment / Version 11.0/ January 8, 2019 
 
 
 
 
Amendment / Version 12.0/ April 2, 2019 
 
 
 
 
 
Amendment / Version 13.0/ May 9, 2019 
 
 
 
 
Amendment / Version 14.0/ July 11, 2019 
 
 
 
 
Amendment / Version 15.0/ December 3, 2019 
 
Amendment / Version 16.0 / March 11, 2020 
 
CIRB revision to v16.0 was dated April 23, 2020
 
Amendment / Version 17.0 / January 28, 2021 
 
Amendment / Version 18.0 / January 3, 2023 
 
 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
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SCHEMA 
 
Tumor Types:  Patients older than 21 years with histologically or cytologically confirmed 
CD19+ Precursor B-acute lymphoblastic leukemia (Pre-B cell ALL) OR CD19+ mixed phenotype 
acute leukemia (MPAL) with relapse following or refractory to at least one prior line of therapy, 
or adults ≥60 years old with a new diagnosis of Pre-B cell ALL CD19+ MPAL who are either not 
a candidate for or do not wish to receive traditional induction chemotherapy. Patients 16-21 
years-old will be eligible following a second relapse or if refractory to at least two prior lines of 
therapy. 
 
Performance Status:  ECOG 0-2 
 
Abnormal Organ Function Permitted: 
• Total bilirubin 
 
 
≤2.0 mg/dL (except patients with Gilbert 
Syndrome, who can have total bilirubin <3.0 mg/dL) 
• AST(SGOT)/ALT(SGPT) 
≤5× ULN 
• Serum creatinine 
 
 
≤1.5× ULN  
OR 
• 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 x 1.00  
72 x serum creatinine in mg/dL  
 
Prior Therapy: 
• > 90 days after stem cell infusion for allogeneic hematopoietic stem cell 
transplant (HSCT), have no evidence of acute graft-versus-host disease 
(GVHD) or active chronic (grade 2-4) GVHD, and are off all transplant-
related immunosuppression ≥ 2 weeks 
• Prior blinatumomab permitted if leukemia remains CD19+ and no 
unacceptable toxicity with prior blinatumomab treatment 
• If Ph+ ALL, then patient must have failed at least one 2nd or 3rd generation 
TKIs and been off treatment for > 1week 
• > 3 weeks off induction or reinduction chemotherapy 
• > 4 weeks off investigational drugs or immunotherapy (e.g. rituximab) 
 
Phase of Study:  1 
 
Treatment Plan:  Blinatumomab will be administered by continuous intravenous infusion for 28 
days. Nivolumab treatment will start on day 11 of blinatumomab infusion in cycle 1 and continue 
every 2 weeks. If the combination proves tolerable, then ipilimumab will be added in subsequent 
cohorts starting on day 11 of cycle 1 and continue every 6 weeks. Treatment will continue for 5 
cycles of blinatumomab and up to one year of nivolumab/ipilimumab. An expansion cohort of 6 
patients will be treated at MTD for blinatumomab, nivolumab and ipilimumab. Also, an 
expansion cohort of 6 patients will be treated at MTD for blinatumomab and nivolumab only. 

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Dose Escalation Schedule# 
Dose Level 
Dose 
Blinatumomab& 
Nivolumab 
Ipilimumab 
All Dose Levels 
Nivolumab and ipilimumab (where indicated) will be initiated on 
Day 11 
Level A-1* 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28  
80 mg IV every 2 
weeks  
None 
Level A1* 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28 
240 mg IV every 
2 weeks  
None 
Level B-1 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28 
80 mg IV every 2 
weeks 
1 mg/kg IV every 6 
weeks  
Level B1 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28 
240 mg IV every 
2 weeks  
1 mg/kg IV every 6 
weeks 
* Safety run-in of blinatumomab and nivolumab:  Up to 6 subjects will be treated at dose level 
A1 and dose level A-1 (if necessary) prior to addition/dose escalation with ipilimumab. 
# Dose expansion of blinatumomab, nivolumab, and ipilimumab:  An expansion cohort of 6 
subjects will be treated at the MTD.   
# Dose expansion of blinatumomab and nivolumab only: An expansion cohort of 6 subjects 
will be also treated at the MTD for blinatumomab and nivolumab only. 
& In Cycle 2 and subsequent cycles blinatumomab will be administered at 28 µg/day IV 
continuous infusion Days 1-28.  Blinatumomab cycles are administered every 42 days. 
 
 
 
 

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Regimen Description 
Agent 
Premedications
; Precautions 
Dose** 
Route 
Schedule** 
Cycle 
Length 
Blinatumomab& 
20 mg IV 
dexamethasone 
1 hour prior to 
initiation in each 
cycle and at step 
dose escalation 
in cycle 1 
9 µg/day 
on Days 1-
7 
28 µg/day 
on Days 8-
28 
Continuous IV 
infusion  
Days 1-28 
of each 
cycle up to 
5 cycles 
42 days  
(6 weeks) 
 
 
 
Nivolumab 
None 
80 or 240 
mg IV 
IV, 30-minute 
infusion 
Day 11, 
and then 
every 2 
weeks for 1 
year 
Ipilimumab 
None 
1 mg/kg 
IV, 90-minute 
infusion  
Day 11, 
and then 
every 6 
weeks for 1 
year 
**Doses and schedule as appropriate for assigned dose level. 
& In Cycle 2 and subsequent cycles blinatumomab will be administered at 28 µg/day IV 
continuous infusion Days 1-28.  Blinatumomab cycles are administered every 42 days. 
 

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 TABLE OF CONTENTS 
SCHEMA 
..................................................................................................................................3 
1. 
OBJECTIVES ......................................................................................................................9 
1.1 
Primary Objectives ...................................................................................................9 
1.2 
Secondary Objectives ...............................................................................................9 
1.3 
Exploratory Objectives ............................................................................................9 
2. 
BACKGROUND ...............................................................................................................11 
2.1 
Study Diseases .......................................................................................................11 
2.2 
CTEP IND Agents .................................................................................................12 
2.3 
Rationale ................................................................................................................21 
2.4 
Correlative Studies Background ............................................................................24 
2.5 
Summary ................................................................................................................29 
3. 
PATIENT SELECTION ....................................................................................................30 
3.1 
Pre-Registration Eligibility Criteria .......................................................................30 
3.2 
Registration Eligibility Criteria..............................................................................30 
3.3 
Exclusion Criteria ..................................................................................................32 
3.4 
Inclusion of Women and Minorities ......................................................................34 
4. 
REGISTRATION PROCEDURES ...................................................................................35 
4.1 
Investigator and Research Associate Registration with CTEP ..............................35 
4.2 
Site Registration .....................................................................................................36 
4.3 
Patient Registration ................................................................................................38 
4.4 
General Guidelines .................................................................................................39 
5. 
TREATMENT PLAN ........................................................................................................40 
5.1 
Agent Administration .............................................................................................40 
5.2 
Overall Study Design .............................................................................................40 
5.3 
Study Drugs ...........................................................................................................44 
5.4 
Definition of Dose-Limiting Toxicity ....................................................................46 
5.5 
General Concomitant Medication and Supportive Care Guidelines ......................48 
5.6 
Duration of Therapy ...............................................................................................54 
5.7 
Duration of Follow Up ...........................................................................................55 
5.8 
Criteria for Removal from Study ...........................................................................55 
5.9 
Criteria to Resume Treatment ................................................................................55 
5.10 
Treatment Beyond Progression ..............................................................................56 
6. 
DOSING DELAYS/DOSE MODIFICATIONS................................................................57 
6.1 
General ...................................................................................................................57 
6.2 
Blinatumomab ........................................................................................................57 
6.3 
Nivolumab and Ipilimumab ...................................................................................62 
6.4 
Special Considerations ...........................................................................................69 
7. 
ADVERSE EVENTS:  LIST AND REPORTING REQUIREMENTS ............................70 

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7.1 
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs) ...............70 
7.2 
Adverse Event Characteristics ...............................................................................84 
7.3 
Expedited Adverse Event Reporting ......................................................................84 
7.4 
Routine Adverse Event Reporting .........................................................................87 
7.5 
Secondary Malignancy ...........................................................................................88 
7.6 
Second Malignancy ................................................................................................88 
8. 
PHARMACEUTICAL INFORMATION ..........................................................................89 
8.1 
CTEP IND Agent(s) ...............................................................................................89 
8.2 
Blinatumomab Administration-Inpatient and Outpatient Procedures ....................97 
9. 
BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES ........................................99 
9.1 
Overview ................................................................................................................99 
9.2 
Methods................................................................................................................100 
10. 
STUDY CALENDAR .....................................................................................................104 
11. 
MEASUREMENT OF EFFECT......................................................................................110 
11.1 
Antitumor Effect – Hematologic Tumors ............................................................110 
12. 
STUDY OVERSIGHT AND DATA REPORTING / REGULATORY 
REQUIREMENTS ...........................................................................................................112 
12.1 
Study Oversight ...................................................................................................112 
12.2 
Data Reporting .....................................................................................................112 
12.3 
CTEP Multicenter Guidelines ..............................................................................114 
12.4 
Collaborative Agreements Language ...................................................................114 
13. 
STATISTICAL CONSIDERATIONS.............................................................................117 
13.1 
Overall..................................................................................................................117 
13.2 
Analysis Population .............................................................................................117 
13.3 
Study Design/Endpoints.......................................................................................117 
13.4 
Study Design ........................................................................................................118 
13.5 
Sample Size/Accrual Rate ....................................................................................122 
13.6 
Stratification Factors ............................................................................................123 
13.7 
Analysis of Secondary Endpoints ........................................................................123 
13.8 
Analysis of Exploratory Endpoints ......................................................................123 
REFERENCES ............................................................................................................................125 
APPENDIX A:  PERFORMANCE STATUS CRITERIA ..........................................................134 
APPENDIX B:  PATIENT DRUG INFORMATION HANDOUT AND WALLET CARD .....135 
APPENDIX C:  BIOASSAY TEMPLATES ...............................................................................137 
APPENDIX D:  MANAGEMENT ALGORITHMS FOR NivOLUMAB-/IPILIMUMAB- 
RELATED ADVERSE EVENTS: ENDOCRINOPATHY, GASTROINTESTINAL, 
HEPATIC, NEUROLOGICAL, PULMONARY, RENAL, AND SKIN ADVERSE 

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EVENTS ..........................................................................................................................143 
APPENDIX E: operating procedures for specimen collection ....................................................151 
APPENDIX F:  CORRELATIVE STUDIES COLLECTION WORKSHEET ..........................155 
APPENDIX G: WRITING TEST ................................................................................................156 
APPENDIX H:  Shipment of blinatumomab IV Bag from Site/Pharmacy to Patient’s Home ...157 
 
 
 

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1. OBJECTIVES 
 
1.1 
Primary Objectives 
 
1.1.1 To evaluate the safety and tolerability of the blinatumomab given in combination with 
nivolumab alone, or in combination with both nivolumab and ipilimumab in subjects with 
poor-risk, relapsed or refractory CD19+ Pre-B cell ALL or CD19+ mixed phenotype acute 
leukemia (MPAL). 
 
1.1.2 To determine the maximum tolerated dose (MTD) of the combination of blinatumomab 
plus nivolumab, and blinatumomab plus both nivolumab and ipilimumab and to further 
confirm the safety of the combination therapy in subjects with poor-risk, relapsed or 
refractory CD19+ Pre-B cell ALL or CD19+ mixed phenotype acute leukemia (MPAL). 
 
1.2 
Secondary Objectives 
 
1.2.1 To observe and record anti-leukemia activity of blinatumomab and nivolumab, and 
blinatumomab plus both nivolumab and ipilimumab, including the effects on minimal 
residual disease (MRD).  Although the clinical benefit of nivolumab and ipilimumab has 
not yet been established in ALL, the intent of offering this treatment is to provide a 
possible therapeutic benefit, and thus the patient will be carefully monitored for tumor 
response and symptom relief in addition to safety and tolerability. 
 
1.2.2 To assess preliminary anti-leukemia activity in expansion cohorts of patients with poor-
risk, relapsed or refractory CD19+ precursor B-lymphoblastic leukemia, or CD19+ mixed 
phenotype acute leukemia (MPAL). 
 
1.3 
Exploratory Objectives 
 
1.3.1 To examine changes in absolute lymphocyte count and distribution of T cell subsets 
(CD4+, CD8+, Tregs, Teffs) and their differentiation status, NK cells, and B cells before and 
post-blinatumomab, and immune checkpoint inhibitor(s) therapy in both peripheral blood 
and the bone marrow microenvironment.  
 
1.3.2 To explore changes in T cell co-signaling receptors expression in defined T cell 
subpopulations and their canonic transcription factor expression in both peripheral blood 
and bone marrow before and post-blinatumomab, and immune checkpoint inhibitor(s) 
therapy. 
 
1.3.3 To examine changes in expression of co-signaling molecules on leukemia blasts 
(CD10+/CD19+/CD34+) before and after treatment with blinatumomab and checkpoint 
inhibitors. 
 
1.3.4 To examine the serum levels of cytokines before and after treatment with blinatumomab 
and checkpoint inhibitors, including the levels of sCTLA-4. 
 

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1.3.5 To perform immune profiling of T cell repertoire and characterize T cell transcriptional 
signature before and after treatment. 
 
 
 

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2. BACKGROUND 
 
2.1 
Study Diseases 
 
2.1.1 Acute lymphoblastic leukemia (ALL) 
 
Acute lymphoblastic leukemia (ALL) is highly curable in children with 10-year overall survival 
(OS) as high as 85% in recent studies.1 However, cure rates in adult ALL in the United States are 
much poorer with a 5-year relative survival of 35.5%.2 The poor survival for adults is likely 
attributable to the high frequency of relapse and the poor prognosis of patients with relapsed 
disease. The large Medical Research Council (MRC) UKALL12/ECOG2993 trial that enrolled 
1,508 patients showed that 44% of adult ALL patients relapse after first complete remission 
(CR1) at a median of just 11 months.  Median OS for those who relapsed was 24 weeks, and 
only 22% of relapsed patients were alive at 1 year.3 A separate study including 357 adults with a 
first relapse of B-precursor ALL (Pre-B ALL) who were previously treated with chemotherapy 
alone showed a CR rate of 46% after salvage chemotherapy, but a median survival of just 5.8 
months for those who did not achieve CR2.  The duration of first remission was an important 
prognostic factor as those who maintained a longer CR1 (i.e. >18 months) had a higher 
probability to achieve a second remission.4 Thus, it is not surprising that the response rate for 
patients receiving a salvage regimen due to a second relapse or refractory disease is worse with 
only 18% of patients achieving a CR and a median survival of just 3 months. Overall, 1-year 
survival for patients who fail to respond to frontline therapy is only 15%.5,6 Thus there is a 
significant need for new therapies in adult ALL to treat both relapsed and refractory patients.              
 
In addition to the poor prognosis of patients with relapsed or refractory ALL, older adults often 
have worse outcomes with standard chemotherapy regimens.  While pediatric-inspired regimens 
have improved outcomes in adolescents and young adults with ALL, this approach remains 
challenging in older patients with a cumulative incidence of chemotherapy-related death of 23% 
for those over 45 years old.7-9 Similarly, patients who are 60 years of age or older and receive the 
standard induction regimen of hyper-fractionated cyclophosphamide, vincristine, doxorubicin, 
and dexamethasone (Hyper-CVAD) suffer an induction-related mortality rate of 10% with an 
additional 34% dying in first remission due to chemotherapy-related toxicities.10 Given these 
poor outcomes, older patients are often deemed unfit for traditional treatment regimens, so there 
is a need to develop alternative regimens for this patient population that are both tolerable and 
effective.  
 
2.1.2 CD19+ Mixed Phenotype Acute Leukemia (MPAL) 
 
Mixed phenotype acute leukemia (MPAL) is rare, representing 0.5-2.4% of acute leukemias 
based on the 2008 WHO criteria.  The disease occurs predominantly in adults (68%), and 60% 
express CD19 in historical case series with only about 25% of those cases showing evidence of 
the Philadelphia chromosome.11,12 Due to the rarity of MPAL there are no prospective 
randomized trials to point towards the optimal treatment approach, so treatment approaches are 
varied.13 In one large case series, first-line treatment was based on ALL therapy in 27 patients, 
AML therapy in 34 patients, or a combination thereof in 5 patients, while one patient received 
single agent imatinib.11  Historically, complete remission rates with ALL-based regimens (64-

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85%) have been far superior to remission rates with AML-based regimens (28-41%).11,14,15 
However, despite a reasonable initial response to ALL-based chemotherapy regimens, median 
survival is just 18 months with the majority of patients dying from relapsed or refractory 
disease.11 Thus there is a significant need for new therapies in adult CD19+ MPAL to treat both 
relapsed and refractory patients. 
 
2.2 
CTEP IND Agents 
 
2.2.1 Blinatumomab 
 
Blinatumomab (AMG103, MT103, and NSC#-707389) is a fusion protein composed of two 
single-chain antibodies (scFv), murine anti-CD19 scFv and murine anti-CD3 scFv.  It has dual 
specificity for CD19, a B-cell lineage-specific antigen, and the invariant CD3ε subunit of the T-
cell receptor (TCR), which is present on all T lymphocytes.16 Upon contact with CD19+ target 
cells, blinatumomab induces polyclonal T cell activation and T cell-mediated tumor cell lysis 
through both the CD4+ and CD8+ T cell subsets with the CD8+ population (effector memory T 
cells, TEM) responsible for the most rapid killing.17 Blinatumomab-activated T cells are capable 
of serial killing at low effector-to-target (E:T) cell ratios, which is possibly a consequence of 
the much greater affinity of the BiTE for CD19 (10-9 M) as compared to CD3 (10-7 M).18 This 
differential affinity allows CD3+ T lymphocytes to dissociate from the antibody construct more 
readily than the target cells and subsequently bind additional tumor cells.19 Its high therapeutic 
index is derived from the fact that CD19 is expressed on most B-lineage malignancies including 
B-precursor ALL and lymphomas but is absent on hematopoietic stem cells (HSCs).20 
Treatment with blinatumomab is associated with a rapid depletion of peripheral B cells, 
accompanied by T cell activation and a transient increase in cytokines. 
 
2.2.1.1 
Nonclinical Development of Blinatumomab 
 
The in vitro efficacy of blinatumomab was first investigated in NALM-6, RAJI, and DoHH2 cell 
lines using donor T cells from 86 different donors obtained from local blood banks.  In contrast to 
other CD19-specific T-cell-recruiting bispecific antibody formats, blinatumomab demonstrated 
target cell lysis within a few hours, in the absence of any extra T-cell stimuli, and at low 
effector:T cell ratios using unstimulated lymphocytes.  In these assays, blinatumomab exhibited 
ED50 values of 10-12 to 10-13 M, which greatly exceeded its binding affinities with KD ranges of 10-
7 to 10-9.  Notably, the efficacy of blinatumomab as measured by cytotoxicity assays varied 
significantly depending on the T cell donor.21 The in vitro success of blinatumomab led to 
investigation of its in vivo efficacy in NOD/SCID mice.  In these experiments, NOD/SCID mice 
were inoculated with NALM-6 cells leading to either subcutaneous tumors or frank leukemia.  In 
mice with subcutaneous tumors, treatment with blinatumomab and human peripheral blood 
mononuclear cells (PBMCs) led to increased survival and suppressed tumor outgrowth in the 
absence of any T cell costimulatory compounds.  In the leukemic form, injection of blinatumomab 
and human PBMCs led to the delayed onset of neurological symptoms including the complete 
prevention of neurological symptoms in a subset of mice.22   
 
 

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2.2.1.2 
Clinical Development of Blinatumomab 
 
Blinatumomab is being evaluated as monotherapy and in combination with cytotoxic 
chemotherapy in completed and ongoing clinical trials in CD19+ B-cell malignancies including 
Precursor B-lymphoblastic leukemia (Pre-B ALL) and Non-Hodgkin Lymphoma (NHL).   
 
2.2.1.2.1 Pharmacokinetics 
 
Blinatumomab consists of a single chain of 504 amino acids with a molecular weight of 
approximately 54 kDa. The pharmacokinetics of blinatumomab was assessed over a dose range 
from 5 to 90 mcg/m2/day (approximately equivalent to 9-162 mcg/day). Following continuous 
intravenous infusion, the steady state serum concentration (Css) was achieved within a day and 
remained stable over time. The estimated mean (SD) volume of distribution based on terminal 
phase (Vz) was 3.93 (2.32) L in adult ALL patients. The estimated mean (SD) systemic 
clearance was 1.81 (0.58) L/hour and the estimated mean (SD) half-life was 1.47 (0.53) hours 
in adult ALL patients. Negligible amounts of blinatumomab were excreted in the urine at the 
tested clinical doses. Like other protein therapeutics, blinatumomab is expected to be 
degraded into small peptides and amino acids via catabolic pathways. At the clinical doses of 9 
mcg/day and 28 mcg/day for the treatment of adult relapsed/refractory ALL, the mean (SD) Css 
was 246 (305) pg/mL and 632 (510) pg/mL, respectively. 
 
2.2.1.2.2  Efficacy 
 
Blinatumomab was first studied in patients with relapsed NHL. In the initial phase I study of 
blinatumomab in patients with indolent NHL, blinatumomab (0.5 to 90 μg/m2/day) was given 
over 4-8 weeks and demonstrated dose-dependent efficacy. Responses were observed at ≥15 
μg/m2/day dose level with the MTD being defined at 60 μg/m2/day. Unfortunately, dose-limiting 
toxicities including CNS toxicities were first encountered at a dose of 15 g/m2/day with 29.6% 
of patients treated at this and higher dose levels requiring treatment discontinuation due to 
toxicities, the majority of which were neurologic.23 A low peripheral blood B-to-T cell ratio was 
associated with neurologic toxicity, which was reduced with a double stepwise dosing approach. 
At the MTD, the overall response rate was 69% (24/35) across the indolent lymphoma types.24  
Subsequent long-term follow-up of patients in this trial showed significantly improved overall, 
progression-free, and treatment-free survival for those patients treated with the target dose of 60 
g/m2/day compared to those who received lower doses of blinatumomab.25  In a phase II study 
of patients with relapsed/refractory diffuse large B cell lymphoma (DLBCL), a stepwise dosing 
approach of blinatumomab escalating to a dose of 112 g/day was found to offer the optimal 
risk-benefit ratio and an overall response rate of 43% was achieved with a median response 
duration of 11.6 months.  In this study, 12% of patients discontinued treatment prematurely due 
to adverse events.26  
 
The success of blinatumomab in ALL was first demonstrated in a study of 21 patients who 
achieved a hematologic complete response with induction and consolidation but had persistent 
MRD that could be measured by PCR.  Treatment with blinatumomab (15 µg/m2/day 
continuously for 4 weeks every 6 weeks up to 4 cycles) led to clearance of MRD in 80% of the 
evaluable patients with a 61% relapse free survival at a median observation of 33 months, which 

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compares quite favorably with an expected RFS of 20% in patients with a known molecular 
relapse.27,28 A confirmatory single-arm, phase II study using blinatumomab in MRD+ Pre-B 
ALL enrolled 116 patients with 78% achieving clearance of MRD after one cycle of treatment 
leading to a median overall survival of 40.4 months as opposed to just 12.0 months for patients 
who failed to clear their MRD.29,30 
 
In an initial trial of thirty-six patients with relapsed/refractory Ph-negative, B-precursor ALL 
treated with blinatumomab, 69% achieved CR or CR with partial hematologic recovery (CRh), 
and 88% of responders achieved MRD negative status.  During the dose finding stage of this 
study, 28.5% of patients who were treated with a flat dose of 15 µg/m2 daily over four weeks 
were replaced due to adverse events, while none of the patients who were treated with a step-
wise dose escalation using 5 μg/m2 daily for one week followed by 15 µg/m2 daily for three 
weeks suffered adverse events requiring replacement.31 Given the improved tolerability of the 
step-wise dosing approach, it has become the standard dosing regimen for blinatumomab in 
subsequent studies in ALL.  In a larger study of 189 adults with relapsed/refractory Ph-negative, 
B-precursor ALL, 44% of patients achieved CR or CRh after 1-2 cycles of blinatumomab with 
82% of responders clearing their MRD.  An additional 8% of patients achieved a blast free 
hypoplastic or aplastic bone marrow for a total response rate of 52% after two cycles of 
treatment.24 The median relapse-free survival was 5.9 months, with MRD responders having a 
median RFS of only 6.9 months. The majority of grade 3 or greater adverse events were 
restricted to hematologic toxicities such as febrile neutropenia (25%), neutropenia (16%), and 
anemia (14%); except for grade 3 cytokine release syndrome (2%) and grade 3 and/or 4 
neurologic events (13%).32 The success of blinatumomab has not been restricted to Ph-negative 
ALL, as a recent trial including 45 patients with relapsed or refractory Ph-positive Pre-B ALL 
who had failed at least one second-generation TKI demonstrated a response rate (CR + CRh) of 
36% with 86% of responders achieving clearance of MRD.33 The TOWER trial is an ongoing, 
randomized, open-label phase 3 study to evaluate the efficacy of blinatumomab versus 
investigator choice standard of care (SOC) chemotherapy in adult subjects with 
relapsed/refractory ALL.  Subjects are randomized 2:1 to blinatumomab versus 1 of 4 SOC 
chemotherapy regimens.  Patients receiving blinatumomab in this trial are eligible for up to 9 
cycles of treatment with the last 4 cycles designated as maintenance therapy and given every 12 
weeks as opposed to the standard 6 week interval.24  
 
2.2.1.2.3  Toxicology 
 
Nine hundred thrirty-two subjects (819 adult and 113 pediatric subjects) have received treatment 
in company-sponsored cIV infusion studies in the blinatumomab clinical development program. 
Subjects have been treated with blinatumomab at doses ranging from 0.5 μg/m²/day to 90 
μg/m²/day. The maximum duration of exposure has been 196 days at a dose of 5/15 μg/m2/day.  
Treatment-emergent adverse events (TEAEs) were reported for similar percentages of subjects 
across the R/R ALL, MRD-positive ALL, and NHL studies. The most frequently reported (those 
reported in ≥ 20% of subjects overall) TEAEs were pyrexia, headache, nausea, anemia, 
hypokalemia, and diarrhea.  Across studies, 55.8% of subjects had AEs of grade ≥ 3 that were 
considered by the investigator to be related to treatment. The most frequently reported treatment-
related events of grade ≥ 3 were lymphopenia (8.2%), neutropenia (13.7%), febrile neutropenia 
(16.5%), and leukopenia (7.7%).  Across studies, 37.1% of subjects had serious adverse events 

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that were considered by the investigator to be related to treatment. The most common treatment-
related serious adverse events overall were lymphopenia (5.3%), pyrexia (8.2%), encephalopathy 
(3.0%), and tremor (2.5%). The incidence of many TEAEs was 2-fold or more higher in the NHL 
population than in the other indications, which was likely attributable to the increased dose of 
blinatumomab used in the NHL studies.  Most permanent treatment discontinuations were due to 
nervous system events.  Approximately 16.4% of subjects across all studies had TEAEs leading 
to study discontinuation that were considered by the investigator to be related to treatment. The 
most frequently reported treatment-related events leading to study discontinuation were 
encephalopathy (2%), aphasia (1.1%), and tremor (1.1%).  Similarly, the most common cause of 
dose interruptions due adverse events were those ascribed to nervous system events.  Of note, in 
the adult R/R ALL studies, any grade ≥ 3 CNS event required treatment interruption.  
Approximately 29% of subjects had TEAEs leading to treatment interruption across all studies. 
The most frequently reported treatment-related events leading to treatment interruption were 
pyrexia (4.0%), cytokine release syndrome (1.8%), encephalopathy (1.7%), and, and tremor 
(1.6%).24 
 
2.2.1.2.4  Pharmacodynamics/Biomarkers24 
 
Pharmacodynamic (PD) measures included lymphocyte subsets and cytokines. The response to 
blinatumomab was characterized by peripheral B-cell depletion, T-cell activation and 
redistribution as well as transient cytokine elevation. Consistent PD profiles were observed 
across clinical trials following the cIV regimen. 
 
T-cell dynamics: Following blinatumomab cIV infusion, peripheral T-cell counts initially 
declined within 1 to 2 days to very low levels, a phenomenon described as redistribution from 
periphery to tissues. After the initial decline, T-cells started to increase and reached baseline 
levels in about 14 days. Increase of T-cell counts above baseline was found in some subjects. 
There was no difference between the dynamics of CD4+ and CD8+ T cells. A high inter-
individual variability was observed in T-cell baseline levels.  The time to return to baseline was 
variable across subjects (10 to 30 days). 
 
B-cell Dynamics: B-cell counts in peripheral blood decreased rapidly and became undetectable 
during treatment at doses ≥ 5 μg/m2/day (or 9μg/day) in most subjects. No recovery of B-cell 
counts was observed during the drug-free period between treatment cycles. Incomplete depletion 
of B cells was observed at doses of 0.5 and 1.5 μg/m2/day.  High inter-individual variability was 
found in baseline B-cell counts. Associated with the B-cell depletion, decreases in 
immunoglobulin (Ig) levels have been observed.  Long-term Ig levels were measured in 6 MRD-
positive ALL subjects treated with blinatumomab. Partial to complete recovery of IgM and IgG 
levels and incomplete recovery of IgA were observed during the long-term safety follow-up 
period.34 
 
Cytokine Dynamics:  The measured cytokines were TNF-α, IL-2, IL-6, IL-8, IL-10, IL-12, IL-4, 
and IFN-γ. Transient elevation of cytokines was observed in some subjects in the first 2 days 
following the blinatumomab infusion. The elevated cytokine levels returned to baseline within 
24 to 48 hours during the infusion period. In subsequent treatment cycles, cytokine elevation was 
only observed in few subjects with much less intensity.  The magnitude of cytokine elevation 

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trended higher at higher doses. The inter-subject variability in cytokine elevation was large. 
 
See Section 8.1.1 for drug information. 
 
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.35  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.36  
 
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, 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-

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1 with PD-L1 and PD-L2 results in negative regulatory stimuli that down-modulate the activated 
T-cell immune response through SHP-1 phosphastase. 
 
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.37  
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,38 renal,39-41 esophageal,42 gastric,43 ovarian,44 
pancreatic,45 lung,46 and other cancers.35 
 
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 
 
In intravenous (IV) repeat-dose toxicology studies in cynomolgus monkeys, nivolumab alone 
was well tolerated.35  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.35  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 

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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.35  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 (ORs) (complete or 
partial responses [CR or PR]) were seen in NSCLC, melanoma, and RCC.  ORs were observed at 
all doses.47  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.48  In the RCC cohort, median duration of response was 12.9 
months for both doses with 5 of the 10 responses lasting ≥1 year.49   
 
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).36  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.50  
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 MTD of nivolumab was not defined.51 Serious adverse events (SAEs) occurred in 32 of 296 
patients (11%) similar to the immune-related inflammatory events seen with ipilimumab:  
pneumonitis, vitiligo, colitis, hepatitis, hypophysitis, and thyroiditis (with noted pulmonary 
toxicity resulting in 3 deaths. Renal failure, symptomatic pancreatic and DM, neurologic events, 
and vasculitis have also been reported.).   In combination with ipilimumab in the concurrent-
regimen group,36 grade 3 or 4 treatment-related events were noted in 53% of patients.  Skin rash 

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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.36  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 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 PD-L1 expression and responses 
may not be present in patients treated with the combination.  Tissue expression of PD-L2, 
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.   
 
See Section 8.1.2 for drug information. 
 
2.2.3 Ipilimumab  
 
Ipilimumab (BMS-734016, MDX010, MDX-CTLA4, YervoyTM) is a fully human monoclonal 
immunoglobulin (Ig) G1κ specific for human cytotoxic T lymphocyte antigen 4 (CTLA-4, 
CD152), which is expressed on a subset of activated T cells.52  CTLA-4 is a negative regulator of 
T-cell activation.  Ipilimumab binds to CTLA-4 and inhibits its interaction with ligands on 
antigen-presenting cells (APCs).  The proposed mechanism of action for ipilimumab’s effects in 
subjects with melanoma is indirect, possibly through T-cell potentiation and mediation of 
antitumor immune responses. 
 
Ipilimumab has been approved for the treatment of unresectable metastatic melanoma in over 40 
countries including the United States (US, March 2011), the European Union (July 2011), and 
Australia (July 2011).  An initial dose finding study of ipilimumab in metastatic melanoma (0.3 
mg/kg, 3 mg/kg, and 10 mg/kg every three weeks X 4) demonstrated that responses and AEs 
were dose-dependent.53 In a subsequent phase III study in metastatic melanoma, ipilimumab was 
given every 3 weeks at 3 mg/kg, and 10-15% of patients suffered grade 3 or 4 irAEs including 7 
such events that resulted in death among 540 participants (1.3%) who received ipilimumab.  The 
most common grade 3 and 4 irAEs were in part similar to those seen with nivolumab including 
diarrhea and endocrine abnormalities, and could generally be managed by withholding treatment 
and giving steroids.54 When compared to nivolumab, side effects from ipilimumab tend to be 
more common and more serious but remain manageable. 
 
BMS and Medarex (acquired by BMS in Sep-2009) have co-sponsored an extensive clinical 
development program for ipilimumab, encompassing >13,800 subjects in several cancer types in 
completed and ongoing studies, including a compassionate use program.52  The focus of the 

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clinical program is in melanoma, prostate cancer, and lung cancer, with advanced melanoma 
being the most comprehensively studied indication.  Ipilimumab is being investigated both as 
monotherapy and in combination with other modalities such as chemotherapy, radiation therapy, 
and other immunotherapies. 
 
CTEP’s clinical development of ipilimumab focuses on cervical, gastrointestinal, ovarian, 
prostate cancer, chronic lymphocytic leukemia, head and neck squamous cell carcinoma, solid 
tumors, Hodgkin and non-Hodgkin lymphomas, melanoma, and myelodysplastic syndrome. 
While the toxicity and clinical responses overlap, mechanisms of immune activation and range of 
responses appear to be different for each of the single agents.  In a phase I study of patients with 
myelodysplastic syndrome (MDS) refractory to hypomethylating agents led by JHU, 27.3% of 
the patients maintained stable disease for >6 months, and three of eleven patients were able to 
undergo allogeneic HSCT without additional toxicities.55 The lack of increased transplant-related 
toxicities following ipilimumab administration is particularly relevant in ALL, as allogeneic 
HSCT after a CR remains the preferred treatment paradigm in relapsed/refractory patients.  
 
Preclinical data support the combinations of nivolumab and ipilimumab.56   
 
The combination of ipilimumab with nivolumab has been reported to result in improved 
responses in advanced melanoma marked by time to response, number of responses, depth and 
duration of responses, PFS, and OS compared to single agent ipilimumab.36  
 
For RCC results have been reported.57 
 
The success of PD-1 and CTLA-4 targeted agents as monotherapy has stimulated intense interest 
in combination therapy including recent studies demonstrating the feasibility and efficacy of dual 
nivolumab and ipilimumab treatment in advanced melanoma.  A double-blind phase III trial 
randomized patients with advanced melanoma to combination therapy with 1 mg/kg of 
nivolumab and 3 mg/kg of ipilimumab every 3 weeks or standard monotherapy with either 
nivolumab or ipilimumab.  This study demonstrated a significant increase in objective responses 
(57.6% for the combination vs. 19.0% for ipilimumab vs. 43.7% for nivolumab) and median 
progression-free survival (11.5 months for the combination vs. 2.9 months for ipilimumab vs. 6.9 
months for nivolumab) for patients treated with the combination of ipilimumab and nivolumab.  
The incidence of grade 3 and 4 AEs was significantly higher in the combination arm (55.0%) 
than in the nivolumab (16.3%) or ipilimumab (27.3%) monotherapy arms.58 In an attempt to 
mitigate these toxicities, the combination is now primarily being evaluated in other disease 
settings with an increased dose of nivolumab (3 mg/kg) and a reduced dose of ipilimumab (1 
mg/kg) q 3 weeks x 4 induction doses.  Clearly, the side effects from combined immune 
checkpoint blockade are not trivial; however, in a review of 288 patients treated with hyper-
CVAD, a standard adult ALL induction regimen, 54% of patients required hospitalization for 
treatment-related side effects.59 This suggests that the treatment-related side effects of combined 
immune checkpoint blockade are acceptable when compared to traditional chemotherapy 
regimens for hematologic malignancies.  Furthermore, the majority of irAEs are managed with 
steroids.  Importantly, steroids are also indicated for the management of cytokine release 
syndrome (CRS) during blinatumomab administration, and it has been shown that patients are 
able to achieve remissions with blinatumomab monotherapy in spite of concurrent steroid 

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administration.60 Thus if a patient receiving the combination of blinatumomab and immune 
checkpoint inhibitor(s) develops an irAE requiring steroids, then the initiation of steroids would 
not be expected to compromise the efficacy of continued treatment with blinatumomab.  
 
See Section 8.1.3 for drug information. 
 
2.3 
Rationale 
 
2.3.1 Immune Checkpoint Blockade and Leukemia 
 
Immune inhibitory pathways, known as immune checkpoints, are upregulated in cancer cells and 
the tumor microenvironment leading to immune tolerance.61 Major advances in immune 
checkpoint blockade over the last decade have resulted in impressive responses in solid tumors, 
but these novel agents have yet to gain traction in the treatment of leukemia. In a phase I trial, 
checkpoint blockade with an anti-programmed death ligand 1 (PD-L1) antibody, demonstrated 
objective responses in melanoma, non-small cell lung cancer (NSCLC), ovarian cancer, and renal 
cell carcinoma (RCC) with nearly 35% of patients demonstrating stable or improved disease after 
24 weeks.62 Based on this and subsequent studies, checkpoint inhibitors targeting the immune 
checkpoints PD-1 and CTLA-4 are approved for use in melanoma, RCC, and NSCLC; while recent 
studies have demonstrated promising results in Hodgkin’s and Non-Hodgkin’s lymphomas.63,64  
 
Studies investigating the role of immune checkpoint pathways in leukemia are limited.65 Clearly, 
the immune system plays a critical role in controlling leukemia as evidenced by the potent activity 
of a graft-versus-leukemia (GVL) effect following allogeneic HSCT in curing ALL and AML.66,67 
This suggests that leukemia cells are responsive to T cells and that anti-leukemia immunity may 
be susceptible to augmentation by checkpoint co-signaling molecule modulation. Preclinical 
studies using two different murine models of AML have shown that signaling through the PD-
1/PD-L1 axis impairs anti-leukemic immunity and the in vivo blockade of this pathway improved 
outcomes.68-70 Across different human studies, the frequency of PD-L1-expressing AMLs varied 
from 18% to more than 50%, increased after ex vivo stimulation by IFN-γ, after chemotherapy or 
at relapse.71-73 We recently studied T-cell dynamics and inhibitory receptor (iR) expression in 
peripheral blood (PB) and bone marrow (BM) of AML patients. In our studies, we have identified 
several dominant expression patterns of iRs suggesting that iR signatures are consistent with 
immune recognition of AML and their role in sculpturing the effector T-cell responses against 
AML cell populations.74 Furthermore, the analysis of CD8+ T-cell gene expression profiles using 
microarrays revealed signatures of “T-cell exhaustion” at the time of diagnosis. Analysis of 
differentially-expressed genes and corresponding fold-changes through the use of Ingenuity 
pathway analysis identified downregulation of several co-stimulatory signaling pathways in CD8+ 
T cells retrieved from patients with leukemia in comparison to healthy controls, underscoring the 
relevance of immune inhibitory pathways in controlling T-cell-mediated anti-leukemia responses. 
After chemotherapy, the gene expression pattern in CD8+ T cells differed substantially in patients 
that achieved a response in comparison to those that did not enter remission and became similar to 
healthy controls. 
 
Recent reports suggest that immune checkpoint pathways are also operational in ALL as evidenced 
by the expression of multiple co-inhibitory molecules on leukemia blasts and T cells from ALL 

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patients, including PD-L1 and PD-1, respectively.75,76 The CD80/CD86 – CD28/CTLA-4 pathway 
provides key second signals that can regulate the activation or the inhibition of T cell responses. 
Both CD86 expression on ALL blasts and a soluble form of CTLA-4 (sCTLA-4) are found at a 
significantly higher frequency in ALL patients than healthy controls, and higher levels of each 
correlate with relapse risk and probability of survival following treatment.77,78 Experimental 
evidence suggests that current anti-CTLA-4 antibodies bind both sCTLA-4 and membrane-bound 
CTLA-4 and as such that their administration may improve the immune recognition of ALL cells.79 
Furthermore, immune inhibitory pathways appear to be susceptible to upregulation within pro-
inflammatory milieu such as the one created by blinatumomab, thereby promoting resistance to 
blinatomumab therapy and providing a unique opportunity for therapeutic intervention.  
 
2.3.2 Immune Checkpoint Inhibition Combined with BiTE Antibodies in Leukemia 
 
Recent laboratory findings suggest a role for combining BiTE antibody constructs with immune 
checkpoint blockade to enhance BiTE antibody efficacy in both AML and ALL.  In regard to 
AML, the CD33/CD3 BiTE antibody construct AMG330 efficiently eliminated 19 of 38 primary 
AML samples in an ex vivo cytotoxicity assay.80 The kinetics of AMG330-mediated lysis of 
primary AML cells was dependent on the initial E:T ratio, presence of central and effector memory 
T cells in the culture, and the intensity of CD33 expression on leukemia cells. Interestingly, the 
addition of AMG330 to primary AML cultures and the resulting pro-inflammatory environment 
led to the significant upregulation of PD-L1 on leukemia cells and PD-1 on the proliferating 
CD45RA-/CCR7+/- memory T cell subset.  The importance of this finding was further illustrated 
by the subsequent mechanistic studies which revealed that blockade of the PD-1/PD-L1 axis can 
significantly augment AMG330-induced leukemia cell lysis. This effect was particularly 
pronounced at lower E:T ratios and accompanied by a significant increase in T-cell proliferation 
and interferon-γ secretion.80 These findings provide important pre-clinical rationale for combining 
BiTE antibodies and PD-L1/PD-1 pathway inhibitors in AML.   
 
Several lines of evidence suggest that PD-1/PD-L1 axis is operational in ALL and may represent 
a potential mechanism of blinatumomab resistance. First, serial BM samples from a patient who 
failed to respond to blinatumomab demonstrated significant upregulation of PD-L1 on tumor cells 
after blinatumomab administration (2% at baseline vs. 40% after blinatumomab) without evidence 
of loss of CD19 expression on the tumor cells, which is an alternative mechanism of blinatumomab 
resistance. Second, an increase in PD-1 expression on BM lymphocytes was noted at the time of 
therapeutic failure.  The primary patient’s CD3+T cells were unable to lyse patient’s leukemia cells 
ex vivo in the presence of blinatumomab while the cells were effectively killed by healthy 
lymphocytes.75 Finally, Feuchtinger et al. analyzed 20 primary ALL CD10+/CD19+ BM cells, and 
found that PD-L1, but also other co-inhibitory molecule such as HVEM, and co-stimulatory 
molecule such as CD86, were upregulated compared to healthy CD10+CD19+cells. PD-L1 
upregulation on ALL blasts was noted upon exposure to Th1 cytokines such as interferon-γ or 
TNF-α. More importantly, PD-L1 was consistently more highly expressed on CD19+CD10+ BM 
cells in blinatumomab non-responders compared to responders and in relapsed ALL compared to 
initial diagnosis.  Similarly, PD-1 but also other co-inhibitory molecule such as Tim-3 were more 
highly expressed (and co-expressed) on T cells from ALL patients when compared to healthy 
controls. In functional studies, the blinatumomab effect on T cells (proliferation and interferon-y 
production) in vitro appeared to be target cell-dependent and correlated with the target cell-

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expression of co-signaling molecules. Combined inhibition of the PD-1 and CTLA-4 pathways 
with blinatumomab enhanced effector T cell function of healthy donors and patient’s T cells 
against ALL target cells more than PD-1 inhibition alone while inhibition of co-stimulatory CD28-
CD80/86 interactions downregulated T cell effector function and proliferation. These findings led 
to the treatment of a single 12 year-old refractory ALL patient with the combination of 
pembrolizumab and blinatumomab, which resulted in strong T cell expansion and a significant 
decrease in ALL blasts.76 Overall, the implication of these studies is that blinatumomab combined 
with co-inhibitory molecule blockade (PD-1/PD-L1, CTLA-4, or both) could be a rational strategy 
to overcome blinatumomab resistance in CD19+ ALL.  
 
2.3.3 Improving Outcomes in ALL after Blinatumomab Treatment 
 
Though the initial study of blinatumomab in relapsed/refractory Pre-B ALL demonstrated a CR 
rate of 69%, a subsequent larger study in patients at high risk for poor outcomes led to a more 
modest response rate of 43%.31,32 This response rate was comparable to that seen with cytotoxic 
chemotherapy in prior studies in relapsed Pre-B ALL.4 Furthermore, this study also showed the 
limited durability of responses to blinatumomab with a median RFS of just 6.9 months among 
those who achieved MRD negative status following treatment.  Thus while blinatumomab has 
shown significant activity with an acceptable safety profile in patients with relapsed or refractory 
Pre-B ALL, many patients still fail to achieve a response or relapse shortly after achieving a 
response, including MRD responders.  Given the short duration of remission and high risk of 
relapse following blinatumomab, consolidation with an allogeneic HSCT has been shown to be a 
feasible strategy; however, only a subset of patients who achieve remission with blinatumomab 
will be candidates for allogeneic HSCT and post-transplant relapse remains a problem.32,81 Thus, 
there is a need to develop additional strategies to increase and prolong responses after 
blinatumomab treatment. Monitoring of T-cell kinetics in relapsed and refractory patients treated 
on the initial phase II study identified that the expansion of CD3+ T cells during the first 2 cycles 
correlates with the response, with long-term survivors having a higher degree of T-cell and TEM-
cell expansion. Interestingly, T-cell expansion was limited in MRD responders with shorter 
survival and was not seen in MRD non-responders. B cell kinetics revealed their rapid and 
persistent clearance in MRD responders while detectable return of peripheral B cells was noted 
before cycle 2 in non-responders.81 Given the correlation between T-cell expansion, MRD 
clearance and subsequent long-term survival after blinatumomab treatment, augmenting the 
initial or early anti-leukemia T-cell response following blinatumomab is a rational strategy to 
improve response rate and extend its durability.  
 
2.3.4 Dose Selection 
 
The initial doses of blinatumomab, nivolumab, and ipilimumab to be used in this trial have been 
selected based on the results of prior trials demonstrating the safety of these drugs at the selected 
doses as well as the efficacy of blinatumomab at the selected dose in the treatment of ALL.  All 
participants in this study will receive blinatumomab using the standard dosing regimen that has 
been FDA approved for the treatment of relapsed and/or refractory ALL based on the results of 
two Phase II trials.31,32 As blinatumomab is the only agent in this trial that is known to have 
significant activity in ALL, it is critical that its dose remain unchanged.  Nivolumab will initially 
be given in combination with blinatumomab at a flat dose of 240 mg every two weeks.  

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Population pharmacokinetics support the flat dose of 240 mg as being identical to 3 mg/kg for 
subjects weighing 80 kg, which was identified as a safe dose of nivolumab in the initial phase I 
trial.35,51 Furthermore, data from the phase I trial of nivolumab suggest that its side effects are not 
dose-dependent, so lower doses may not mitigate toxicities even when combined with 
blinatumomab.  However, if significant toxicities should arise at a flat dose of 240 mg every 2 
weeks of nivolumab, then further patients will be treated at a de-escalated nivolumab dose of 80 
mg every 2 weeks.  In combination with nivolumab and blinatumomab, ipilimumab will first be 
given at a dose of 1 mg/kg every 6 weeks with escalation in subsequent patients to a dose of 3 
mg/kg every 6 weeks, if the initial dose proves tolerable in combination with nivolumab and 
blinatumomab.  This differs from a recent phase III study combining nivolumab and ipilimumab 
in metastatic melanoma that used an ipilimumab dose of 3 mg/kg every 3 weeks with 1 mg/kg 
every 3 weeks of nivolumab.58 However, in the initial phase I study combining ipilimumab and 
nivolumab for the treatment of metastatic melanoma, nearly all treatment-related adverse events 
were reduced in patients who received 1 mg/kg of ipilimumab with 3 mg/kg of nivolumab every 
3 weeks as compared to those who received 3 mg/kg of ipilimumab with 1 mg/kg of nivolumab 
every 3 weeks, although the objective response rate was comparable.36 Furthermore, the reported 
half-life of ipilimumab is 15.4 days, and the combination with nivolumab does not seem to effect 
the clearance of ipilimumab.52  Thus the decreased dose density of ipilimumab proposed in this 
study has strong biologic rationale and should help to mitigate the toxicities of ipilimumab. 
 
2.4 
Correlative Studies Background 
 
The goal of the correlative studies in this trial will be to characterize the effect of treatment on T 
cells particularly on their re-distribution, in vivo expansion, activation, and effector 
differentiation in both the BM and PB compartments over time.  This has recently been studied 
extensively by our group in AML, but there is currently a paucity of data in ALL.  Thus the 
correlative studies are designed to gain insight about T-cell function in ALL patients prior to 
treatment, during blinatumomab monotherapy, following the addition of immune checkpoint 
inhibitors to blinatumomab, at the conclusion of treatment, and at the time of relapse.  These 
studies will also characterize the effects of these treatments on co-signaling molecule expression 
and the expression of transcription factors in T-cell subpopulations.  These investigations will 
not be limited to the immune inhibitory pathways for which there are currently commercially 
available inhibitors (i.e. PD-1/PD-L1 and CTLA-4/CD80/CD86), as inhibitors of many other 
pathways are currently in development, and we expect that interrogation of other pathways will 
identify potential future targets for immune checkpoint inhibition. 
 
2.4.1 
Dynamics of lymphocyte subpopulations in both peripheral blood and the bone 
marrow microenvironment pre- and post-blinatumomab and immune 
checkpoint inhibitor(s) treatment.  
 
Current data from patients treated with blinatumomab suggests tri-phasic T-cell kinetics: T-cell 
counts decline within hours after the start of blinatumomab infusion, recover to baseline within a 
few days followed by T-cell expansion with, on average, more than doubling of T-cell counts at 
2-3 weeks under continued infusion of blinatumomab, and lastly T-cell contraction in between 
cycles.  Patients who achieved MRD clearance following blinatumomab and were long-term 
survivors had a higher degree of T-cell and TEM-cell expansion after the first two treatment 

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cycles compared to patients having MRD response but short survival or non-responders.34 This 
implies that T-cell expansion might be a key factor for improving response and survival of 
relapsed/refractory ALL patients after blinatumomab immunotherapy.  In terms of T-cell 
subpopulations, T-cell expansion was associated with increases in CD3+ TEM, CD8+ TEM, 
CD8+TEMRA, CD4+ TCM cells.82  There are limited data on the relevance of other T-cell 
subpopulations except a suggestion from a small study of ALL patients refractory to 
blinatumomab therapy that a high percentage of Tregs can predict a lack of response to therapy.83 
In terms of checkpoint inhibitors, the absolute lymphocyte count (ALC) has been found to be a 
specific pharmacodynamic biomarker of ipilimumab, and the degree of increase in the ALC has 
been associated with survival in patients with melanoma.84-86  Ipilimumab administration is 
followed by enhanced T-cell proliferation and a rise in CD8+ TCM and CD4+ TEM cells.87,88  
Ipilimumab-induced changes in Tregs have been more controversial across different studies with 
both decreases and increases in circulating FoxP3+Tregs observed in patients responding to 
treatment.84,89  In contrast to ipilimumab, data on the predictive role of immune cell subsets and 
changes in ALC in cancer patients during PD-1 or PD-L1 blockade are lacking.  In addition, no 
association between ALC and clinical response was observed when nivolumab and ipilimumab 
were administered in combination, suggesting that the combination of these two antibodies 
generated immune responses with unique features compared to their administration as 
monotherapy.36  
 
We anticipate that the addition of nivolumab or nivolumab/ipilimumab to blinatumomab will be 
associated with increased T-cell effector differentiation and proliferation and improved post-
treatment antitumor responses.  Thus we propose monitoring of T-cell dynamics during 
treatment as an integrated biomarker to support the collection of mandatory PB and BM 
specimens.  
 
The overarching goals of these studies are to:  a) characterize the effect of blinatumomab in 
combination with checkpoint inhibition on T cells particularly on their re-distribution, in vivo 
expansion, activation, and effector differentiation in both PB and BM compartment over time 
and in relation to the response to therapy. We will also examine functional dynamics of Tregs 
and their fractions, B cells, and NK cells; b) identify potential predictive biomarker candidates 
(in combination with studies in Section 2.4.2) to guide improved selection of ALL patients who 
are more likely to benefit from addition of checkpoint inhibitors to blinatumomab therapy; c) 
characterize the mechanisms of relapse / refractoriness to blinatumomab combined with 
checkpoint inhibition such as T-cell dysfunction. 
 
Our expectation is that the treatment strategy being investigated in this study will enable ALL 
patients who would not respond to a single-agent blinatumomab to respond to the combination of 
blinatumomab and immune checkpoint inhibition, and even enhance the depth and durability of 
response in those patients who may be responders to blinatumomab alone. 
 
2.4.2 
Changes in T-cell co-signaling receptors and canonic transcription factor 
expression in defined T cell subpopulations in both peripheral blood and bone 
marrow pre- and post-blinatumomab and immune checkpoint inhibitor(s) 
therapy. 
Studies performed by us and others suggest the presence of multiple aberrations in T-cell co-

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signaling receptors and canonic transcription factor expression in defined T-cell subpopulations 
in patients with AML but this has never been studied in depth in patients with ALL.  Our group 
has shown that co-expression of a number of inhibitory receptors (iRs), such as CTLA-4, PD-1, 
TIM-3, 2B4 or BTLA, on T cells in patients with AML differs between PB and BM and changes 
through the course of the treatment.74 Recent reports provided several lines of evidence that 
immune checkpoint pathways are also operational in ALL and may represent a potential 
mechanism of therapeutic resistance, including to blinatumomab.  First, PD-1 but also other co-
inhibitory molecule such as Tim-3 were more highly expressed (and co-expressed) on T cells 
from ALL patients compared to healthy controls.76 Second, an increase in PD-1 expression on 
BM lymphocytes was noted at the time of therapeutic failure.75 Finally, in functional studies, the 
blinatumomab effect on T cells (proliferation and interferon-y production) in vitro appeared to be 
target cell-dependent and correlated with the target cell-expression of co-signaling molecules.  
Combined inhibition of the PD-1 and CTLA-4 pathways with blinatumomab enhanced effector 
T-cell function of healthy donors and patient’s T cells against ALL target cells more than PD-1 
inhibition alone while inhibition of co-stimulatory CD28-CD80/86 interactions downregulated 
T-cell effector function and proliferation.76  
 
Thus we anticipate that administration of blinatumomab in combination with checkpoint 
inhibitors should result in strong T-cell differentiation and expansion and potent anti-leukemia 
activity. Whether the expression of iRs differs in patients with ALL at presentation and relapse 
and what is the effect of therapy is unknown.  As a part of this proposal we will conduct 
comprehensive analysis of signaling receptors and canonic transcription factor expression in 
defined T-cell subpopulations in both PB and BM before and post-blinatumomab and immune 
checkpoint inhibitor therapy.  This represents a very relevant unmet need for future integration of 
checkpoint inhibitors or any other immunotherapy approaches seeking to overcome T-cell 
exhaustion, increase the response rates to therapies, and/or maintain remission in ALL. Thus, in 
addition to studies proposed in Section 2.4.1, we propose monitoring the dynamics of signaling 
receptors and canonic transcription factors expression in defined T-cell subpopulations during 
treatment as an integrated biomarker to support the collection of mandatory PB and BM 
specimens.  As discussed in Section 2.4.1, the main goals of these studies are to characterize the 
effect of blinatumomab in combination with checkpoint inhibition on T-cell dynamics (re-
distribution, in vivo expansion, activation, and effector differentiation) but also on expression of 
co-signaling molecules in both PB and BM compartment over time, to identify potential 
predictive biomarker candidates to guide better selection of ALL patients who are more likely to 
benefit from the addition of checkpoint inhibitors to blinatumomab therapy, and to characterize 
the mechanisms of relapse / refractoriness after blinatumomab combined with checkpoint 
inhibition such as T-cell dysfunction. 
 
2.4.3 
Expression of co-signaling molecules on leukemia blasts (CD10+/CD19+/CD34+) 
before and after treatment with blinatumomab and checkpoint inhibitors. 
 
Upregulation of programmed death-ligand 1 (PD-L1) on tumor cells in response to endogenous 
anti-tumor immunity inhibits adaptive immune responses by inducing T-cell dysfunction. 
Expression of PD-L1 on tumor cells has been associated with poor outcome in solid cancers as 
well as hematologic malignancies.  Overall, cytokine-induced PD-L1 expression on tumors 
represents evasion of tumor immunity termed “adaptive resistance.”  Several lines of evidence 

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suggest that the PD-1/PD-L1 axis is operational in ALL and may represent a potential 
mechanism of blinatumomab resistance.  Feuchtinger et al. analyzed 20 primary ALL 
CD10+/CD19+ BM cells, and found that PD-L1, but also other co-inhibitory molecule such as 
HVEM, and co-stimulatory molecule such as CD86, were upregulated compared to healthy 
CD10+CD19+ cells.  PD-L1 upregulation on ALL blasts was noted upon exposure to Th1 
cytokines such as interferon-γ or TNF-α.  They observed that surface expression of the PD-L1 on 
the CD10+CD19+ cells was significantly higher in patients at the time of relapse than at the time 
of primary diagnosis and at both time points the expression was higher than in healthy controls.  
More importantly, PD-L1 was consistently more highly expressed on CD19+CD10+ BM cells in 
blinatumomab non-responders compared to responders.76  Kohnke et al. analyzed serial BM 
samples from a patient who failed to respond to blinatumomab and demonstrated significant 
upregulation of PD-L1 on tumor cells after blinatumomab administration (2% at baseline vs. 
40% after blinatumomab) without evidence of loss of CD19 expression, which is an alternative 
mechanism of blinatumomab resistance.75  
 
We anticipate that administration of nivolumab or nivolumab/ipilimumab following 
blinatumomab will inhibit PD-L1/PD-1 and CTLA-4/CD80/86 axis, respectively, and result in 
increased responses.  Thus we propose flow cytometric studies on leukemia blasts 
(CD19/CD10/CD34 plus other leukemia specific marker) to examine for the expression of co-
signaling molecules (PD-L1, B7-H3, VISTA, Gal-9, CD86, PVR, PVR2, OX40L, ICOSL) at 
baseline, within ten days of blinatumomab treatment (before immune checkpoint inhibitor 
administration), in non-responders after cycle 1 and/or 2 and at the time of relapse. These serial 
studies are proposed to identify alternative resistance mechanisms that could be employed by 
ALL cells to evade blinatumomab/checkpoint inhibition and thus will provide critical 
information on the selection of best combinations in the future. 
 
2.4.4 
Cytokine studies 
 
Blinatumomab treatment has been associated with transient release of cytokines such as IL-2, IL-
6, IL-10, IFN-γ and TNF-α.  However, there was not a clear pattern of cytokine release and 
response.82 Administration of novel immunotherapeutics, including immune checkpoint 
inhibitors, alone or in combination with chemotherapy have resulted in systemic immune-related 
AEs.90  Whether administration of nivolumab and nivolumab/ipilimumab following 
blinatumomab will increase cytokine expression and if increases in cytokines will be associated 
with toxicity is unknown. Thus, we will be collecting and storing serial plasma samples (at the 
time of PB collection) and if there is a strong rationale we will conduct measurement of 
cytokines to assess blinatumomab and checkpoint inhibitors-induced global T-cell activation.  
We will examine the levels of cytokines before and after treatment with blinatumomab and 
checkpoint inhibitors, including the levels of sCTLA-4.  In particular, sCTLA-4 is found at a 
significantly higher frequency in ALL patients than healthy controls, and higher levels of 
sCTLA-4 correlate with relapse risk and the probability of survival following treatment.77,78  
Experimental evidence suggests that current anti-CTLA-4 antibodies bind both sCTLA-4 and 
membrane-bound CTLA-4 and as such that their administration may improve the immune 
recognition of ALL cells.79 We anticipate that the levels of sCTLA-4 may decrease upon 
ipilimumab treatment. 
 

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2.4.5 
Immune profiling of T cell repertoire and characterize T cell transcriptional 
signature before and after treatment 
 
2.4.5.1 
Immune Profiling of T-cell repertoire 
 
High throughput deep sequencing of the TCRV-β CDR3 region is very valuable technology to 
better characterize the T-cell repertoire changes after checkpoint inhibitor administration.  The 
best metric of TCR repertoire diversity are changes in clonality index and repertoire 
diversification.  This strategy is being increasingly used to assess T-cell repertoire changes in 
both periphery and intra-tumor environment providing critical mechanistic clues.  Previous 
studies have shown that ipilimumab leads to TCR diversification and the induction of new 
tumor-antigen specific T-cell responses as early as two weeks after first administration.91-93  
However, it remains unclear how simultaneous use of multiple immunotherapeutics will affect 
the TCR repertoire and if standardized metrics will correlate with toxicity or clinical response.  
We anticipate that treatment with blinatumomab will lead to diversification of the TCR 
repertoire that would be further modeled by checkpoint inhibitors.  The studies proposed in this 
protocol will evaluate TCR diversity in T cells isolated from PB and BM from patients before 
and after treatment with blinatumomab and checkpoint inhibitors on the parent clinical trial.  We 
will determine TCR diversity and clonal composition using a molecular and computational 
approach based on high-throughput DNA sequencing of rearranged TCRβ CDR3 regions from 
T-cell genomic DNA.  The findings derived from these analyses are meant to generate 
hypotheses and will be expanded upon with additional studies.  
 
2.4.5.2 
Characterization of T-cell transcriptional signature before and after treatment 
 
We have substantial experience with this approach from our ongoing analysis of T-cell 
dysfunction in patients with AML (data not shown).  We now have evidence at the 
transcriptional level that CD8+ T cells from AML patients have significant up-regulation of 
genes involved in T-cell co-inhibition and transcription factors associated with T-cell exhaustion 
when compared to healthy controls.  Serial gene expression analysis of CD8+ T cells (at 
diagnosis and after induction chemotherapy) using the Human Prime View Gene Expression 
Array (http://www.affymetrix.com) revealed that CD8+ T-cell gene signatures differ in patients 
who achieve complete response versus non responding (NR) patients at the time of response 
assessment. Most strikingly, the set of genes up-regulated in responding patients clustered 
together with healthy controls, whereas NR patients clustered separately.74  Gene expression will 
be analyzed with focus on “pretreatment” and “response to treatment” analyses.  We predict 
based on our previous work that several key co-stimulatory signaling pathways will be 
downregulated in CD8+ T cells retrieved from patients with ALL in comparison to healthy 
controls and that these pathways will differ after blinatumomab, nivolumab ± ipilimumab 
administration.  We will also examine whether there is differential-expression of genes between 
CD8+ T cells in BM relative to those in circulation.  These studies are likely to provide 
important insights into the T-cell transcriptome in patients with ALL in particular as it relates to 
the immunomodulatory strategies to modulate their function.  The goal of this analysis is to 
provide the biological understanding necessary for future clinical studies of blinatumomab and 
checkpoint inhibitors in ALL including improved selection of patients who may benefit from this 
therapeutic strategy. 

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2.5 
Summary 
 
Outcomes in relapsed or refractory ALL as well as outcomes for older patients who receive 
traditional induction chemotherapy remain poor with a significant risk of relapse and death.3-6,8,10 
The novel BiTE antibody blinatumomab has recently demonstrated efficacy in both Ph-positive 
and Ph-negative Pre-B ALL that has relapsed or is refractory to treatment, but only half of the 
patients respond and the duration of remission from this treatment is typically short.33,94 Pre-
clinical studies suggest that inhibition of PD-1/PD-L1 immune regulatory axis could augment the 
blinatumomab-initiated T-cell response, thereby overcoming a potential mechanism of 
blinatumomab resistance.75,76 There is also evidence that the CTLA-4/CD80/CD86 immune 
regulatory pathway is upregulated in ALL, suggesting that inhibition of this pathway in 
combination with blinatumomab could yield a more robust immune-mediated attack on CD19+ 
ALL cells.77,78 Combinations of the anti-PD1 antibody nivolumab and anti-CTLA4 antibody 
ipilimumab have demonstrated remarkable efficacy in melanoma with sustained responses and 
an acceptable side effect profile.58 Thus there is strong rationale for combining blinatumomab 
with both single and dual immune checkpoint blockade in relapsed or refractory Pre-B ALL in 
the interest of increasing the frequency and duration of remissions by improving the T cell-
mediated immune response to the underlying malignancy.  
 
 
 

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3. PATIENT SELECTION 
 
3.1 
Pre-Registration Eligibility Criteria  
 
3.1.1 Patients must have suspected refractory or relapsed pre-B cell ALL or mixed phenotype 
acute leukemia (MPAL), or if newly diagnosed, the patient must be 60 years of age or 
older. 
3.1.2 Bone marrow and/or peripheral blood specimens will be submitted for correlative 
studies as outlined in Section 9. Patients who have a dry tap will still be eligible. 
 
3.2 
Registration Eligibility Criteria 
 
3.2.1 Patients must have histologically or cytologically confirmed by the local institution 
CD19+ Precursor B-acute lymphoblastic leukemia (Pre-B cell ALL) OR CD19+ mixed 
phenotype acute leukemia (MPAL): a) with relapse following or refractory to at least one 
prior line of therapy if older than 21 years; b) in second or higher relapse or refractory to 
at least two prior lines of therapy if 21 years old and younger (16-21); c) or they must 
have a new diagnosis of Pre-B cell ALL or CD19+ MPAL but are ≥60 years old and are 
either not a candidate for or do not wish to receive traditional induction chemotherapy. 
 
3.2.2 The evidence of CD19+ expression on leukemia cells must be confirmed by pathology 
review of the bone marrow and/or peripheral blood specimens (flow cytometry and/or 
immunohistochemistry) collected at the time of current relapse and prior to the initiation 
of therapy. 
 
3.2.3 Patients with Ph+ Pre-B cell ALL OR Ph+ MPAL will be eligible if they have been 
refractory to or intolerant of treatment with at least 1 second-generation or third-
generation tyrosine kinase inhibitor (TKI). 
 
3.2.4 Patients who were treated with blinatumomab in the past will be allowed on the study as 
long as they have persistent CD19 expression on leukemia cells and did not experience 
unacceptable toxicities with prior blinatumomab administration. Patients who were 
treated with chimeric antigen receptor (CAR)-modified T cells targeting CD19 in the past 
will be allowed on the study as long as they have persistent CD19 expression on 
leukemia cells.  
 
3.2.5 Patients with a history of allogeneic HSCT will be eligible if they are more than 90 days 
removed from the date of stem cell infusion, have no evidence of acute graft-versus-host 
disease (GVHD) or active chronic (grade 2-4) GVHD, and are off of all transplant-related 
immunosuppression for at least 2 weeks. 
 
3.2.6 Age ≥16 years.  Because no dosing or adverse event data are currently available on the 
use of blinatumomab in combination with nivolumab ± ipilimumab in pediatric patients, 
children are excluded from this study, but will be eligible for future pediatric trials. 
 
3.2.7 ECOG/Karnofsky performance status of 0-2 (Karnofsky ≥60%, see Appendix A). 

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3.2.8 Life expectancy of greater than 12 weeks. 
 
3.2.9 Patients must have normal organ function as defined below: 
− 
total bilirubin 
 
 
 
 
≤2.0 mg/dL (except patients with 
Gilbert Syndrome, who can have total bilirubin <3.0 mg/dL) 
− 
AST(SGOT)/ALT(SGPT) 
 
 
≤5× ULN 
− 
Serum creatinine 
 
 
 
 
≤1.5× ULN  
 
 
 
                      OR 
− 
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 x 1.00 72 x serum creatinine in 
mg/dL  
 
3.2.10 The effects of nivolumab, ipilimumab, and blinatumomab on the developing human fetus 
are unknown.  For this reason, women of child-bearing potential (WOCBP) and men 
must agree to use adequate contraception (hormonal or barrier method of birth control; 
abstinence) prior to study entry and for the duration of study participation.  WOCBP 
should use an adequate method to avoid pregnancy for 23 weeks after the last dose of 
investigational drug.  Women of childbearing potential must have a negative serum or 
urine pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) within 24 
hours prior to the start of treatment on the study.  Women must not be breastfeeding.  
Men who are sexually active with WOCBP must use any contraceptive method with a 
failure rate of less than 1% per year.  Men receiving nivolumab ± ipilimumab and 
blinatumomab and who are sexually active with WOCBP will be instructed to adhere to 
contraception for a period of 31 weeks after the last dose of investigational product.  
Women who are not of childbearing potential (i.e., who are postmenopausal or surgically 
sterile as well as azoospermic men) do not require contraception.   
 
Note:  Women of childbearing potential (WOCBP) is defined as any female who has 
experienced 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 woman over 45 
in the absence of other biological or physiological causes.  In addition, women 
under the age of 55 must have a documented serum follicle stimulating hormone 
(FSH) level less than 40 mIU/mL.   
 
Should a woman 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. 
 
3.2.11 Adequate pulmonary function as assessed by oxygen saturation ≥90% when ambulating 
and not requiring supplemental oxygen. 
 

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3.2.12 Patients with a known history of testing positive for human immunodeficiency virus 
(HIV) or known acquired immunodeficiency syndrome (AIDS) will be eligible if: 
1. 
They are generally healthy from an HIV perspective and on a stable 
antiretroviral regimen for >6 months. 
2. 
They have had no AIDS-defining conditions in the past 12 months other 
than historically low CD4+ cell counts. 
3. 
They have an undetectable viral load on standard assays. 
 
3.2.13 Patients with a known history of hepatitis C (HCV) will be eligible if they have an 
undetectable viral load.  If the patient received treatment for HCV, then that treatment 
must have been completed at least three weeks prior to enrollment. 
 
3.2.14 Ability to understand and the willingness to sign a written informed consent document. 
 
3.3 
Exclusion Criteria 
 
3.3.1 Patients who have had chemotherapy or other systemic therapy or radiotherapy, or those 
who have not recovered from adverse events due to prior administered agents as follows: 
chemotherapy, radiotherapy or surgery ≤ 3 weeks prior to entering the study, targeted 
therapy (e.g., TKI) ≤ 1 week prior to entering the study; autologous HSCT ≤ 6 weeks 
prior to entering the study; investigational drug or immunotherapy (e.g. rituximab) ≤ 4 
weeks prior to entering the study.  Prophylactic intrathecal chemotherapy within one 
week of enrollment allowed. Patients will be allowed to receive cytoreduction with 
hydroxyurea, 6-mercaptopurine, corticosteroids (dexamethasone, prednisone or similar) 
or cyclophosphamide provided that it is discontinued at least 24 hours prior to the 
initiation of study treatment. Pre-phase treatment with dexamethasone 10 mg/m2 
(maximum total 24 mg per day) for up to 5 days is required for patients with bone 
marrow blasts more than 50%, peripheral blood blasts of 15,000/μL or higher, or elevated 
lactate dehydrogenase suggesting rapidly progressing disease as per investigator’s 
assessment. Pre-phase treatment must be stopped at least 24 hours prior to the initiation 
of blinatumomab. 
 
3.3.2 Patients who are receiving any other investigational agents. 
 
3.3.3 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.   
 
3.3.4 Patients with active central nervous system leukemia are excluded from this clinical trial 
because they may develop progressive neurologic dysfunction that would confound the 
evaluation of neurologic and other adverse events.  Patients with a history of CNS 
leukemia but no active disease at the time of enrollment are eligible.  The absence of 
CNS disease must be confirmed by flow cytometric and cytologic examination of the 
cerebrospinal fluid (CSF) within 7 days of study enrollment. 
 
3.3.5 Active leukemia in the testes or isolated extramedullary relapse. Patients with a history of 

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treated leukemia in testes but no active disease at the time of enrollment are eligible. 
 
3.3.6 History of allergic reactions attributed to compounds of similar chemical or biologic 
composition to nivolumab, ipilimumab, or blinatumomab. 
 
3.3.7 History of severe hypersensitivity reaction to any monoclonal antibody. 
 
3.3.8 Uncontrolled intercurrent illness including, but not limited to, active, uncontrolled 
infection; symptomatic congestive heart failure; unstable angina pectoris; cardiac 
arrhythmia; or psychiatric illness/social situations that would limit compliance with study 
requirements.  Patients with infection under treatment and controlled with antibiotics are 
eligible. 
 
3.3.9 Pregnant women are excluded from this study because nivolumab and ipilimumab have 
the potential for teratogenic or abortifacient effects.  Because there is an unknown but 
potential risk for adverse events in nursing infants secondary to treatment of the mother 
with nivolumab and ipilimumab, breastfeeding should be discontinued if the mother is 
treated with nivolumab and ipilimumab.  These potential risks may also apply to 
blinatumomab. 
 
3.3.10 History of any chronic hepatitis including alcoholic, non-alcoholic steatohepatitis 
(NASH), drug related, autoimmune, chronic viral positive tests for hepatitis B virus 
surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) in the absence of hepatitis 
B surface antibody (anti-HBs), or a positive hepatitis C (HCV) viral load.  These patients 
are excluded due to the risk for autoimmune hepatitis with immune checkpoint inhibitors 
exacerbating their known liver disease as well as the unknown risk for hepatitis B and/or 
C reactivation with blinatumomab and immune checkpoint inhibitors.   
 
3.3.11 Subjects with active autoimmune disease, a history of known or suspected autoimmune 
disease or a history of a syndrome requiring systemic corticosteroids (>10 mg daily of 
prednisone equivalent) except for the treatment of malignancy with the exception of: 
a. 
Isolated vitiligo 
b. 
Resolved childhood atopy 
c. 
History of a positive ANA titer without associated symptoms or history of 
symptoms of an autoimmune disorder 
d. 
Controlled thyroid disorders 
e. 
Type I diabetes mellitus 
f. 
Psoriasis, Sjögren’s syndrome, and arthropathies not requiring systemic treatment 
 
Autoimmune diseases: 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, autoimmune vasculitis, 
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 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
34 
 
exacerbation of disease.  
 
3.3.12 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), or as prephase treatment for 
cytoreduction as specified in 3.2.1 is permitted.  Patients will receive steroids with 
blinatumomab to reduce cytokine release syndrome (CRS) as specified in the protocol. 
 
3.3.13 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. 
 
3.3.14 Patients who have a history of clinically relevant CNS pathology such as epilepsy, 
seizure, paresis, aphasia, stroke, severe brain injuries, dementia, Parkinson’s disease, 
cerebellar disease, psychosis, or other significant CNS abnormalities.  A history of 
treated CNS leukemia will be allowed if recent CNS studies confirm the absence of 
active CNS disease at the time of study entry (screening). 
 
3.3.15 Patients with a known concurrent malignancy that is progressing or requires active 
treatment.  Exceptions include basal cell carcinoma of the skin or squamous cell 
carcinoma of the skin that has undergone potentially curative therapy or carcinoma in situ 
of the cervix. 
 
3.3.16 Subjects with interstitial lung disease that is symptomatic or may interfere with the 
detection or management of suspected drug-related pulmonary toxicity. 
 
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. 
 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
35 
 
4. REGISTRATION PROCEDURES 
 
4.1 
Investigator and Research Associate Registration with CTEP 
 
Food and Drug Administration (FDA) regulations and National Cancer Institute (NCI) 
policy require all investigators participating in any NCI-sponsored clinical trial to register 
and to renew their registration annually. To register, all individuals must obtain a Cancer 
Therapy Evaluation Program (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.   
 
Additional information can be found on the CTEP website at 
https://ctep.cancer.gov/investigatorResources/default.htm 
 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
36 
 
For questions, please contact the RCR Help Desk by email at <RCRHelpDesk@nih.gov.> 
 
4.1.1 CTEP Associate Registration Procedures / CTEP-IAM Account 
 
The Cancer Therapy Evaluation Program (CTEP) Identity and Access Management 
(IAM) application is a web-based application intended for use by both Investigators (i.e., 
all physicians involved in the conduct of NCI-sponsored clinical trials) and Associates 
(i.e., all staff involved in the conduct of NCI-sponsored clinical trials). 
 
Associates will use the CTEP-IAM application to register (both initial registration and 
annual re-registration) with CTEP and to obtain a user account. 
 
Investigators will use the CTEP-IAM application to obtain a user account only.  (See 
CTEP Investigator Registration Procedures above for information on registering with 
CTEP as an Investigator, which must be completed before a CTEP-IAM account can be 
requested.) 
 
An active CTEP-IAM user account is required to access all CTEP applications and, if 
applicable (e.g., all Network trials), all Cancer Trials Support Unit (CTSU) applications 
and websites. 
 
Additional information can be found on the CTEP website at 
http://ctep.cancer.gov/branches/pmb/associate_registration.htm. 
 
For questions about Associate Registration or CTEP-IAM Account Creation, please 
contact the CTEP Associate Registration Help Desk by email at 
ctepreghelp@ctep.nci.nih.gov. 
 
4.1.2 Investigator Brochure Access for CTEP IND agents 
 
The current version of the Investigator Brochure (IB) 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 via email to 
IBcoordinator@mail.nih.gov or by phone (240) 276-6575 Monday through Friday between 
8:30 am and 4:30 pm (ET). 
 
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 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
37 
 
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 this study are 
not required to submit 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 intent 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 #10030 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 
• Click on the By Lead Organization folder to expand, then select LAO-MD017, 
and protocol #10030. 
• 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 10030 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) 
• A Study Initiation Visit (SIV) is required for each participating site prior to 
activation. The local site PI must participate on the call as well as their Research 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
38 
 
Nurse, Study Coordinator, and Pharmacist. To schedule a SIV, please email the 
LAO Protocol Contact and reference the protocol in the subject line of the email.  
 
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 in to 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 tab 
• 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 
protocol or the enrolling investigator’s status with the NCI or their affiliated networks. 
 
4.3 
Patient Registration 
 
4.3.1 Pre-Registration Procedures 
In order to submit the baseline bone marrow aspirate and biopsy and peripheral blood 
samples, the patient must be pre-registered and assigned a subject ID. The following 
should be confirmed by the site prior to pre-registering the patient:  
 
• Informed consent: the patient must be aware of the neoplastic nature of his/her 
disease and willingly consent after being informed of the procedure to be 
followed, the experimental nature of the therapy, alternatives, potential benefits, 
side-effects, risks, and discomforts. Current human protection committee approval 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
39 
 
of this protocol and a consent form is required prior to patient consent and 
registration.  
• Dose Level and Accrual: prior to discussing protocol entry with prospective 
patients, site staff must contact the Johns Hopkins Regulatory contact to check the 
status of the dose level accrual. 
• Correlative Studies: bone marrow and/or peripheral blood will be submitted for 
correlative studies for all patients pre-registered to this study. Note: If the 
procedure is a dry tap, the patient is still eligible. The peripheral blood must be 
submitted. 
 
4.3.2 Registration Procedures through 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.  
 
4.3.3  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 or request slot reservations:  Be on an ETCTN Corresponding 
or Participating Organization roster with the role of Registrar. Registrars must 
hold a minimum of an AP registration type.  
• To approve slot reservations or 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. 
 
4.4 
General Guidelines 
 
Following registration, patients should begin protocol treatment as rapidly as possible. 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. 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
40 
 
5. TREATMENT PLAN 
 
5.1 
Agent Administration 
 
Treatment will be initiated on an inpatient basis. Reported adverse events and potential risks are 
described in Section 7. Appropriate dose modifications are described in Section 6. No 
investigational or commercial agents or therapies other than those described below may be 
administered with the intent to treat the patient's malignancy. The cycle length is 42 days for all 
dose levels.   
 
Treatment will consist of the combination of blinatumomab and nivolumab, with or without 
ipilimumab per the dose escalation schedule below. A run-in of blinatumomab (10 days with 
planned dose escalation on day 8) prior to combination therapy will be incorporated at all dose 
levels to help determine the effect of blinatumomab on immune regulatory pathways in leukemia 
and as a means of minimizing the potential for overlapping toxicities, as many of 
blinatumomab’s most significant side effects occur within the first few days of administration or 
after a dose increase. Nivolumab with or without ipilimumab will start on day 11 of cycle 1. 
When nivolumab and ipilumumab are scheduled on the same day, nivolumab should be given 
first followed by ipilimumab as described in Section 5.3.4 
 
Pre-treatment phase (pre-phase):  Pre-phase treatment with dexamethasone 10 mg/m2 (maximum 
total 24 mg per day intravenously) for up to 5 days for patients with bone marrow blasts more 
than 50%, peripheral blood blasts of 15,000/μL or higher, or elevated lactate dehydrogenase 
suggesting rapidly progressing disease as per investigator’s assessment is required unless other 
cytoreductive measures as outlined below have already been successfully implemented. Pre-
phase treatment should be completed at least 24 hours before starting blinatumomab (study 
treatment). Other pre-phase treatment for cyto-reduction including cyclophosphamide, 6-MP, 
hydroxyurea, or corticosteroids (dexamethasone, prednisone or similar) (in patients not meeting 
the aforementioned criteria) may be used at the investigator’s discretion but must be completed 
at least 24 hours prior to blinatumomab infusion. 
 
5.2 
Overall Study Design 
 
This is a multi-site, open-label, phase 1 study of blinatumomab and nivolumab with or without 
ipilimumab in patients with CD19+ Pre-B ALL or CD19+ MPAL.  The DLT evaluation window 
for all dose levels is the first cycle of treatment comprising 42 days from the initiation of 
blinatumomab. The considerations for opening a new dose level may only occur after the 
required number of subjects has passed the DLT observation period. 
 
5.2.1 Dose Escalation 
 
A standard 3+3 dose escalation design for blinatumomab and nivolumab will be used to ascertain 
the safety and tolerability of this combination. The first 3 patients will be enrolled at dose level 
DL A1 and monitored for the first cycle of treatment (42 days) for DLTs before enrolling 
additional patients. If ≤1 patient experience a DLT, an additional 3 patients will be enrolled at 
DL A1 to better define the safety and tolerability before proceeding to the combination of 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
41 
 
blinatumomab with nivolumab and ipilimumab. If ≤1 of 6 patients experience a DLT, dose 
escalation will proceed to DL B1 with the next 3 patients. If ≥2 of 3 or ≥2 of 6 patients 
experience a DLT at DL A1, then dose de-escalation may be implemented BUT ONLY after 
thorough evaluation of toxicities, discussion with CTEP, investigators and CTEP agreement with 
the next three patients enrolled at DL A-1. If ≤1 of 3 patients experience a DLT, an additional 3 
patients will be enrolled at DL A-1 to better define the safety and tolerability, before proceeding 
to the combination of blinatumomab with nivolumab and ipilimumab. If ≤1 of 6 patients 
experience a DLT, dose escalation will proceed to DL B-1 with the next 3 patients. If ≥2 of 3 or 
≥2 of 6 patients experience a DLT at DL A-1, then dose escalation will be stopped and the 
combination of blinatumomab and nivolumab will not be further pursued in this patient 
population unless specific modifications to the treatment plan could be made to ameliorate 
toxicities. This would require review of all the toxicities, discussion with CTEP, investigators, 
and their agreement, and official amendment to the study. 
 
When the safety of blinatumomab in combination with nivolumab has been established as above, 
the trial will proceed to either DL B1 or DL B-1, and a standard 3+3 dose escalation design for 
blinatumomab and nivolumab with ipilimumab will be used to ascertain the safety of this 
combination. Two dose levels (DL B-1, DL B1) may be used to evaluate this combination.  
Depending on the results from the combination of blinatumomab and nivolumab as outlined 
above, patients will first be enrolled at either DL B1 or DL B-1.  If ≤1 of 3 patients experiences a 
DLT at DL B1, an additional 3 patients will be enrolled at DL B1. If ≤1 of 6 patients experience 
a DLT, then this will be defined as the MTD. If ≥2 or more of 3 or 6 patients experience a DLT 
at DL B1, then dose de-escalation may be implemented BUT ONLY after thorough evaluation of 
toxicities, discussion with CTEP, investigators and CTEP agreement and the next three patients 
may be enrolled at DL B-1.  If the triplet combination starts at DL B-1 based on the results from 
the combination of blinatumomab and nivolumab alone, then three patients will be enrolled at 
DL B-1.  If ≤1 of 3 patients experiences a DLT at DL B-1, an additional 3 patients will be 
enrolled at DL B-1. If no more than 1 of 6 patients experience a DLT at DL B-1, then this dose 
level will be defined as MTD. If 2 or more of 3 or 6 patients experience a DLT at DL B-1, then 
dose escalation will be halted and the combination of blinatumomab, nivolumab and ipilimumab 
will not be further pursued in this patient population unless additional data become available 
supporting different doses or schedules of nivolumab and ipilimumab administration. This will 
require review of all toxicity, discussion with CTEP and official study amendment.  The MTD of 
blinatumomab in combination with nivolumab and ipilimumab is defined as the highest dose at 
which no more than 1 out of 6 patients experience a DLT.  When the MTD of blinatumomab in 
combination with nivolumab and ipilimumab is determined, an additional 6 patients will be 
enrolled in an expansion cohort to further characterize safety, tolerability and any preliminary 
signs of biological or clinical activity.   An expansion cohort of an additional 6 patients at the 
MTD of blinatumomab and nivolumab without ipilimumab will be also pursued to further 
characterize safety, tolerability and any preliminary signs of biological or clinical activity for this 
combination. The expansion cohort at the MTD of blinatumomab and nivolumab will be open 
for enrollment while dose-escalation continues for blinatumomab, nivolumab and ipilimumab. 
Enrollment priority: Patients will be enrolled in dose-escalation cohort for blinatumomab, 
nivolumab and ipilimumab first. However, if no slots are available, patients will be allowed to 
enroll in dose expansion cohort for blinatumomab and nivolumab. Once the MTD for 
blinatumomab, nivolumab and ipilimumab is defined, the enrollment in dose expansion cohorts 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
42 
 
for blinatumomab/nivolumab and blinatumomab/nivolumab plus ipilimumab will be 1:1. This 
amendment was discussed with CTEP on 03/12/2019. Based on safety and efficacy data, the 
dose level A1 was defined as MTD for blinatumomab and nivolumab combination (1 of 6 
patients with DLT; 5 of 6 patients with complete remission). 
 
 
 
 
Dose Escalation Schedule# 
Dose Level 
Dose 
Blinatumomab& 
Nivolumab 
Ipilimumab 
All Dose Levels 
Nivolumab and ipilimumab (where indicated) will be initiated on 
Day 11 of Cycle 1 
Level A-1* 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28  
80 mg IV every 2 
weeks  
None 
Level A1* 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28 
240 mg IV every 
2 weeks  
None 
Level B-1 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28 
80 mg IV every 2 
weeks 
1 mg/kg IV every 6 
weeks  
Level B1 
9 µg/day IV continuous 
infusion on Days 1-7 
28 µg/day IV continuous 
infusion on Days 8-28 
240 mg IV every 
2 weeks  
1 mg/kg IV every 6 
weeks 
 Safety run-in of blinatumomab and nivolumab:  Up to 6 subjects will be treated at dose level 
A1 and dose level A-1 (if necessary) prior to addition/dose escalation with ipilimumab. 
# Dose expansion of blinatumomab, nivolumab, and ipilimumab:  An expansion cohort of 6 
subjects will be treated at the MTD.   
# Dose expansion of blinatumomab and nivolumab: An expansion cohort of 6 subjects   will be 
also treated at the MTD for blinatumomab and nivolumab only. 
& In Cycle 2 and subsequent cycles blinatumomab will be administered at 28 µg/day IV 
continuous infusion Days 1-28.  Blinatumomab cycles are administered every 42 days. 

NCI Protocol #:  10030 
Version Date: January 3, 2023 
 
43 
 
 
Regimen Description 
Agent 
Premedications
; Precautions 
Dose** 
Route 
Schedule** 
Cycle 
Length 
Blinatumomab 
20 mg IV 
dexamethasone 
1 hour prior to 
initiation in each 
cycle and at step 
dose escalation 
in cycle 1 
9 µg/day on 
Days 1-7 
28 µg/day on 
Days 8-28 
Continuous IV 
infusion 
Days 1-28 
of each 
cycle up to 
5 cycles 
42 days  
(6 weeks) 
 
 
 
Nivolumab 
None 
80 or 240 mg 
IV 
IV, 30-minute 
infusion 
Day 11, 
and then 
every 2 
weeks for 1 
year& 
Ipilimumab 
None 
1 mg/kg 
IV, 90-minute 
infusion 
Day 11, 
and then 
every 6 
weeks for 1 
year& 
** Doses and schedule as appropriate for assigned dose level.  In Cycle 2 and subsequent 
cycles, blinatumomab will be administered at 28 μg/day IV continuous infusion on Days 1-28. 
& Patients will be eligible to continue receiving nivolumab and ipilimumab for up to 1 year 
 
5.2.2 Dose Expansion 
 
An additional 6 patients will be treated at the MTD for both combinations: blinatumomab and 
nivolumab alone; and blinatumomab/nivolumab plus ipilimumab to gain additional safety 
information and to explore preliminary biological and clinical activity of these combination 
therapies. When the MTD of blinatumomab in combination with nivolumab and ipilimumab is 
determined (either DLB1: Nivolumab 240 mg plus Ipilimumab 1 mg/kg or DLB-1: Nivolumab 
80 mg and Ipilimumab 1 mg/kg), an additional 6 patients will be enrolled in an expansion cohort 
to further characterize safety, tolerability and any preliminary signs of biological or clinical 
activity of nivolumab and ipilimumab in combination with blinatumomab.  However, if the 
combination of blinatumomab, nivolumab and ipilimumab is found to be intolerable, then the 
expansion cohort of an additional 6 patients will be only pursued at the MTD of blinatumomab 
and nivolumab alone (either DLA1: Nivolumab 240 mg or DLA-1: Nivolumab 80 mg) to further 
characterize safety, tolerability and any preliminary signs of biological or clinical activity for 
blinatumomab and nivolumab combination.  
 
Based on the review of safety and efficacy data, in discussion with CTEP on 03/13/2019, a 
separate expansion cohort of an additional 6 patients at the MTD of blinatumomab and 
nivolumab alone was added to the study in addition to the expansion cohort of nivolumab, 
ipilimumab and blinatumomab (triple combination) to further characterize safety, tolerability and 

NCI Protocol #:  10030 
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44 
 
any preliminary signs of biological or clinical activity for this combination. 
 
Continuous evaluation of adverse events will be performed throughout enrollment in the 
expansion cohort. If, at any time, the aggregate rate of treatment-related toxicities meeting DLT 
criteria exceeds 30% across all subjects treated in the expansion cohort, the safety data will be 
discussed and further enrollment may be suspended. 
 
5.3 
Study Drugs 
 
5.3.1 Blinatumomab 
 
 
Blinatumomab will be administered as a continuous IV infusion over four weeks followed by a 
two-week treatment-free interval. It is recommended that patients are hospitalized at least during 
the first 14 days of the first cycle and the first two days of the subsequent cycles. The 
hospitalization time depends on the investigator´s judgment, as well as safety and tolerability of 
blinatumomab. 
 
Cycle 1: The planned initial dose of blinatumomab is 9 g/day administered via continuous 
intravenous infusion on days 1-7 of the first 42-day cycle.  If patients tolerate the initial infusion 
without significant adverse events, then the dose of blinatumomab will be escalated to 28 g/day 
administered via continuous intravenous infusion on days 8-28 of cycle 1.  There will be a 
minimum blinatumomab treatment-free interval of 14 days following the completion of 
blinatumomab infusion prior to the initiation of the next cycle.  Patients will be eligible for up to 
five cycles of blinatumomab if they achieve complete remission (CR) or CR with incomplete 
hematologic recovery (CRh) following 1-2 cycles of treatment.  Given that this is a group of 
patient with a very high risk ALL, patients will be eligible to proceed to allogenic HSCT at the 
treating physician’s discretion at any time after a response is documented. For patients receiving 
cycles 2-5, the planned dose of blinatumomab is 28 g/day to be administered via continuous 
infusion on days 1-28 of each 42-day cycle. 
 
Blinatumomab should be infused at a constant flow rate using an infusion pump. The pump 
should be programmable, lockable, non-elastomeric, and have an alarm. Blinatumomab infusion 
bags should be infused over 24 or 48 hours according to the instructions on the pharmacy label 
on the bags (Section 8.1.1). The solution should be administered using IV tubing that contains a 
sterile, non-pyrogenic, low protein-binding, 0.2 micron in-line filter. The IV line should never be 
flushed, especially when changing bags or at the completion of infusion, due to the risk of excess 
dosage. Blinatumomab should be infused through a dedicated lumen.  Nivolumab +/- ipilimumab 
will be infused through a separate line from blinatumomab to allow continuous blinatumomab 
infusion when nivolumab +/- ipilimumab are administered.  
 
Blinatumomab is known to cause cytokine release syndrome (CRS).  To reduce the incidence of 
CRS associated with blinatumomab administration, all patients will be pre-medicated with 
dexamethasone 20 mg to be given intravenously one hour prior to the initiation of blinatumomab 
on day 1 of each cycle, prior to a step dose escalation (such as cycle 1 day 8), or when restarting 
an infusion after an interruption of 4 hours or more. 
 

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5.3.2 Nivolumab 
 
Nivolumab will be given every two weeks (±2 days) at a dose of 80 or 240 mg for up to 1 year.  
Nivolumab administration starts on day 11 of cycle 1; however, the first dose of nivolumab may 
be delayed up to 4 days (until day 15) in cycle 1 if necessary to allow resolution of any adverse 
events associated with blinatumomab administration.  If the delay is more than 4 days then the 
nivolumab should be administered at the next scheduled time (day 25±2 days of cycle 1).  
Patients may be dosed no less than 12 days from the previous dose of drug.  Patients may 
continue on nivolumab for up to one year from the start of treatment on the study if they achieve 
CR or CRh following 1-2 cycles of treatment.   
 
Nivolumab is to be administered as IV infusion over approximately 30 minutes, using a 
volumetric pump with a 0.2/1.2-micron low protein binding (polyethersulfone membrane) in-line 
filter at the protocol-specified dose. The drug can be diluted with 0.9% normal saline or D5W for 
delivery but the total drug concentration of the solution cannot be below 0.35 mg/mL.  It is not to 
be administered as an IV push or bolus injection.  At the end of the infusion, flush the line with a 
sufficient quantity of normal saline.  Nivolumab will be administered through a separate line 
from blinatumomab to allow continuous blinatumomab infusion during nivolumab 
administration. A flat dose of 240 mg can be infused undiluted or diluted so as not to exceed a 
total infusion volume of 120 mL. 
 
For nivolumab and ipilimumab combination studies see section 5.3.4.  
 
5.3.3 Ipilimumab 
 
Ipilimumab will be given at a dose of 1 mg/kg every 6 weeks. Patients may be dosed no less than 
38 days from the previous dose of drug.  Ipilimumab administration starts on day 11 of cycle 1; 
however, the first dose of ipilimumab may be delayed up to 4 days (until day 15) in cycle 1 if 
necessary to allow resolution of any adverse events associated with blinatumomab 
administration. If the delay is more than 4 days and as the goal is to administer ipilimumab and 
nivolumab on the same day, then the ipilimumab should be administered at the next scheduled 
time of nivolumab administration (day 25 ± 2 days).  Patients may continue on ipilimumab for 
up to one year from the start of treatment on the study if they achieve CR or CRh following 1-2 
cycles of treatment.   
 
The dosing calculations should be based on the actual body weight. If the subject’s weight on the 
day of dosing differs by >10% from the weight used to calculate the original dose, the dose must 
be recalculated. All doses should be rounded to the nearest milligram or as per institutional 
guidelines. There will be no dose modifications allowed.  
 
Study drug is to be administered as an IV infusion using a volumetric pump through an in-line, 
sterile, non-pyrogenic, low-protein-binding filter with a pore size of 0.2 micrometer to 1.2 
micrometer.  
 
The infusion should be administered over approximately 90 minutes, followed by a normal saline 

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(NS) flush with an adequate amount of NS to completely flush the residual fluid (dead space) in 
the administration set (approximately 30 - 50 mL).  Ipilimumab will be administered through a 
separate line from blinatumomab to allow continuous blinatumomab infusion during ipilimumab 
administration.   
 
5.3.4 Nivolumab with Ipilimumab 
 
Nivolumab and ipilimumab should be given on the same day, whenever possible. If one 
medication needs to be held/delayed, the other medication should ideally be held as well to allow 
concurrent dosing. 
 
When infusions of ipilimumab and nivolumab are given on the same day, the preferred treatment 
is to give nivolumab followed by ipilimumab. 
  
Toxicity management for the combined agents follows the same template guidelines and 
algorithms that are provided in Section 6.3 and Appendix D for single agent nivolumab.   
 
Follow the same infusion timing guidelines: nivolumab over 30 minutes and ipilimumab over 90 
minutes. The length of each cycle and the number of cycles or doses should be explained clearly.   
 
When both nivolumab and ipilimumab are to be administered on the same day, separate infusion 
bags and filters must be used for each infusion. Nivolumab is to be administered first. The 
nivolumab infusion must be promptly followed by a saline flush to clear the line of nivolumab 
before starting the ipilimumab infusion.  
 
5.4 
Definition of Dose-Limiting Toxicity 
 
Dose-limiting toxicity (DLT) will be assessed for the first cycle of treatment (6 weeks/42 days) 
at all dose levels. 
 
A DLT is considered a treatment-related toxicity. Subjects who are withdrawn from the study 
before the completion of the DLT evaluation period in any phase for a reason other than a DLT 
will be replaced (NOTE: This includes subjects who may be removed during the blinatumomab-
only run-in phase, prior to addition of nivolumab/ipilimumab). A toxicity with a clear etiology 
NOT related to a study treatment agent may not be considered a DLT; the Protocol Chair should 
be consulted in all cases. 
 
DLTs include any grade 3 or higher non-hematologic toxicities which requires a subject to 
permanently discontinue protocol treatment during the DLT period as defined in Section 6.2.2 
and 6.3.4 with the following exceptions:  
 
A) Any grade 3 or 4 drug-related laboratory abnormality or electrolyte abnormality that can 
be managed with electrolyte replacement, hormone replacement, insulin or that does not 
require treatment discontinuation 
B) Any grade 3 or higher toxicities that are frequent in ALL population such as fever, 
infection, bleeding, fatigue, bone pain, disseminated intravascular coagulation, tumor 

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lysis syndrome. Grade 4 infections which are felt by the PI to be primarily related to 
nivolumab ± ipilimumab administration or may have been exacerbated by nivolumab ± 
ipilimumab administration will be considered DLT. The PI and study team will closely 
monitor the cumulative rate of infections through the trial and in the expansion cohort to 
see whether the rate is higher than expected with blinatumomab alone. 
C) Any grade 3 or 4 event that occurs during the blinatumomab run-in period prior to the       
initiation of nivolumab or ipilimumab and requires permanent treatment discontinuation 
will not be considered a DLT.  During the phase II trial based on which blinatumomab 
received FDA approval, 10% of patients permanently discontinued blinatumomab due to 
adverse events that were thought to be treatment-related and 18% of patients discontinued 
treatment due to adverse events.32 Thus adverse events requiring treatment 
discontinuation due to blinatumomab monotherapy are common and expected, so they 
should not be defined as DLTs in a trial to assess combination therapy.      
 
For hematologic toxicity, the only adverse event that will be considered dose limiting is: 
 
Grade ≥4 neutropenia or thrombocytopenia with a hypocellular bone marrow and no evidence of 
residual leukemia lasting for >42 days. Given that severe anemia, neutropenia and 
thrombocytopenia are features of advanced ALL and commonly encountered in this patient 
population, they will not be used to define DLT except if associated with prolonged treatment-
associated aplasia as described above. 
 
Management and dose modifications associated with the above adverse events are outlined in 
Section 6.  Dose delay would be permitted as indicated in Section 6.   
 
Dose escalation will proceed within each cohort according to the following scheme.  Dose-
limiting toxicity (DLT) is defined above.     
 
Number of Patients with DLT at a 
Given Dose Level 
Escalation Decision Rule 
0 out of 3 
Enter 3 patients at the next dose level.** 
≥2 
Dose escalation will be stopped.  This dose level will be 
declared the maximally administered dose (highest dose 
administered).  Three (3) additional patients will be 
entered at the next lowest dose level if 0 or 3 patients 
were treated previously at that dose. 
1 out of 3 
Enter at least 3 more patients at this dose level. 
• If 0 of these 3 patients experience DLT, proceed to 
the next dose level. 
• If 1 or more of this group suffer DLT, then dose 
escalation is stopped, and this dose is declared the 
maximally administered dose.  Three (3) additional 
patients will be entered at the next lowest dose level 

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if only 3 patients were treated previously at that dose. 
≤1 out of 6 at highest dose level 
below the maximally administered 
dose 
This is generally the recommended phase 2 dose. At 
least 6 patients must be entered at the recommended 
phase 2 dose. 
**For dose levels A1 and A-1 (if necessary), six total patients will be enrolled even if there are 
no toxicities among the first three patients 
 
5.5 
General Concomitant Medication and Supportive Care Guidelines 
 
Because there is a potential for interaction of blinatumomab, nivolumab, and ipilimumab 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.  The Principal Investigator 
should be alerted if the patient is taking any agent known to affect or with the potential for drug 
interactions.  The study team should check a frequently-updated medical reference for a list of 
drugs to avoid or minimize use of.  Appendix B (Patient Drug Information Handout and Wallet 
Card) should be provided to patients if available. 
 
5.5.1 Supportive Care Guidelines  
 
In general, concomitant medications and therapies deemed necessary for the supportive care and 
safety of the subject are allowed, provided their use is documented in the medical records and 
meets the dose modification guidelines outlined in Section 6. The administration of any other 
therapies intended to treat the primary condition including chemotherapy and biologic agents is 
NOT permitted. Similarly, the use of other concurrent investigational drugs is not allowed.  
 
5.5.2 Permitted Concomitant Medications  
 
• Corticosteroids: Inhaled or topical steroids and adrenal replacement doses ≤10 mg 
daily prednisone equivalents are permitted in the absence of active autoimmune disease. 
Subjects 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), for treatment of 
non-autoimmune conditions (e.g., delayed-type hypersensitivity reaction caused by 
contact allergen), treatment of toxicities (e.g., cytokine release syndrome or neurologic 
toxicity due to blinatumomab or autoimmune toxicities caused by ipilimumab or 
nivolumab), and for treatment of infusion reactions and premedication (i.e. 20 mg of 
dexamethasone prior to blinatumomab initiation and step doses, and prior to re-initiating 
infusion if interrupted for ≥4 hours) is permitted. Additionally, prephase treatment with 
dexamethasone 10 mg/m2 (maximum total 24 mg per day) for up to 5 days is required 
with bone marrow blasts more than 50%, peripheral blood blasts of 15,000/μL or higher, 
or elevated lactate dehydrogenase suggesting rapidly progressing disease as per 
investigator’s assessment to reduce the tumor burden and mitigate the potential for 
cytokine release syndrome unless other acceptable cytoreductive measures, as written in 

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3.2.1 and 5.1 have previously been employed.  There is a published case report 
suggesting that for cases of life-threatening cytokine release syndrome for which 
dexamethasone and supportive care measures are not adequate, consideration may be 
given to the administration of tocilizumab, the anti-IL-6 monoclonal antibody.90 
 
5.5.3 Antiemetics 
 
Antiemetics will be used according to standard practices. Any 5-hydroxytryptamine (5-HT3) 
receptor inhibitor (ex. ondansetron) combined with prochlorperazine or similar can be used 
during treatment, as needed. 
 
5.5.4 Antimicrobial Prophylaxis 
 
Patients should receive prophylaxis directed against gram-negative gastrointestinal infections 
(GI), Candidiasis/mold, Pneumocystis pneumonia (PCP), and/or herpes simplex virus (HSV), 
according to individual institutional practices.  
 
5.5.5 Intrathecal Prophylaxis  
 
Intrathecal prophylaxis must be used according to institutional standard practice for all patients 
with the choice of agent at the discretion of the investigator.  Maximum doses of up to 15 mg of 
methotrexate, up to 100 mg of cytarabine, or 40 mg of cytarabine and 12 mg of methotrexate in 
triple therapy should be employed.95-97 Hydrocortisone 50 mg intrathecally can optionally 
combined with methotrexate if desired to lessen the risk of arachnoiditis.  To reduce the risk of 
CNS leukemia relapse, intrathecal prophylaxis should be administered during screening and on 
day 29-35 of at least the first two cycles at the conclusion of blinatumomab infusion as activity 
of blinatumomab has not been established in patients with CNS leukemia.  This schedule of CNS 
prophylaxis administration has been adopted from prior blinatumomab trials to avoid 
confounding neurologic events related to intrathecal chemotherapy administration during 
blinatumomab administration.31 
 
5.5.6 Colony Stimulating Factors   
 
The routine use of colony stimulating factors is disallowed.  The use of colony stimulating 
factors in the presence of severe neutropenic infection should be used in accordance with ASCO 
guidelines and discussed with the study chair before implementation.98 
 
5.5.7 Management of Tumor Lysis Syndrome 
 
Tumor lysis occurs as part of initial cytoreductive therapy. The most extreme form, TLS, is 
characterized by hyperuricemia, hyperphosphatemia, increased lactate dehydrogenase (LDH), 
coagulopathy, and a potential cytokine release syndrome. Since the occurrence of TLS is 
magnified in the presence of large tumor burdens, we will require prephase treatment as 
specified in 3.2.1 and 5.5.2 for any patient who has > 50% bone marrow blasts, ≥15,000/µL 
peripheral blood blasts, or an elevated LDH suggestive of rapidly progressive disease as per the 
investigator’s assessment.  

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• To prevent hyperuricemia, all patients without known allergy will receive allopurinol 
300-600 mg PO qday continuing through the period of maximal tumor lysis or other anti-
uricemia regimen per institutional practice.  Rasburicase may be used per institutional 
policy for hyperuricemia.  Screening for G6PD deficiency should be obtained in 
susceptible populations before beginning Rasburicase. 
• To decrease the risk of hyperphosphatemia, an oral phosphate binder per institutional 
practice (ex. sevelamer 400-800 mg) may be administered orally every 4-6 hours 
beginning on with prephase or protocol treatment and continued as tolerated until 
maximum tumor lysis has occurred. 
• Cytokine release syndrome (CRS) can occur shortly after completion of blinatumomab 
infusion, accompany severe TLS, and present with fever, bronchospasm with dyspnea 
and/or respiratory distress, altered blood pressure, myalgias, arthralgias, tumor pain 
and/or urticarial rash. Any patient with cytokine release syndrome should receive 20 mg 
dexamethasone (or equivalent steroid) IV immediately.  Tocilizumab may also be used at 
the discretion of the investigator for CRS as per section 5.5.2. and 5.5.8.1. 
 
5.5.8 Hypersensitivity/Infusion Reactions  
 
5.5.8.1 
Blinatumomab 
 
Reactions may manifest as fevers, chills, rigors, headache, rash, urticaria, 
angioedema, pruritis, arthralgias, hypo- or hypertension, bronchospasm, or other 
symptoms.  
 
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.  
 
• For Grade 1 symptoms: (Mild reaction; infusion interruption not indicated; 
intervention not indicated)  
 
Continue therapy with supportive care, as per local institutional guidelines.  
 
• For Grade 2 symptoms: Moderate reactions require therapy or infusion 
interruption but respond promptly to symptomatic treatment (e.g., antihistamines, 
non-steroidal anti-inflammatory drugs, narcotics, corticosteroids, bronchodilators, IV 
fluids).  The infusion of blinatumomab must be stopped immediately. 
 
Supportive care, as per institutional guidelines. 
 
If the interruption is four hours or longer, re-start of the infusion should be performed 
in the hospital, under the supervision of the investigator. The subject should be 
observed overnight for possible side effects after the re-start, either in the hospital or 
in the outpatient setting as applicable. 

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Within one hour prior to start of treatment, or re-start of treatment if interruption is 
four hours or longer, and within one hour prior to any dose increases, patients must 
receive 20 mg of dexamethasone intravenously. 
 
• For Grade 3 symptoms: (Severe reactions) 
The infusion of blinatumomab must be stopped immediately. 
 
Dexamethasone should be administered at a dose of at least 24 mg per day (8 mg 
every 8 hours orally or IV) up to three days.  If symptoms persist, then tocilizumab 
may be used at the investigator’s discretion as per 5.5.2.  
 
The dexamethasone dose will then be reduced step-wise over up to four days. 
 
Hold blinatumomab until toxicity resolves to grade ≤1, then resume drug at 9 µg/day 
for one week.  If toxicity remains grade ≤1, increase dose to 28 µg/day to complete 
the 28-day cycle of therapy. 
 
Within one hour prior to re-start of treatment and within one hour prior to any 
increases, patients must receive 20 mg of dexamethasone intravenously. 
 
If grade 3 recurs after blinatumomab is resumed, stop drug permanently. 
 
If the initial adverse event last for ≥ 2 weeks without improvement, then 
blinatumomab will be permanently discontinued.  
 
• For Grade 4 symptoms: (Severe reactions) 
The infusion of blinatumomab must be stopped immediately and permanently. 
 
Dexamethasone should be administered at a dose of at least 24 mg per day (8 mg 
every 8 hours orally or IV) up to three days.  If symptoms persist, then tocilizumab 
may be used at the investigator’s discretion as per 5.5.2.   
 
The dexamethasone dose will then be reduced step-wise over up to four days. 
 
 
 
Investigators should follow their institutional guidelines for the treatment of 
anaphylaxis. Remain at bedside and monitor subject until recovery from symptoms.  
 
5.5.8.2 
Nivolumab and Ipilimumab  
 
NOTE: The same infusion reaction guidelines apply to ipilimumab. Any reference to 
nivolumab below should be used also for considerations of ipilimumab-related 
infusion reactions.  
 
Since nivolumab contains only human immunoglobulin protein sequences, it is 
unlikely to be immunogenic and induce infusion or hypersensitivity reactions. 

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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.  
 
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.  
 
• For Grade 1 symptoms: (Mild reaction; infusion interruption not indicated; 
intervention not indicated)  
 
Infusion rate may be slowed or interrupted and 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 
subject closely.  
 
The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg 
(acetaminophen) at least 30 minutes before additional nivolumab administrations, 
slowing infusion rate as above. 
  
• For Grade 2 symptoms: Moderate reaction requires therapy or infusion 
interruption but responds promptly to symptomatic treatment (e.g., antihistamines, 
non-steroidal anti-inflammatory drugs, narcotics, corticosteroids, bronchodilators, IV 
fluids); close observation for recurrence and treatment medications may need to be 
continued for 24-48 hours, and no further nivolumab will be administered at that visit.  
 
Stop the nivolumab infusion, begin an IV infusion of normal saline, and treat the 
subject with diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 
1000 mg (acetaminophen); remain at bedside and monitor subject 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 
subject closely. If symptoms recur, re-administer diphenhydramine 50 mg IV, and 
remain at bedside and monitor the subject until resolution of symptoms. The amount 
of study drug infused must be recorded on the electronic case report form (eCRF).  
The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and (acetaminophen) (or paracetamol) 325 to 
1000 mg should be administered at least 30 minutes before additional nivolumab 
administrations. If necessary, corticosteroids (recommended dose: up to 25 mg of IV 
hydrocortisone or equivalent) may be used. 
 
 
 

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• For Grade 3 or Grade 4 symptoms: (Severe reactions)  
 
o Grade 3 symptoms: prolonged (i.e., not rapidly responsive to symptomatic 
medication and/or brief interruption of infusion); recurrence of symptoms 
following initial improvement; hospitalization indicated for other clinical 
sequelae (e.g., renal impairment, pulmonary infiltrates).  
 
o Grade 4 symptoms: (life threatening; pressor or ventilatory support 
indicated): Nivolumab will be permanently discontinued.  
 
Immediately discontinue infusion of nivolumab. 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. Subject 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 subject until recovery from symptoms.  
 
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. 
 
5.5.9 Prohibited and Restricted Therapies  
 
Subjects in this study may use standard vaccines with certain exceptions. Where possible, routine 
vaccination for influenza and pneumoccal pneumonia should be given prior to the start of 
therapy but may be administered during treatment when clinically indicated. Vaccination should 
be given when there is enough separation to distinguish any vaccine reactions from drug toxicity. 
There is no experience using live attenuated vaccination during blinatumomab, nivolumab, and 
ipilimumab therapy in patients with ALL, so live vaccine should not be given during treatment.  
 
Subjects may not use any of the following therapies during the study (unless utilized to treat a 
drug-related adverse event):  
 
• Any non-study anti-cancer agent (investigational or non-investigational).  
• Any other investigational agents  
• Any other CTLA-4 inhibitors or agonists OR any other PD-1 inhibitors or agonists 
• CD137 or other immunologic activation agonists  
• Immunosuppressive agents  
• Chronic systemic corticosteroids at supraphysiologic doses  

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5.6 
Duration of Therapy 
 
In general, treatment may continue for up to 5 cycles of blinatumomab and up to 1 year of 
nivolumab/ipilimumab or until one of the following criteria are met:   
 
• 
Disease relapse, progression, or a lack of a complete remission by the end of the 2nd 
cycle of treatment 
• 
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 D): 
Any dosing interruption lasting >6 weeks for nivolumab or ipilimumab or >2 weeks 
for blinatumomab, with the following exceptions:   
− 
Dosing interruptions 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 greater than the specified time intervals, the Principal 
Investigator must be consulted.  Tumor assessments should continue as per 
protocol even if dosing is interrupted.  
• 
Dosing with blinatumomab, nivolumab and/or ipilimumab may be individually held 
or discontinued with other study treatment(s) continuing if drug-related toxicity can 
be definitively attributed to an agent(s) and other individual agent re-treatment 
criteria are met as outlined in Sections 6.2.1, 6.3.1., and 5.9.  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. 
• 
Pregnancy  
o All WOCBP 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. Institutional policy and local regulations should 
determine the frequency of on study pregnancy tests for WOCBP enrolled in the 
study.  
o The investigator must immediately notify CTEP in the event of a confirmed 
pregnancy in a subject participating in the study. 
•  Initiation of breast feeding by the patient 
•  Subject non-compliance  
• 
Treatment required with other chemotherapeutic, investigational anti-neoplastic 
drugs, or allogeneic hematopoietic stem cell transplant. Patients should be off 
nivolumab therapy for at least 6 weeks prior to having allogeneic stem cell transplant. 
• 
Delay of blinatumomab for more than 14 days within a cycle due to unresolved 
toxicities or delay of nivolumab or ipilimumab for more than six weeks due to 
unresolved toxicities.  
• 
Death or lost for follow-up 
• 
Completed treatment 
 
Please see Section 6 for specific discontinuation criteria of blinatumomab, nivolumab, and 
ipilimumab individually due to toxicity. 

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5.7 
Duration of Follow Up 
 
Patients will be followed for overall survival and relapse every 3 months for 2 years after 
removal from study treatment or until death, whichever occurs first.  Patients removed from 
study treatment for unacceptable adverse event(s) will be followed until resolution or 
stabilization of the adverse event.  Assessments for toxicity/adverse events are to continue for 
100 days after the last dose of nivolumab/ipilimumab.  Because many patients enrolled in this 
protocol will be candidates for a subsequent allo-HSCT, and there have been recent reports of 
increased toxicity among patients who undergo allo-HSCT following treatment with PD-1 
inhibitors, all patients who go onto allo-HSCT following the completion of treatment on the 
study will undergo continuous monitoring.  The clinical failures of acute grade 3-4 graft versus 
host disease and post-transplant non-relapse mortality will be monitored continuously for the 
first 100 post-transplant days. We will also collect data on development of additional cancers, 
subsequent therapy for their cancer, and survival.  Medical records including laboratory, 
pathology, operative, and radiology reports will be obtained at the discretion of the Protocol 
Chair.  
 
All reasons for discontinuation of therapy should be documented clearly in the medical record. If 
a subject discontinues or withdraws from the study, every attempt will be made to get a bone 
marrow biopsy and study bloods if the subject is able and willing to do so. 
 
5.8 
Criteria for Removal from Study 
 
Patients will be removed from study treatment when any one of the applicable criteria listed in 
Section 5.6. is met. For this protocol, all patients, including those who discontinue protocol 
therapy early, will be followed for 2 years from the end of study treatment for relapse and for 
survival (even if non-protocol therapy is initiated). Patient will be removed from study if any one 
of the following criteria is met: completion of follow up period, patient withdraws consent form 
study, death, or patients is lost for follow up. The reason for study removal and the date the 
patient was removed must be documented in the Case Report Form. 
 
5.9 
Criteria to Resume Treatment 
 
For non-autoimmune or non-inflammatory events patients may resume treatment with study drug 
when the drug-related AE(s) resolve to Grade ≤1 or baseline value, with the following 
exceptions: 
• Evaluation to exclude any additional immune mediated events endocrine, GI, and 
liver/pancreas function as clinically indicated must be made prior to restarting.  
• Non-drug-related toxicity including hepatic, pulmonary toxicity, diarrhea, or colitis, must 
have resolved to baseline before treatment is resumed. 
 
If the criteria to resume treatment are met, the patient should restart treatment no sooner than the 
next scheduled time point per protocol.  However, if the treatment is delayed past the next 
scheduled time point per protocol the treatment should resume at the earliest convenient point 
that is within the six week delay period for nivolumab/ipilimumab or the fourteen day delay 

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period for blinatumomab, as per Section 5.6.  
 
Dosing with blinatumomab, nivolumab and/or ipilimumab may be individually held or 
discontinued with other study treatment(s) continuing if drug-related toxicity can be definitively 
attributed to an agent(s) and other individual agent re-treatment criteria are met as outlined 
below.  However, patients with renal, CNS, or pulmonary toxicity must be removed from study.   
 
For patients treated with high dose steroids:  Must resolve to baseline within 6 weeks of 
treatment.  Subjects being tapered after high dose corticosteroids over one month followed by a 
two-week observation period will be allowed an additional two weeks to restart treatment (a 
maximum eight week interruption).  
 
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/ipilimumab.  
 
Must have had no recurrence of symptoms or new symptoms during steroid taper. 
 
5.10 
Treatment Beyond Progression 
 
Not applicable 
 
 
 
 

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6. DOSING DELAYS/DOSE MODIFICATIONS 
 
6.1 
General  
 
Dosing with blinatumomab, nivolumab and/or ipilimumab may be individually held or 
discontinued with other study treatment(s) continuing if drug-related toxicity can be definitively 
attributed to an agent(s) and other individual agent re-treatment criteria are met as outlined 
below. All discontinuations, relationships to treatment, and treatment decisions must be clearly 
documented in the medical record. Any questions should be discussed with the Protocol Chair.  
 
Although blinatumomab and immune checkpoint blockade have distinct toxicity profiles, they do 
share many adverse events.  There is the possibility that one agent may potentiate the other and 
hence drug causality will not always be clear.  In the event of uncertainty, dose reductions and/or 
delays will follow the most conservative approach.  
 
Dose reductions due to toxicity are permanent. Dose escalation is not allowed.  
 
NOTE: Tumor assessments should continue as per protocol even if dosing is delayed. 
 
6.2 
Blinatumomab 
 
6.2.1 Re-Treatment Criteria 
 
Prior to administration of first dose of blinatumomab in each cycle, subject’s organ function and 
treatment-related toxicities must have recovered to the following values: 
 
− 
total bilirubin 
≤2.0 mg/dL (except patients with Gilbert Syndrome, 
who can have total bilirubin <3.0 mg/dL) 
− 
AST(SGOT)/ALT(SGPT) 
≤5× ULN 
− 
Serum creatinine 
≤1.5 X ULN (Cr Cl of ≥50 mL/min)  
 
6.2.2 Dose Modifications for Blinatumomab-Related Toxicity 
 
Before any re-start, for an interruption of 4 hours or longer, pre-treatment with 20 mg of 
intravenous dexamethasone has to be administered. Re-start of the infusion should be performed 
under supervision of the investigator. The subject should be observed overnight for possible side 
effects after the re-start, either in the hospital or in the outpatient setting as applicable. 
 
Please see Table 6.1 for determination of treatment cycle duration following treatment 
interruption for all adverse events and Table 6.2 for dose modifications for adverse events 
possibly, probably or definitely related to blinatumomab. 
 
 

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Table 6.1. Determination of Cycle Length Following Treatment Interruption for Adverse 
Events 
Length of Dose 
Interruption Due to 
AE 
Length of 
Treatment Prior to 
AE Onset 
Investigator Action Once Blinatumomab is 
Restarted 
≤ 7 days 
-- 
Continue same cycle of blinatumomab for a 
total treatment duration of 28 days on 
blinatumomab. 
8-14 days 
≤ 14 days 
Cycle of treatment will be re-started as if a 
new cycle and continue for an additional 28 
days total. 
8-14 days 
> 14 days 
This cycle of treatment will be terminated. 
> 14 days 
-- 
Permanent discontinuation of treatment. 
NOTE: If the above adverse events resolve to a level allowing resumption of blinatumomab in 
less than 14 days, but logistical difficulties arise, restart of treatment can be postponed for up 
to five additional days without resulting in permanent treatment discontinuation 
 
If immune-related adverse events related to nivolumab or ipilimumab occur that require use of 
high dose steroids, the delay in blinatumomab cycle administration up to 6 weeks may be 
allowed to allow for tapering of steroids to prednisone 10 mg or less. 
 
Table 6.2 Table of Dose Modifications for Adverse Events Possibly, Probably, or Definitely 
Related to Blinatumomab 
 
Toxicity - Adverse Event 
CTCAE v4.0 
terminology 
AE Grade 
Action 
Events within the 
“Nervous system 
disorders” or 
“Psychiatric disorders” 
System Organ Class 
(SOC) 
 
 
Grade 1 
Continue at the same dose level 
Grade 2 
Dexamethasone should be administered at a dose of 
at least 24 mg per day (8 mg every 8 hours orally or 
IV) for up to three days. The dexamethasone dose 
will then be reduced step-wise over up to four days.  
Grade 3 
Infusion of the blinatumomab must be stopped 
immediately.  
Dexamethasone should be administered at a dose of 
at least 24 mg per day (8 mg every 8 hours orally or 
IV) for up to three days. The dexamethasone dose 
will then be reduced step-wise over up to four days.  
Hold blinatumomab until AE resolves to Grade ≤ 1 
and for at least 3 days, then resume drug at 9 
mcg/day. Escalate to 28 mcg/day after 7 days if the 
toxicity does not recur and if it resolved within 7 
days. If the toxicity takes more than 7 days to 
resolve, do not escalate to 28 mcg/day. If toxicity 
occurs at 9 mcg/day or it takes more than 14 days 

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Toxicity - Adverse Event 
CTCAE v4.0 
terminology 
AE Grade 
Action 
to resolve, discontinue blinatumomab permanently. 
Infusion should be re-started in the hospital, under 
supervision of the investigator and the patient 
should remain hospitalized for at least two days.  
Within one hour prior to re-start of treatment and 
within one hour prior to any dose increases, 
patients must receive 20 mg of dexamethasone 
intravenously.  
In the first three days after re-start, vital sign 
measurements and writing tests (Appendix G) 
should be performed. 
If patient has already been dose reduced to 9 
mcg/day dose for any reason and Grade 3 event 
occurs, blinatumomab should be discontinued 
permanently.  
Grade 4 
Infusion of blinatumomab must be stopped 
immediately. 
Dexamethasone should be administered at a dose of 
at least 24 mg per day (8 mg every 8 hours orally or 
IV) for up to three days. The dexamethasone dose 
will then be reduced step-wise over up to four days. 
Blinatumomab should be discontinued 
permanently. 
Seizure 
Grade 1-3 
As per Grade 3 Nervous System/Psychiatric 
Disorders (above). Appropriate prophylactic / 
therapeutic doses of anticonvulsant treatment (e.g. 
phenytoin or levetiracetam) will be administered 
during subsequent infusions of blinatumomab. If 
seizure recurs discontinue blinatumomab 
permanently. 
Grade 4 
Discontinue blinatumomab permanently 
Cytokine release 
syndrome (CRS), 
Allergic reaction, 
Anaphylaxis, or Infusion 
related reaction 
Grade 1 
Continue therapy with supportive care, as per local 
institutional guidelines. 
Grade 2 
The infusion of the blinatumomab must be stopped 
immediately. 
Supportive care, as per institutional guidelines. 
If the interruption is longer than four hours, re-start 
of the infusion should be performed in the hospital, 
under supervision of the investigator. 
Within one hour prior to re-start of treatment and 
within one hour prior to any dose increases, 
patients must receive 20 mg of dexamethasone 
intravenously. 

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Toxicity - Adverse Event 
CTCAE v4.0 
terminology 
AE Grade 
Action 
Grade 3 
The infusion of the blinatumomab must be stopped 
immediately. 
Dexamethasone should be administered at a dose of 
at least 24 mg per day (8 mg every 8 hours orally or 
IV) for up to three days. 
The dexamethasone dose will then be reduced step-
wise over up to four days. 
Hold blinatumomab until the toxicity resolves to 
Grade ≤ 1, then resume drug at 9 mcg/day for one 
week. If toxicity remains Grade ≤ 1, increase dose 
to 28 mcg/day to complete 28-day cycle of therapy. 
Within one hour prior to the re-start of treatment 
and within one hour prior to any dose increases, 
patients must receive 20 mg of dexamethasone 
intravenously. 
If Grade 3 toxicity recurs after blinatumomab is 
resumed, stop drug permanently. 
If the initial adverse event lasts >14 days without 
improvement, then blinatumomab will be 
permanently discontinued. 
Grade 4 
Blinatumomab should be discontinued 
permanently. 
Liver functions 
Aspartate 
aminotransferase 
increased, Alanine 
aminotransferase 
increased (AST, ALT); 
bilirubin increased 
Grade 1-2 
Continue at same dose level. 
Grade 3-4 
Hold blinatumomab until AE resolves to Grade ≤ 1, 
then resume drug at 9 mcg/day for one week. If 
toxicity remains Grade ≤ 1, increase dose to 28 
mcg/day to complete the 28-day cycle of therapy. If 
Grade 3-4 toxicity recurs, stop the drug 
permanently. 
Within one hour prior to the restart of treatment and 
within one hour prior to any dose increases, 
patients must receive 20 mg of dexamethasone 
intravenously. 
Disseminated 
intravascular 
coagulation 
Grade 2 
Continue at same dose level. 
Grade 3-4 
Hold blinatumomab until AE resolves to Grade ≤ 2, 
then resume drug at 9 mcg/day for one week. If 
toxicity remains Grade ≤ 1, increase dose to 28 
mcg/day to complete 28-day cycle of therapy. If 
Grade 3-4 toxicity recurs, stop drug permanently. If 
the initial adverse event lasts for > 14 days without 
improvement, then blinatumomab will be 
permanently discontinued. 
Within one hour prior to the restart of treatment and 

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Toxicity - Adverse Event 
CTCAE v4.0 
terminology 
AE Grade 
Action 
within one hour prior to any dose increases, 
patients must receive 20 mg of dexamethasone 
intravenously. 
Thromboembolic event 
Grade 1 
Continue at the same dose level. 
Grade 2-4 
Hold blinatumomab until clot and clinical situation 
stabilized, then resume drug at 9 mcg/day for one 
week. If no progression of thrombus, increase dose 
to 28 mcg/day to complete the 28-day cycle of 
therapy. If progression of existing thrombosis or 
new thrombosis or Grade 4 initially, stop drug 
permanently. 
Within one hour prior to the restart of treatment and 
within one hour prior to any dose increases, 
patients must receive 20 mg of dexamethasone 
intravenously. 
Hematologic toxicities 
Lymphocyte count 
decreased 
 
Grade 1-4 
 
Continue at the same dose level. 
Neutrophil count 
decreased 
Grade 1-4 
Continue at the same dose level. 
Platelet count decreased 
Grade 1-4 
Continue at the same dose level. 
All other AEs within the 
“Investigations” SOC 
and “Metabolism and 
nutrition disorders” 
SOC 
Grade 1-4 
Continue at the same dose level, provided AE is not 
medically consequential and has been readily 
corrected. 
If the abnormality is medically consequential, refer 
to guidelines for other non-hematologic AEs. 
Patients who develop Grade 3 or 4 electrolyte 
laboratory abnormalities may continue study 
treatment without interruption but should receive 
appropriate medical therapy. 
Other non-hematologic 
AEs 
Grade 1-2 
Continue at same dose level. 
Grade 3-4 
Hold blinatumomab until the AE resolves to Grade 
≤ 1, then resume drug at 9 mcg/day for one week. If 
the toxicity remains Grade ≤ 1, increase the dose to 
28 mcg/day to complete the 28-day cycle of 
therapy. If Grade 3 recurs, reduce the dose to 9 
mcg/day and if after one week toxicity is Grade ≤ 
2, continue at 9 mcg/day. If Grade 4 toxicity recurs, 
stop the drug permanently. If the toxicity takes 
more than 14 days to resolve, discontinue 
blinatumomab permanently. 
Within one hour prior to the restart of treatment and 
within one hour prior to any dose increases, 

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Toxicity - Adverse Event 
CTCAE v4.0 
terminology 
AE Grade 
Action 
patients must receive 20 mg of dexamethasone 
intravenously. 
Blinatumomab may be held or discontinued as needed for supportive care. 
  
6.3 
Nivolumab and Ipilimumab 
 
6.3.1 Re-Treatment Criteria 
 
For non-autoimmune or non-inflammatory events patients may resume treatment with study drug 
when the drug-related AE(s) resolve to Grade ≤1 or baseline value, with the following 
exceptions:  
 
• Evaluation to exclude any additional immune mediated events endocrine, GI, and liver / 
pancreas function as clinically indicated must be made prior to restarting.  
• Non-drug-related toxicity including hepatic, pulmonary toxicity, diarrhea, or colitis, 
must have resolved to baseline before treatment is resumed.  
 
If the criteria to resume treatment are met, the patient should restart treatment no sooner than the 
next scheduled time point per protocol. However, if the treatment is delayed past the next 
scheduled time point per protocol the treatment should resume at the earliest convenient point 
that is within the six-week delay period.        
 
For patients receiving both nivolumab and ipilimumab who experience grade 2 or 3 adverse 
events requiring discontinuation of treatment with the combination, the treating investigator may 
consider continuing treatment with single agent nivolumab at the same dose when the event 
resolves to baseline. However, patients with renal, CNS, cardiac or pulmonary toxicity must be 
removed from study. For this protocol, if the treating investigator believes the subject is 
benefitting from treatment and feels it is in the best interest of the participant to continue on 
nivolumab single agent, this may be considered after discussion with the Protocol Chair. 
 
For patients treated with high dose steroids:  
• Adverse events 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  

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6.3.2 Dose Delays 
 
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 as for grade 2 events 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 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. 
 
6.3.3 Dose Modifications for Nivolumab-/Ipilimumab-Related Toxicity 
 
NOTE: No dose reductions apply to nivolumab or ipilimumab, only dose delays. The above 
dose delay criteria/time frames apply for nivolumab-/ipilimumab-related toxicity.  
 
For information on specific toxicity and management plans for nivolumab or 
nivolumab/ipilimumab combination treatment, see below and reference management 
guidelines/algorithms in Appendix D, as noted. 
 
 

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Skin Rash and Oral 
Lesions 
 
Management/Next Dose for Nivolumab and Nivo/Ipi Combination 
≤ Grade 1 
No change in dose * 
Grade 2 
No change in dose *  
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 for Nivolumab and Nivo/Ipi Combination 
≤ Grade 1 
 No change in dose. 
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 for Nivolumab and Nivo/Ipi Combination 
≤ Grade 1 
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 
 
 
 

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Pancreatitis 
Amylase/Lipase  
Management/Next Dose for Nivolumab and Nivo/Ipi Combination 
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 for Nivolumab and Nivo/Ipi Combination 
Grade 1 
Consider holding 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. Resume no change in dose after 
pulmonary and/or ID consultation excludes nivolumab and associated 
lymphocytic pneumonitis as the cause of the pneumonitis. If 
nivolumab/ipilimumab related, hold until baseline. Patients must be 
stable off steroids for two weeks. Resume at same dose level. 
Grade 3 
Hold dose pending evaluation. Resume no change in dose after 
pulmonary and/or ID consultation excludes nivoumab and associated 
lymphocytic pneumonitis as the cause of the pneumonitis. If 
nivolumab/ipilimumab related, off protocol therapy. 
Grade 4 
Off protocol therapy 
Distinguishing inflammatory pneumonitis is often a diagnosis of exclusion for patients who do not 
respond to antibiotics and have no causal organism identified including influenza.  Most patients with 
respiratory failure or hypoxia will be treated with steroids.  Bronchoscopy may be required and analysis 
of lavage fluid for lymphocytic predominance may be helpful.  Patients with new lung nodules should 
be evaluated for sarcoid like granuloma.  Please consider recommending seasonal influenza killed 
vaccine for all patients. 
Recommended management:  See Pulmonary Adverse Event Management Algorithm  
 
 
 
 
 
 
 

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Other GI N-V  
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose.  
Grade 2 
Hold pending evaluation for gastritis duodenitis and other immune 
adverse events or other causes.  Resume at same dose level after 
resolution to ≤ Grade 1.   
Grade 3 
Hold pending evaluation until ≤ Grade 1.  Resume at same dose level. If 
symptoms do not resolve within 7 days with symptomatic treatment  patients 
should go off protocol therapy 
Grade 4 
Off protocol therapy 
Patients with grade 2 or 3 N-V should be evaluated for upper GI inflammation and other immune related 
events.   
 
 
 
Cardiac  Toxicities*  Management/Next Dose for Nivolumab and Nivo/Ipi Combination 
≤ Grade 1  
Hold dose pending evaluation and observation.**  Evaluate for signs 
and symptoms of CHF, ischemia, arrhythmia or myositis.  Obtain 
history EKG, CK (for concomitant myositis), CK-MB.  Repeat troponin, 
CK and EKG 2-3 days.  If troponin and labs normalize may resume 
therapy. If labs worsen or symptoms develop then treat as below.  Hold 
pending evaluation.  
Grade >2 with 
suspected 
myocarditis 
Hold dose.**  Admit to hospital.  Cardiology consult.  Rule out MI and 
other causes of cardiac disease.  Cardiac Monitoring.  Cardiac Echo.  
Consider cardiac MRI and cardiac biopsy.  Initiate high dose 
methylprednisolone.  If no improvement within 24 hours, add either 
infliximab, ATG or tacrolimus. Consult algorithm for more details.  
Resume therapy if there is a return to baseline and myocarditis is 
excluded or considered unlikely. 
Grade >2 with 
confirmed 
myocarditis   
Off protocol therapy.  Admit to CCU (consider transfer to nearest 
Cardiac Transplant Unit).  Treat as above.  Consider high dose 
methylprednisolone   
Add ATG or tacrolimus if no improvement.   Off treatment. 
*Including CHF, LV systolic dysfunction, Myocarditis, CPK, and troponin  
**Patients with evidence of myositis without myocarditis may be treated according as “other 
event”   
Note:  The optimal treatment regimen for immune mediated myocarditis has not been 
established.  Since this toxicity has caused patient deaths, an aggressive approach is 
recommended.   
 
 
 
 
 
 
 

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Fatigue  
Management/Next Dose for Nivolumab 
≤ Grade 1 
No change in dose. 
Grade 2 
No change in dose 
Grade 3 
Hold until ≤ Grade 2.  Resume at same dose level 
Grade 4 
Off protocol therapy 
Fatigue is the most common adverse event associated with immune checkpoint therapy.  Grade 2 or 
greater fatigue should be evaluated for associated or underlying organ involvement including pituitary, 
thyroid, and hepatic, or muscle (CPK) inflammation  
 
 
Neurologic events  
 
Management/Next Dose for Nivolumab and Nivo/Ipi Combination 
≤ Grade 1 
No change in dose.  
Grade 2 
Hold dose pending evaluation and observation. # Hold until resolves to 
baseline. . Off protocol therapy if treatment with steroids is required.  
Resume at same dose level for peripheral isolated n. VII (Bell’s palsy)^  
Grade 3 
Off protocol therapy  
Grade 4 
Off protocol therapy 
*Patients with any CNS events including aseptic meningitis, encephalitis, symptomatic hypophysitis, or 
myopathy, peripheral demyelinating neuropathy, cranial neuropathy (other than peripheral n. VII^), GB 
syndrome, myasthenia gravis should be off study.   
Recommended management:  See Neurologic Adverse Event Management Algorithm  
 
 
Endocrine 
Hypophysitis 
Adrenal 
Insufficiency  
 
Management/Next Dose for Nivolumab and Nivo/Ipi Combination 
≤ Grade 1 
Asymptomatic TSH elevation* If asymptomatic continue therapy.  
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  
 
 

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Renal   
Management/Next Dose for Nivolumab and Nivo/Ipi combination 
≤ Grade 1 
Continue therapy; monitor creatinine weekly.  If returns to baseline, 
resume routine monitoring per protocol.  If worsens, treat as below. 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. If treated with 
steroids patients must be stable off steroids for two weeks. 
Grade 3 
Hold until ≤ Grade 1.  Resume at same dose level. If treated with 
steroids patients must be stable off steroids for two weeks. 
Grade 4 
Off treatment 
Recommended management: See Renal Management Algorithm. 
 
 
Infusion reaction  
Management/Next Dose for Nivolumab and Nivo/Ipi combination 
≤ Grade 1 
Evaluate patient and monitor per institution protocols. Continue at same 
dose level. 
Grade 2 
Hold until ≤ Grade 1.  Resume at same dose level. 
Grade 3 
Off treatment. 
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 5.5.8.2 infusion reactions 
 
 
Fever  
Management/Next Dose for Nivolumab and Nivo/Ipi combination 
≤ 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 5.5.8.2.    infusion reactions   
 
 
ALL OTHER 
EVENTS 
Management/Next Dose for Nivolumab and combination 
Nivolimab/Ipililmumab  
≤ Grade 1 
No change in dose  
Grade 2 
Hold until ≤ Grade 1 OR baseline(exceptions as noted below in 
Section 6.3.4)     
Grade 3 
 Withold dose ≤ Grade 1 OR baseline. Off protocol therapy 
(exceptions as noted below in Section 6.3.4)   
Grade 4 
Off protocol therapy 
 
Recommended management:  As clinically indicated  
 

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6.3.4 Discontinuation of Nivolumab/Ipilimumab Treatment 
 
Nivolumab and ipilimumab treatment should be discontinued if any of the following criteria are met: 
 
• 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.  
• 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. NOTE: Any grade 3 or 4 drug-related laboratory abnormality or electrolyte 
abnormality that can be managed with electrolyte replacement, hormone replacement, insulin 
or that does not require treatment does not require discontinuation.  
• Any adverse event that requires discontinuation of treatment per Section 6.3.3.  
• Any subjects who require additional immune suppressive treatment beyond steroids should 
go off study treatment.  
• Subjects requiring >2 dose delays for the same type of event should go off protocol therapy.  
• Any dosing interruption lasting >6 weeks, with the following exceptions:  
 
o Subjects being tapered after high dose corticosteroids over one month followed by 
a two-week observation period will be allowed an additional two weeks to restart 
treatment (a maximum eight week interruption).  
o Dosing interruptions >6 weeks that occur for non-drug-related reasons may be 
allowed if approved by the Protocol Chair. Prior to re-initiating treatment in a subject 
with a dosing interruption lasting >6 weeks, the Protocol Chair must be consulted.  
 
6.4 
Special Considerations 
 
In the event that blinatumomab or nivolumab and/or ipilimumab are discontinued, the other study 
drugs may be continued per criteria above after discussion with the Protocol Chair.  
 
 
 
 

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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 (Section 7.2) will 
determine whether the event requires expedited reporting via the CTEP Adverse Event Reporting 
System (CTEP-AERS) in addition to routine reporting. 
 
7.1 
Comprehensive Adverse Events and Potential Risks List(s) (CAEPRs) 
 
The Comprehensive Adverse Event 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 of AEs, 
the Specific Protocol Exceptions to Expedited Reporting (SPEER), appears in a separate column 
and is identified with bold and italicized text.  The 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.  
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. 
 
7.1.1 CAEPRs for CTEP IND Agents 
 
7.1.1.1 CAEPR for Blinatumomab (AMG103, NSC 765986) 
Frequency is provided based on 1276 patients. Below is the CAEPR for Blinatumomab (AMG 103).  
   Version 2.5, September 4, 20191 
 
 Adverse Events with Possible  
 Relationship to Blinatumomab (AMG 103) 
 (CTCAE 5.0 Term) 
[n= 1276] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting  
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
  
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
Anemia 
 
 
 Anemia (Gr 2) 
 
Blood and lymphatic system 
disorders - Other 
(coagulopathy)2 
 
 Blood and lymphatic system 
disorders - Other (coagulopathy)2 
(Gr 2) 
 
 
Blood and lymphatic system 
disorders - Other 
(hematophagic histiocytosis) 
  
 
 
Blood and lymphatic system 
disorders - Other 
(lymphadenitis) 
  
 
 
Blood and lymphatic system 
disorders - Other 
(lymphadenopathy) 
  

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 Adverse Events with Possible  
 Relationship to Blinatumomab (AMG 103) 
 (CTCAE 5.0 Term) 
[n= 1276] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting  
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
  
 
 
Blood and lymphatic system 
disorders - Other 
(pancytopenia) 
  
 
Disseminated intravascular 
coagulation2,3 
 
 Disseminated intravascular 
coagulation2,3 (Gr 2) 
 
Febrile neutropenia 
 
 Febrile neutropenia (Gr 3) 
CARDIAC DISORDERS 
  
 
Sinus tachycardia 
 
 Sinus tachycardia (Gr 2) 
GASTROINTESTINAL DISORDERS 
  
 
Abdominal pain 
 
 Abdominal pain (Gr 2) 
 
Constipation 
 
 Constipation (Gr 2) 
 
Diarrhea 
 
 Diarrhea (Gr 2) 
 
 
Gastric hemorrhage 
  
 
 
Gastrointestinal disorders - 
Other (pneumoperitoneum) 
  
 
Mucositis oral 
 
  
Nausea 
 
 
 Nausea (Gr 2) 
 
 
Oral hemorrhage 
  
 
 
Pancreatitis 
  
 
Vomiting 
 
 Vomiting (Gr 2) 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills3 
 
 Chills3 (Gr 2) 
 
Edema limbs 
 
 Edema limbs (Gr 2) 
Fatigue3 
 
 
 Fatigue3 (Gr 2) 
Fever3 
 
 
 Fever3 (Gr 2) 
 
Generalized edema 
 
  
 
Non-cardiac chest pain 
 
  
 
Pain 
 
  
HEPATOBILIARY DISORDERS 
  
 
Hepatobiliary disorders - Other 
(hepatic function abnormal)4 
 
 Hepatobiliary disorders - Other 
(hepatic function abnormal)4 (Gr 2) 
IMMUNE SYSTEM DISORDERS 
  
 
 
Allergic reaction3 
  
 
Cytokine release syndrome3 
 
 Cytokine release syndrome3 (Gr 3) 
 
Immune system disorders - 
Other (immunodeficiency 
[immunoglobulin decreased])5 
 
 Immune system disorders - Other 
(immunodeficiency [immunoglobulin 
decreased])5 (Gr 2) 
INFECTIONS AND INFESTATIONS 
  
Infection6 
 
 
 Infection6 (Gr 4) 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
 
Infusion related reaction 
 
  
 
 
Injury, poisoning and 
procedural complications - 
Other (overdose)7 
  
INVESTIGATIONS 
  
 
 
Activated partial 
thromboplastin time 
prolonged2 
  

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 Adverse Events with Possible  
 Relationship to Blinatumomab (AMG 103) 
 (CTCAE 5.0 Term) 
[n= 1276] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting  
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
  
 
Alanine aminotransferase 
increased4 
 
 Alanine aminotransferase increased4 
(Gr 3) 
 
Alkaline phosphatase increased4  
 Alkaline phosphatase increased4  
(Gr 2) 
 
Aspartate aminotransferase 
increased4 
 
 Aspartate aminotransferase 
increased4 (Gr 4) 
 
Blood bilirubin increased4 
 
 Blood bilirubin increased4 (Gr 2) 
 
Blood lactate dehydrogenase 
increased 
 
  
 
 
Creatinine increased8 
  
 
GGT increased4 
 
 GGT increased4 (Gr 2) 
 
 
Investigations - Other (blood 
fibrinogen increased)2 
  
 
Investigations - Other (C-
reactive protein increased) 
 
 Investigations - Other (C-reactive 
protein increased) (Gr 2) 
 
Investigations - Other (fibrin D 
dimer increased)2 
 
  
Lymphocyte count decreased  
 
 Lymphocyte count decreased (Gr 4) 
Neutrophil count decreased 
 
 
 Neutrophil count decreased (Gr 4) 
Platelet count decreased2 
 
 
 Platelet count decreased2 (Gr 2) 
 
Weight gain 
 
 Weight gain (Gr 2) 
 
Weight loss 
 
  
 
White blood cell decreased 
 
 White blood cell decreased (Gr 4) 
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
  
 
Hyperglycemia 
 
 Hyperglycemia (Gr 2) 
 
Hyperuricemia 
 
  
 
Hypoalbuminemia 
 
  
 
Hypocalcemia 
 
  
Hypokalemia 
 
 
 Hypokalemia (Gr 2) 
 
Hypomagnesemia 
 
  
 
Hypophosphatemia 
 
  
 
 
Tumor lysis syndrome9 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  
 
Arthralgia 
 
  
 
Back pain 
 
 Back pain (Gr 2) 
 
Bone pain 
 
  
 
Generalized muscle weakness 
 
  
 
Myalgia 
 
  
 
Pain in extremity 
 
 Pain in extremity (Gr 2) 
NERVOUS SYSTEM DISORDERS 
  
 
Ataxia10 
 
  
 
Cognitive disturbance10 
 
  
 
Dizziness10 
 
 Dizziness10 (Gr 2) 
 
 
Dysarthria10 
  
 
Dysphasia10 
 
  
 
Encephalopathy10 
 
  
 
 
Facial nerve disorder10 
  

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73 
 
 
 Adverse Events with Possible  
 Relationship to Blinatumomab (AMG 103) 
 (CTCAE 5.0 Term) 
[n= 1276] 
 
 
 Specific Protocol Exceptions to 
Expedited Reporting  
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%)  
  
Headache10 
 
 
 Headache10 (Gr 2) 
 
 
Intracranial hemorrhage 
  
 
 
Leukoencephalopathy 
  
 
Memory impairment10 
 
  
 
Nervous system disorders - 
Other (apraxia) 
 
  
 
Nervous system disorders - 
Other (cerebellar syndrome)10 
 
  
 
 
Nervous system disorders - 
Other10  
  
 
Paresthesia10 
 
  
 
 
Reversible posterior 
leukoencephalopathy 
syndrome 
  
 
Seizure10 
 
  
 
Somnolence10 
 
  
 
 
Transient ischemic attacks10 
  
 
Tremor10 
 
 Tremor10 (Gr 2) 
PSYCHIATRIC DISORDERS 
  
 
 
Agitation10 
  
 
Anxiety10 
 
  
 
Confusion10 
 
  
 
 
Hallucinations10 
  
 
Insomnia 
 
 Insomnia (Gr 2) 
 
 
Personality change10 
  
 
 
Psychosis10 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Cough 
 
 Cough (Gr 2) 
 
Dyspnea 
 
  
 
Epistaxis 
 
  
 
 
Hypoxia 
  
 
Oropharyngeal pain 
 
  
 
 
Pneumonitis 
  
 
Voice alteration10 
 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
Hyperhidrosis 
 
  
 
Pruritus 
 
  
 
Skin and subcutaneous tissue 
disorders - Other (rash)11 
 
 Skin and subcutaneous tissue 
disorders - Other (rash)11 (Gr 2) 
VASCULAR DISORDERS 
  
 
 
Capillary leak syndrome3 
  
 
Flushing3 
 
  
 
Hypertension3 
 
 Hypertension3 (Gr 2) 
 
Hypotension3 
 
 Hypotension3 (Gr 2) 
 
Thromboembolic event2 
 
 Thromboembolic event2 (Gr 2) 
 
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 

NCI Protocol #:  10030 
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74 
 
PIO@CTEP.NCI.NIH.GOV. Your name, the name of the investigator, the protocol and the agent 
should be included in the e-mail. 
 
2Blinatumomab (AMG 103) is known to cause a variety of adverse events associated with coagulopathy 
which may include: Activated partial thromboplastin time prolonged, Disseminated intravascular 
coagulation, Fibrinogen decreased, INR increased, Investigations - Other (blood fibrinogen increased), 
Investigations - Other (fibrin D dimer increased), Investigations - Other (activated partial thromboplastin 
time shortened), Investigations - Other (antithrombin III decreased), Investigations - Other (coagulation 
factor XII level decreased), Investigations - Other (coagulation factor XIII level increased), Investigations - 
Other (haptoglobin decreased), Investigations - Other (protein S decreased), Platelet count decreased, 
and Thromboembolic events. 
 
3Symptoms 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. 
 
4Symptoms of hepatic dysfunction may include Alanine aminotransferase increased, Alkaline 
phosphatase increased, Aspartate aminotransferase increased, Blood bilirubin increased, and GGT 
increased under the INVESTIGATIONS SOC. 
 
5Immunodeficiency (immunoglobulin decreased) includes immunoglobulins decreased, blood 
immunoglobulin G decreased, blood immunoglobulin M decreased, and blood immunoglobulin A 
decreased. 
 
6Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
 
7Overdoses have been observed. Overdoses resulted in adverse reactions, which were consistent with 
the reactions observed at the recommended therapeutic dose and included fever, tremors, and 
headache. In the event of overdose, interrupt the infusion, monitor the patient for signs of toxicity, and 
provide supportive care. Consider re-initiation of blinatumomab at the correct therapeutic dose when all 
toxicities have resolved and no earlier than 12 hours after interruption of the infusion. 
 
 
8Acute kidney injury (acute renal failure) is associated with increased creatinine levels. 
 
9Tumor lysis syndrome is defined as a massive overload of potassium, phosphate, uric acid, plus 
hypocalcemia, potentially causing lethal cardiac arrhythmias and/or renal failure. 
 
10Blinatumomab (AMG103) is known to cause a variety of nervous system disorders which may include: 
Ataxia, Cognitive disturbance, Concentration impairment, Depressed level of consciousness, Dizziness, 
Dysphagia, Dysarthria, Dysesthesia, Dysphasia, Encephalopathy, Facial nerve disorder, Headache, 
Lethargy, Memory impairment, Paresthesia, Peripheral sensory neuropathy, Seizure, Somnolence, 
Syncope, Transient ischemic attacks, Tremor, Voice alteration, Nervous system disorders - Other 
(allodynia), Nervous Systems disorders - Other (cerebellar syndrome), Nervous system disorders - Other 
(dysgraphia), Nervous system disorders - Other (epilepsy), Nervous system disorders - Other (facial 
palsy), Nervous system disorders - Other (hemiparesis), Nervous system disorders - Other (hypertonia), 
Nervous system disorders - Other (hypotonia), Nervous system disorders - Other (pleocytosis), and 
Nervous system disorders - Other (polyneuropathy).  Additionally, symptoms of some nervous system 
disorders are adverse events under the PSYCHIATRIC DISORDERS SOC and may include: Agitation, 
Anxiety, Confusion, Hallucinations, Personality change, and Psychosis. 
 
11Rash includes rash, rash maculo-papular, erythema, local erythema, erythematous rash, generalized 
rash, exanthema, allergic dermatitis, and palmar-plantar erythrodysesthesia syndrome. 
 

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Adverse events reported on Blinatumomab (AMG 103) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that Blinatumomab (AMG 103) caused 
the adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Leukocytosis 
CARDIAC DISORDERS - Atrial fibrillation; Cardiac arrest; Heart failure; Left ventricular systolic 
dysfunction; Myocardial infarction; Pericardial effusion; Sinus bradycardia; Supraventricular tachycardia 
CONGENITAL, FAMILIAL AND GENETIC DISORDERS - Congenital, familial and genetic disorders - 
Other (aplasia) 
EAR AND LABYRINTH DISORDERS - Vertigo 
EYE DISORDERS - Blurred vision; Optic nerve disorder; Papilledema; Periorbital edema; Photophobia 
GASTROINTESTINAL DISORDERS - Abdominal distension; Anal mucositis; Dyspepsia; Dysphagia 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Edema face; Gait disturbance; 
General disorders and administration site conditions - Other (thrombosis in device); Hypothermia; 
Malaise; Multi-organ failure 
INJURY, POISONING AND PROCEDURAL COMPLICATIONS - Fall; Vascular access complication 
INVESTIGATIONS - Cardiac troponin I increased; Electrocardiogram QT corrected interval prolonged; 
INR increased; Investigations - Other (hypoproteinemia); Investigations - Other (lipase decreased); 
Lipase increased; Lymphocyte count increased 
METABOLISM AND NUTRITION DISORDERS - Acidosis; Dehydration; Hypercalcemia; Hyperkalemia; 
Hyperphosphatemia; Hyponatremia; Metabolism and nutrition disorders - Other (fluid overload) 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Muscle cramp; Neck pain 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Leukemia 
secondary to oncology chemotherapy; Treatment related secondary malignancy 
NERVOUS SYSTEM DISORDERS - Amnesia; Facial muscle weakness; Muscle weakness left-sided; 
Nervous system disorders - Other (difficulty following commands); Neuralgia 
PSYCHIATRIC DISORDERS - Delirium; Depression; Psychiatric disorders - Other (altered mental 
status); Psychiatric disorders - Other (sleep disorder); Restlessness 
RENAL AND URINARY DISORDERS - Acute kidney injury7; Hematuria; Proteinuria; Urinary 
incontinence 
REPRODUCTIVE SYSTEM AND BREAST DISORDERS - Genital edema 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Adult respiratory distress syndrome; 
Bronchospasm3; Pleural effusion; Productive cough; Pulmonary edema; Respiratory failure; Respiratory, 
thoracic and mediastinal disorders - Other (chronic obstructive pulmonary disease) 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Dry skin; Purpura; Skin and subcutaneous tissue 
disorders - Other (skin irritation) 
VASCULAR DISORDERS - Hematoma 
 
Note: Blinatumomab (AMG 103) 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 (BMS-936558, MDX-1106) 
 
The Comprehensive Adverse Events and Potential Risks list (CAEPR) provides a single list of reported 
and/or potential adverse events (AE) associated with an agent using a uniform presentation of events by 
body system. In addition to the comprehensive list, a subset, the Specific Protocol Exceptions to 
Expedited Reporting (SPEER), appears in a separate column and is identified with bold and italicized 
text. This subset of AEs (SPEER) is a list of events that are protocol specific exceptions to expedited 
reporting to NCI (except as noted below). Refer to the 'CTEP, NCI Guidelines: Adverse Event Reporting 
Requirements' http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/aeguidelines.pdf 
for further clarification. 
 
Frequency is provided based on 2069 patients. Below is the CAEPR for BMS-936558 (Nivolumab, MDX-

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1106). 
 
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) 
HEPATOBILIARY DISORDERS 
  

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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 - 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. 
 
3Nivolumab being a member of class of agents involved in the inhibition of “immune checkpoints”, may 

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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 
nephritis) 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Bronchospasm; Cough; Dyspnea; 

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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. 
 
7.1.1.3 CAEPR for Ipilimumab 
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 2678 patients. Below is the CAEPR for Ipilimumab (MDX-010). 
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 2.10, March 29, 20191 
 
Adverse Events with Possible  
Relationship to Ipilimumab (MDX-010) 
(CTCAE 5.0 Term) 
[n= 2678] 
 
Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS 
  
 
 
Blood and lymphatic system 
disorders - Other (acquired 
hemophilia) 
  
CARDIAC DISORDERS 
  
 
Atrial fibrillation 
 
  
 
 
Myocarditis2 
  
 
 
Pericardial effusion 
  
EAR AND LABYRINTH DISORDERS 
  
 
Hearing impaired 
 
  
ENDOCRINE DISORDERS 
  
 
Adrenal insufficiency2 
 
  
 
Hyperthyroidism2 
 
  
 
Hypophysitis2 
 
  
 
Hypopituitarism2 
 
  
 
Hypothyroidism2 
 
  
 
Testosterone deficiency2 
 
  
EYE DISORDERS 
  
 
Eye disorders - Other (episcleritis)2  
  
 
Uveitis2 
 
  
GASTROINTESTINAL DISORDERS 
  

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Adverse Events with Possible  
Relationship to Ipilimumab (MDX-010) 
(CTCAE 5.0 Term) 
[n= 2678] 
 
Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
Abdominal pain 
 
  
 
Colitis2 
 
 Colitis2 (Gr 3) 
 
 
Colonic perforation3 
  
 
Constipation 
 
  
Diarrhea 
 
 
 Diarrhea (Gr 3) 
 
Enterocolitis 
 
  
 
Esophagitis 
 
  
 
 
Ileus 
  
Nausea 
 
 
 Nausea (Gr 3) 
 
Pancreatitis2 
 
  
 
Vomiting 
 
  
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS 
  
 
Chills 
 
  
Fatigue 
 
 
 Fatigue (Gr 3) 
 
Fever 
 
 Fever (Gr 2) 
 
 
General disorders and 
administration site conditions - 
Other (Systemic inflammatory 
response syndrome [SIRS]) 
  
 
 
Multi-organ failure 
  
HEPATOBILIARY DISORDERS 
  
 
Hepatobiliary disorders - Other 
(hepatitis)2 
 
  
IMMUNE SYSTEM DISORDERS 
  
 
Autoimmune disorder2 
 
  
 
 
Immune system disorders - Other 
(GVHD in the setting of 
allotransplant)4 
  
INFECTIONS AND INFESTATIONS 
  
 
 
 Infections and infestations - 
Other (aseptic meningitis)2 
  
INJURY, POISONING AND PROCEDURAL COMPLICATIONS 
  
 
Infusion related reaction 
 
  
INVESTIGATIONS 
  
 
Alanine aminotransferase increased  
  
 
Aspartate aminotransferase 
increased 
 
  
 
 
Lymphocyte count decreased 
  
 
Neutrophil count decreased 
 
  
 
Weight loss 
 
  
METABOLISM AND NUTRITION DISORDERS 
  
 
Anorexia 
 
  
 
Dehydration 
 
  
 
Hyperglycemia 
 
  
 
 
Metabolism and nutrition 
disorders - Other (exacerbation 
of pre-existing diabetes mellitus) 
  
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS 
  

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Adverse Events with Possible  
Relationship to Ipilimumab (MDX-010) 
(CTCAE 5.0 Term) 
[n= 2678] 
 
Specific Protocol Exceptions 
to Expedited Reporting 
(SPEER)   
 
Likely (>20%) 
Less Likely (<=20%) 
Rare but Serious (<3%) 
 
 
Arthralgia 
 
  
 
Arthritis 
 
  
 
 
Generalized muscle weakness 
  
 
Musculoskeletal and connective 
tissue disorder - Other 
(polymyositis)2 
 
  
NERVOUS SYSTEM DISORDERS 
  
 
 
Ataxia 
  
 
Facial nerve disorder2 
 
  
 
Guillain-Barre syndrome2 
 
  
 
Headache 
 
  
 
Myasthenia gravis2 
 
  
 
 
Nervous system disorders - 
Other (immune-mediated 
encephalitis)2 
  
 
 
Peripheral motor neuropathy 
  
 
 
Peripheral sensory neuropathy 
  
 
Trigeminal nerve disorder 
 
  
PSYCHIATRIC DISORDERS 
  
 
 
Psychiatric disorders - Other 
(mental status changes) 
  
RENAL AND URINARY DISORDERS 
  
 
Acute kidney injury 
 
  
 
Renal and urinary disorders - Other 
(granulomatous tubulointerstitial 
nephritis) 
 
  
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS 
  
 
Pneumonitis 
 
  
 
 
Respiratory failure 
  
 
 
Respiratory, thoracic and 
mediastinal disorders - Other 
(bronchiolitis obliterans with 
organizing pneumonia) 
  
 
 
Respiratory, thoracic and 
mediastinal disorders - Other 
(lung infiltration) 
  
SKIN AND SUBCUTANEOUS TISSUE DISORDERS 
  
 
 
Erythema multiforme 
  
 
Pruritus 
 
 Pruritus (Gr 3) 
Rash maculo-papular 
 
 
 Rash maculo-papular (Gr 3) 
 
Skin and subcutaneous tissue 
disorders - Other (Sweet's 
Syndrome) 
 
  
 
 
Stevens-Johnson syndrome 
  
 
 
Toxic epidermal necrolysis 
  
 
Urticaria 
 
  
VASCULAR DISORDERS 
  
 
Hypotension 
 
  

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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. 
 
2Ipilimumab can result in severe and fatal immune-mediated adverse events probably due to T-cell 
activation and proliferation. These can include (but are not limited to) autoimmune hemolytic anemia, 
acquired anti-factor VIII immune response, autoimmune aseptic meningitis, autoimmune hepatitis, 
autoimmune thyroiditis, hepatic failure, pure red cell aplasia, pancreatitis, ulcerative and hemorrhagic 
colitis, endocrine disorders (e.g., autoimmune thyroiditis, hyperthyroidism, hypothyroidism, autoimmune 
hypophysitis/hypopituitarism, and adrenal insufficiency), ocular manifestations (e.g., uveitis, iritis, 
conjunctivitis, blepharitis, and episcleritis), sarcoid granuloma, myasthenia gravis, polymyositis, and 
Guillain-Barre syndrome. The majority of these reactions manifested early during treatment; however, a 
minority occurred weeks to months after discontinuation of ipilimumab especially with the initiation of 
additional treatments. 
 
3Late bowel perforations have been noted in patients receiving MDX-010 (ipilimumab) in association with 
subsequent IL-2 therapy. 
 
4Complications including hyperacute graft-versus-host disease (GVHD), may occur in patients receving 
allo stem cell transplant (SCT) after receiving Ipilimumab (MDX-010).  These complications may occur 
despite intervening therapy between receiving Ipilimumab (MDX-010) and allo-SCT. 
 
5In rare cases diplopia (double vision) has occurred as a result of muscle weakness (Myasthenia gravis). 
 
6Gastrointestinal hemorrhage includes Anal hemorrhage, Cecal hemorrhage, Colonic hemorrhage, 
Duodenal hemorrhage, Esophageal hemorrhage, Esophageal varices hemorrhage, Gastric hemorrhage, 
Hemorrhoidal hemorrhage, Ileal hemorrhage, Intra-abdominal hemorrhage, Jejunal hemorrhage, Lower 
gastrointestinal hemorrhage, Oral hemorrhage, Pancreatic hemorrhage, Rectal hemorrhage, 
Retroperitoneal hemorrhage, and Upper gastrointestinal hemorrhage under the GASTROINTESTINAL 
DISORDERS SOC. 
 
7Infection includes all 75 sites of infection under the INFECTIONS AND INFESTATIONS SOC. 
 
 
 Adverse events reported on Ipilimumab (MDX-010) trials, but for which there is insufficient 
evidence to suggest that there was a reasonable possibility that Ipilimumab (MDX-010) caused the 
adverse event: 
 
BLOOD AND LYMPHATIC SYSTEM DISORDERS - Anemia; Blood and lymphatic system disorders - 
Other (pure red cell aplasia)2; Febrile neutropenia 
CARDIAC DISORDERS - Conduction disorder; Restrictive cardiomyopathy 
EYE DISORDERS - Extraocular muscle paresis5; Eye disorders - Other (retinal pigment changes) 
GASTROINTESTINAL DISORDERS - Colonic ulcer; Dyspepsia; Dysphagia; Gastrointestinal disorders - 
Other (gastroenteritis); Gastrointestinal hemorrhage6; Proctitis 
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS - Flu like symptoms; Non-cardiac 
chest pain 
HEPATOBILIARY DISORDERS - Hepatic failure2 
IMMUNE SYSTEM DISORDERS - Allergic reaction 
INFECTIONS AND INFESTATIONS - Infection7 
INVESTIGATIONS - Creatinine increased; Investigations - Other (rheumatoid factor); Lipase increased; 
Platelet count decreased; Serum amylase increased; White blood cell decreased 
METABOLISM AND NUTRITION DISORDERS - Tumor lysis syndrome 
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS - Back pain; Joint range of motion 

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decreased; Myalgia; Pain in extremity 
NEOPLASMS BENIGN, MALIGNANT AND UNSPECIFIED (INCL CYSTS AND POLYPS) - Tumor pain 
NERVOUS SYSTEM DISORDERS - Dizziness; Dysphasia; Ischemia cerebrovascular; Seizure 
PSYCHIATRIC DISORDERS - Anxiety; Confusion; Depression; Insomnia 
RENAL AND URINARY DISORDERS - Proteinuria 
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS - Allergic rhinitis; Cough; Dyspnea; 
Laryngospasm 
SKIN AND SUBCUTANEOUS TISSUE DISORDERS - Alopecia; Dry skin; Hyperhidrosis; Skin 
hypopigmentation 
VASCULAR DISORDERS - Flushing; Hypertension; Vascular disorders - Other (temporal arteritis) 
 
Note: Ipilimumab (BMS-734016; MDX-010 Transfectoma-derived) in combination with other agents could 
cause an exacerbation of any adverse event currently known to be caused by the other agent, or the 
combination may result in events never previously associated with either agent. 
 
7.2 
Adverse Event Characteristics  
 
• CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the revised NCI Common Terminology Criteria for Adverse Events (CTCAE) version 
4.0 will be utilized for AE reporting. All appropriate treatment areas should have access 
to a copy of the CTCAE version 4.0. A copy of the CTCAE version 4.0 can be 
downloaded from the CTEP web site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm. 
 
• For expedited reporting purposes only:   
- 
AEs for the agent that are bold and italicized in the CAEPR (i.e., those listed in the 
SPEER column, Section 7.1.1) should be reported through CTEP-AERS only if the 
grade is above the grade provided in the SPEER. 
- 
Other AEs for the protocol that do not require expedited reporting are outlined in 
section 7.3.4. 
 
• Attribution of the AE: 
- 
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. 
 
7.3 
Expedited Adverse Event Reporting 
 

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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.  
The Coordinating Center of the Corresponding Organization is responsible for submitting to 
the CTSU documentation of AEs that they deem reportable for posting on the CTSU protocol 
web page and inclusion on the CTSU bi-monthly broadcast. 
 
7.3.3 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.  
 
Pregnancy loss is defined in CTCAE as “Death in utero.” Any pregnancy loss should be 
reported expeditiously, as Grade 4 “Pregnancy loss” under the Pregnancy, puerperium 
and perinatal conditions SOC. A pregnancy loss should NOT be reported as a Grade 5 
event under the Pregnancy, puerperium and perinatal conditions SOC, as currently 
CTEP-AERS recognizes this event as a patient death.  
 
A neonatal death should be reported expeditiously as Grade 4, “Death neonatal” under 
the General disorders and administration SOC. 

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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 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 
 
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 

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mechanism (Section 7.4): 
 
CTCAE SOC 
Adverse Event 
Grade Hospitalization/ 
Prolongation of 
Hospitalization 
Attribut
ion 
General disorders 
and administration 
site conditions 
Fatigue 
 
3 
 
+/- 
Possibly/
Probably
/Definite 
Blood and 
Lymphatic System 
Disorders 
Anemia 
Hypocellular Bone Marrow 
Febrile Neutropenia 
3 and 4 
3 and 4 
3 and 4 
 
+/- 
Possibly/
Probably
/Definite 
Investigations 
Lymphocyte count decreased 
Neutrophil count decreased 
Platelet count decreased 
White blood cell decreased 
3 and 4 
3 and 4 
3 and 4 
3 and 4 
+/- 
Possibly/
Probably
/Definite 
Infections and 
Infestations 
All with the exception of unusual 
infections such as PML 
3 and 4 
+/- 
Possibly/
Probably
/Definite 
Metabolism and 
Nutritional 
Disorders 
Anorexia 
Hyperglycemia 
Hypokalemia 
Hypomagnesemia 
Tumor Lysis Syndrome 
3 
3 
3 
3 
3 and 4 
+/- 
Possibly/
Probably/
Definite 
Gastrointestinal 
Disorders 
Oral Pain 
Mucositis 
3 
3 
+/- 
Possibly/
Probably/
Definite 
Skin and 
Subcutaneous 
Tissue Disorders 
Hyperhidrosis (sweating) 
 
3 
 
+/- 
Possibly/
Probably/
Definite 
 
7.4 
Routine Adverse Event Reporting 
 
All Adverse Events must be reported in routine study data submissions.  AEs reported 
expeditiously through CTEP-AERS must also be reported in routine study data 
submissions. 
 
Adverse event data collection and reporting, which are required as part of every clinical trial, are 
done to ensure the safety of patients enrolled in the studies as well as those who will enroll in 
future studies using similar agents.  AEs are reported in a routine manner at scheduled times 
during the trial using Medidata Rave.  For this trial the Adverse Event CRF is used for routine 

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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. 
 
 
 

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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 Blinatumomab 
 
Other Names: AMG103, MT103  
 
Classification: Bispecific T cell engaging antibody 
 
M.W.: ~ 55 kDa 
 
Mode of Action: Through CD3 binding, blinatumomab recruits and engages T cells for 
redirected lysis of CD19-positive B cells, including those expressed with B-cell 
malignancies.  T cells are bound by its anti-CD3 moiety, whereas B cells are bound by 
the anti-CD19 moiety.  The subsequent serial lysis of multiple malignant cells by a single 
blinatumomab-activated T cell closely resembles a natural cytotoxic T cell reaction.  
Treatment with blinatumomab is associated with a rapid depletion of peripheral B cells, 
accompanied by T cell activation and a transient increase in cytokines. 
 
Description: Blinatumomab is a fusion protein composed of two single-chain antibodies 
(scFv), murine anti-CD19 scFv and murine anti-CD3 scFv. 
 
How Supplied:  Amgen provides and NCI/DCTD distributes blinatumomab and IV 
solution stabilizer for blinatumomab. 
 
1. Blinatumomab is available as a 38.5 mcg preservative-free, white to off-white 
lyophilized powder for injection in 4 mL single-use vial.  The agent is formulated with 
3.68 mg citric acid monohydrate, 105 mg trehalose dihydrate, and 25.55 mg lysine 
hydrochloride, and 0.70 mg polysorbate 80, pH 7.  The stopper of the vial is latex free. 
 
2. IV solution stabilizer for blinatumomab (NSC 773150) is not for reconstitution of 
blinatumomab.  The solution is available as a 10 mL single-use vial, preservative-free, 
clear, colorless-to-slightly yellow liquid solution. Each solution consists of 25 mM citric 
acid monohydrate, 1.25 M L-lysine hydrochloride, and 0.1% (w/v) polysorbate 80, pH 
7.  The stopper of the vial is latex free. 
 
Preparation:  NOTE: Only trained staff may prepare blinatumomab IV solution. Sites’ 
standard procedure for compounding blinatumomab must be in compliance with the USP 
<797> guidelines (ISO Class 5 or better). Use aseptic technique and prepare blinatumomab 
IV solution under a qualified laminar flow hood.   
 

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a. You need an empty IV bag that is made of Polyolefin/polyethylene, ethylene vinyl 
acetate (EVA) or PVC non-DEHP. The IV Infusion sets must be a PVC Non-DEHP 
with 0.2 µm inline filter  
b. Next, reconstitute blinatumomab lyophilized powder: 
c. Add 3 mL of Sterile Water for Injection (SWI) to the vial to yield 3.08 mL of 
blinatumomab at a final concentration of 12.5 mcg/mL. 
d. Rotate the vial to dissolve all powder.  Do not shake. 
e. The stability of the reconstituted vial is 4 hours at room temperature (220 C to 270 C) 
or 24 hours refrigerated at 20 to 80 C. 
f. Then, further dilute blinatumomab prior to administration: Steps to prepare solution are 
in sequential order.  The IV solution stabilizer for blinatumomab must be added into the 
0.9% NaCl bag before adding blinatumomab. 
 
Calculations: 
 
24-hour IV bag 
(Inpatient) 
Final Volume 
Volume to be infused 
Infusion rate 
270 mL 
240 mL 
10 mL/hour 
 
 
 
Step 1.  Add the calculated 0.9% NaCl volume into the approved empty IV bag 
 
 
 Calculated 0.9% NaCl (mL):  
 
 [Total volume to be prepared (270 mL)] - [Stabilizer solution volume (5.4 mL)] – 
 
[blinatumomab calculated dose volume (mL)]  
 
 
Step 2. Add 5.4 mL IV solution stabilizer into the normal saline IV bag 
 
 
IV Stabilizer solution (5.4 mL): 
 
0.02 X total volume to be prepared (270 mL) 
 
 
Step 3.  Add the calculated blinatumomab dose volume into solution  
 
 
Blinatumomab calculated dose volume (per 270 mL bag): 
24-hour dose (mcg) ÷ Volume to be infused (240 mL) x total volume to be prepared 
(270 mL) ÷ 12.5 mcg/mL of blinatumomab     
 
NOTE:  the total volume to be made is 270 mL of which patient will receive a total 
volume of 240 mL over 24 hours at 10 mL/hour rate and 30 mL will remain in the IV 
line set.  You may also prepare a 24-hour IV bag for outpatient use but the overfill 
volume for the IV line infusion may be different and must be changed accordingly in 
the calculation. 
 
 
 
 
 
 

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48-hour IV bag 
(outpatient) 
Final Volume 
Volume to be infused 
Infusion rate 
250 mL 
240 mL 
5 mL/hour 
 
Step 1.   Add the calculated volume of 0.9% NaCl into approved empty IV bag: 
 
[Total volume to be prepared (250 mL)] – [IV Stabilizer Solution volume (5 mL)] – 
[blinatumomab calculated dose volume (mL)]  
 
Step 2: Add 5 mL IV stabilizer solution into the normal saline IV bag: 
 
0.02 X total volume to be prepared (250 mL) 
 
Step 3: Add the calculated dose volume of blinatumomab into solution: 
 
48-hour dose (mcg) ÷ volume to be infused (240 mL) x total volume to be prepared (250 
mL) ÷ 12.5 mcg/mL of blinatumomab. 
NOTE: The total volume to be made is 250 mL of which patient will receive 240 mL   
over 48 hours at 5 mL/hour rate and 10 mL will remain in the IV line set. 
 
 
Volume for the dead space of the IV line may be adjusted according to the size of the 
infusion IV line being used at each institution 
 
a) Rotate IV bag to mix thoroughly the solution.  Do not shake. Avoid foaming the IV 
bag. 
b) Visually inspect for floating particles or discoloration of the IV solution.  If that 
occurs, do not use the prepared solution. 
c) Prime the IV line with the prepared IV solution before administering it to 
patient. 
Infusion Pump: 
• Use programmable pump that is approved by the appropriate regulatory authority for the 
country in which the subject is undergoing treatment.    
• Pump alarm must be visual and auditory 
• Pump must be lockable  
• Elastomeric pumps are NOT allowed 
• CADD Infusion pumps are allowed 
 
IV bag label: Suggestion for the IV bag label 
• Patient name and number 
• Name of the drug 
• Dose (mcg/day and volume/day) 
• Infusion rate 
• Expiration date and time  

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• CAUTION: NEW DRUG – Limited by United States law to investigational use. 
• Bag number 
• [Additional information may be provided on the label in accordance with state, local, 
and country pharmacy regulations.] 
 
Storage:  Store intact vials of blinatumomab and IV solution stabilizer of blinatumomab 
refrigerated at 20 – 80C (360- 460F), protect from light.  
 
Stability:  Shelf life stability studies of the intact vials of blinatumomab and stabilizer 
solution are on-going.  
The stability of the prepared IV solution is 8 days when stored refrigerated at 20 to 80 C.  
The total storage and administration time must not exceed 8 days.  Once at room 
temperature, discard the IV bag after 96 hours. 
 
Route(s) of Administration: IV infusion 
 
Method of Administration:  Use a central line to administer the IV solution.  Do not flush 
the IV line as it will create an IV bolus to be administered into the patient.  
 
NOTE: Infusion interruption:  Record all interruption.  Technical or logistical interruption 
must be as minimal as possible and re-start the infusion as soon as possible.  If an interruption 
is longer than four hours, the re-start of the infusion must take place in the hospital under 
supervision of the investigator.  The subject should be observed overnight for possible side 
effects after the re-start, either in the hospital or in the outpatient setting as applicable. Monitor 
patients for potential adverse events as described in the protocol and the Investigator 
Brochure. 
 
Patient Care Implications:  The effect of blinatumomab on fertility has not been evaluated. 
Blinatumomab is not recommended in pregnant women and in women of childbearing 
potential not using contraception. It is not known whether blinatumomab or its metabolites 
are excreted in human milk.  Women are not allowed to breastfeed while receiving 
blinatumomab.  Monitor patients for cytokine release syndrome, tumor lysis syndrome, and 
infusion reaction. Refer to protocol for specific recommendation. Monitor patients for 
psychiatric events such as confusion, disorientation, and cognitive attention disturbances. 
Patients should not drive or operate dangerous machinery while receiving blinatumomab.  
 
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 

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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 
liquid; light (few) particulates may be present. The drug product is a sterile, 
nonpyrogenic, single-use, isotonic aqueous solution formulated in sodium citrate, sodium 
chloride, mannitol, diethylenetriamine pentacetic acid (pentetic acid) and polysorbate 80 
(Tween® 80), 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. 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 should 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 and freezing. 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. 
 
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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 (up to 25°C, 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 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. 
 
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 12.3). 
 
8.1.3 Ipilimumab (NSC 732442) 
 
Chemical Name or Amino Acid Sequence: 4 polypeptide chains, 2 identical heavy chains 
with 447 amino acids and 2 identical light chains consisting of 215 amino acids. 
 
Other Names: Anti-CTLA-4 monoclonal antibody, MDX-010, Yervoy™ 
 
Classification: Human monoclonal antibody 
 
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Mode of Action: Ipilimumab is specific for the CTLA4 antigen expressed on a subset of 
activated T-cells. CTLA4 interaction with the B7 molecule, one of its ligands expressed 
on professional antigen presenting cells, can down-regulate T-cell response. Ipilimumab 
is, thought to act by blocking the interaction of CTLA4 with the B7 ligand, resulting in a 
blockade of the inhibitory effect of T-cell activation. The CTLA4/B7 creates the 
interaction.  
 
Description: Ipilimumab is a fully human immunoglobulin (IgG1) with two 
manufacturing processes – ongoing trials have been using substances manufactured using 
Process B.  New clinical trials will be using ipilimumab that is manufactured by Process 
C. The Process C has been developed using a higher producing sub-clone of the current 
Master Cell Bank, and modified cell culture and purification steps.  
  
How Supplied: Bristol-Myers-Squibb (BMS) supplies Ipilimumab to the DCTD/NCI.  
Ipilimumab injection, 200 mg/40 mL (5 mg/mL), is formulated as a clear to slightly 
opalescent, colorless to pale yellow, sterile, nonpyrogenic, single-use, isotonic aqueous 
solution that may contain particles. 
 
Each vial is a Type I flint glass vial with gray butyl stoppers and sealed with aluminum seals. 
 
 
Process C 
Component 
200 mg/ viala 
Ipilimumab 
213 mg 
Sodium Chloride, USP  
249 mg 
TRIS-hydrochloride 
134.3 mg 
Diethylenetriamine pentacetic acid 
1.67 mg 
Mannitol, USP 
426 mg 
Polysorbate 80 (plant-derived) 
4.69 mg 
Sodium Hydroxide 
QS to pH 7 
Hydrochloric acid 
QS to pH 7 
Water for Injection 
QS: 42.6 mL 
Nitrogenb 
Processing agent 
aIncludes 2.6 mL overfill. 
bNitrogen is used to transfer the bulk solution through the pre-filled and sterilizing 
filters into the aseptic area. 
 
Preparation: Ipilimumab is given undiluted or further diluted in 0.9% NaCl Injection.  
Ipilimumab is stable in a polyvinyl chloride (PVC), non-PVC/non DEHP (di-(2-ethylhexyl) 
phthalate) IV bag or glass container up to 24 hours refrigerated at (20 to 80 C) or at room 
temperature/ room light.  
 
Recommended safety measures for preparation and handling include protective clothing, 
gloves, and safety cabinets. 
  

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Storage: Store intact vials refrigerated at (20 to 80 C), protected from light.  Do not freeze. 
 
Stability: Shelf-life surveillance of the intact vials is ongoing.  Solution as described above is 
stable up to 24 hours refrigerated at (20 to 80 C) or at room temperature/ room light.  
 
CAUTION:  Ipilimumab does not contain antibacterial preservatives.  Use prepared IV 
solution immediately. Discard partially used vials.  
 
Route(s) of Administration: Intravenous infusion.  Do not administer ipilimumab as an IV 
push or bolus injection. 
 
Method of Administration:  Can use a volumetric pump to infuse ipilimumab at the 
protocol-specific dose(s) and rate(s) via a PVC IV infusion set with an in-line, sterile, non-
pyrogenic, low-protein-binding filter (0.2 micron to 1.2 micron). 
 
Patient Care Implications:  Monitor patients for immune-related adverse events, e.g., 
rash/vitiligo, diarrhea/colitis, uveitis/episcleritis, hepatitis and hypothyroidism.  If you 
suspect toxicity, refer to the protocol guidelines for ruling out other causes. 
 
Availability 
 
Ipilimumab is an investigational agent supplied to investigators by the Division of Cancer 
Treatment and Diagnosis (DCTD), NCI. 
 
Ipilimumab is provided to the NCI under a Collaborative Agreement between the 
Pharmaceutical Collaborator and the DCTD, NCI (see Section 12.3). 
 
8.1.4 Agent Ordering and Agent Accountability 
 
8.1.4.1 
NCI-supplied agents may be requested by the responsible 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), Biosketch, Agent Shipment Form, 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. 
 
In general, sites may order initial agent supplies when a subject is being screened for 
enrollment onto the study. 
 
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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.   
 
8.1.4.2 
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. 
 
8.1.4.3 
Useful Links and Contacts 
• CTEP Forms, Templates, Documents:  http://ctep.cancer.gov/forms/ 
• NCI CTEP Investigator Registration:  RCRHelpDesk@nih.gov 
• PMB policies and guidelines: 
http://ctep.cancer.gov/branches/pmb/agent_management.htm  
• PMB Online Agent Order Processing (OAOP) application: 
https://ctepcore.nci.nih.gov/OAOP 
• CTEP Identity and Access Management (IAM) account: 
http://ctepcore.nci.nih.gov/iam/  
• CTEP IAM account help:  ctepreghelp@ctep.nci.nih.gov  
• IB Coordinator: IBCoordinator@mail.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) 
 
8.2 
Blinatumomab Administration-Inpatient and Outpatient Procedures 
 
Inpatient 
 
Blinatumomab will be administered as a continuous IV infusion over four weeks followed by a 
two-week treatment free interval.  It is recommended that patients are hospitalized at least during 
the first 14 days of the first cycle and the first two days of each of the subsequent cycle.  The 
hospitalization time depends on the investigator´s judgment, as well as the safety and 
tolerability of blinatumomab. 
 
The infusion bags will be changed by site nursing personnel.  Close monitoring during the first 
48 - 72 hours of treatment in the first cycle will be indicated because of the potential AEs 
associated with T cell redistribution and potential cytokine release effects triggered by the 
administration of blinatumomab.  Nurses/physicians trained in critical care medicine should be 
available for immediate intervention in case of complications.  Afterwards the treatment may be 
continued on an outpatient basis, if it is judged to be safe and feasible by the investigator. 

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Outpatient 
 
In the outpatient setting, several options are available for blinatumomab administration: 
 
• The patient will return to the study site for all changes of infusion bags. 
• If allowable by the treating physician's institution, infusion bag changes may be performed 
in the patient’s home by an ambulatory/home care service provider. In this case, the 
ambulatory/home care service provider will be given the remaining bags for the week of 
treatment that have been prepared by the site investigational pharmacy in a validated 
shipper for transport. The validated shipper will maintain proper storage conditions during 
transport for the prepared infusion bags. The infusion bags are to kept/stored at the 
ambulatory/home care service provider in a controlled temperature monitored refrigerator 
used at the ambulatory/home care service provider. Patients will be visited by an 
ambulatory/home care service provider at specific intervals to change the infusion bag. The 
ambulatory/home care service will be trained and will receive written instruction for 
transport of drug from the site investigational pharmacy and from the ambulatory/home care 
service provider to the patient’s home for infusion. If necessary shipment of the infusion 
bags from the site investigational pharmacy to the ambulatory/home care service provider 
for subsequent transport to the patient’s home for infusion will be allowed via use of a 
validated shipper and a traceable method of shipment via an express courier. 
• If all options above are not feasible, shipping the prepared infusion bag in a pre-qualified 
insulated shipper directly to patient’s home via overnight courier delivery service for 
administration by home healthcare agency staff is acceptable. Patients are not to open the 
box upon the receipt of the drug.   
 
NOTE: The NCI Drug Accountability Record Form (DARF) must reflect all 
transaction for preparing and providing the infusion bags to an 
ambulatory/home care service provider.  The ambulatory/home care service 
provider must also keep DARFs to log in/out date when receiving the 
infusion bags from the sites and when dispensing the infusion bags to 
patients as well as the times of all infusion bag changes. 
 
NOTE:  The pre-qualified shipper box will include a form of shipment of blinatumomab IV 
bag(s) to patient’s home. That form will be completed by site/pharmacy prior to shipping the IV 
blinatumomab bags. The form is available as Appendix H. The home healthcare service will 
open the box at the time that the IV drug is to be administered to patient. The home healthcare 
service staff will complete the second portion of the form and any discrepancy must be reported 
immediately to the site pharmacy.  
 
 
 

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9. BIOMARKER, CORRELATIVE, AND SPECIAL STUDIES 
 
9.1 
Overview 
 
Mandatory research bone marrow aspirates (40 cc-4 green top tubes-sodium heparin) and research 
peripheral blood specimens (preferred 100 cc [minimum 60 cc]-10 (min 6) green top tubes-sodium 
heparin) will be obtained (preferentially on the same day): at baseline (1-7 days prior to the 
initiation of study treatment; up to 14 days prior to the initiation of study treatment allowed for 
patients requiring prephase treatment), prior to first dose of nivolumab / ipilimumab in cycle 1 
(day 8-11 +/- 4 days), at the end of cycles 1 and 2 (day 29-35), and every 3-4 months up to 1 yr, 
or at the time of relapse or off study. 
 
Additional research peripheral blood specimens (preferred 40 cc [minimum 30 cc]– 3 or 4 green 
top tubes) will be collected in cycle 1 (days 1, 15, and 22; all ±3 days), and prior to cycle 2 (day 
40-42 of cycle 1). 
 
9.1.1 
Collection of specimens  
 
All operating procedures for specimen collection, handling and storage are standardized. 
Common standardized operating procedures (SOPs) are described in Appendix E. The plan is to 
collect research PB (60-100 cc or 30-40 cc) and BM specimens (40 cc) from the patient at the 
time points indicated in Section 9.1 above and on the Study Calendar.  Re-adjustment of the 
direction of bone marrow aspirate needle should take a place after each 5 cc is collected to 
prevent hemodilution.  At the time of sample collection, tubes must be thoroughly mixed to 
prevent clotting.  In the event that the baseline BM aspirate and biopsy was not successful or 
inevaluable, and subject cannot undergo a second BM aspirate and biopsy for any reason, 
including refusal, the subject will be allowed to be treated on study protocol as long as diagnosis 
can be confirmed by other means, including analysis of PB. 
 
9.1.2 
Handling and Shipping of Specimens 
  
A unique subject identifier will be assigned to each subject by the coordinating center and will be 
used to label the samples. The protocol scientific investigator(s) analyzing the samples will be 
blinded as to the direct subject identifiers. 
 
All specimens should be labeled with the patient’s identification number (given at the time of 
registration), and study number. Sample collection date and time, and sample source (PB or BM) 
will be recorded on correlative studies collection worksheet (Appendix F) and copy included in 
delivery. All data will be kept in laboratory log. 
 
Research blood and marrow aspirates will be sent to Johns Hopkins to the laboratory of Dr. Leo 
Luznik. Dr. Luznik laboratory: 1650 Orleans Street, CRB1RM 2M88, Baltimore MD 21287. Tel: 
(410) 955-8567. Dr. Luznik’s e-mail: luznile@jhmi.edu 
 
At each sampling interval, BM and PB mononuclear cells (PBMC) will be processed via Ficoll 
density gradient centrifugation. The washed cells will be counted and viably cryopreserved using 

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a controlled-rate freezer with transfer to the vapor phase of liquid nitrogen for long-term storage. 
Please refer to the JHU Protocol for PBMC/Plasma (Appendix E). 
 
9.1.2.1 
Specimen collection/processing (JHU): The specimens collected at the Sidney 
Kimmel Comprehensive Cancer Center at Johns Hopkins should be delivered to the 
Luznik laboratory immediately after collection.  
 
9.1.2.2 
Specimen collection / processing (Participating Sites). Other participating sites should 
collect PB and BM specimens as outlined in the protocol above. Participating sites 
will have two options: 
 
a) To process specimens following the SOP in Appendix E. Samples will be stored at 
each study site and will be batch shipped on dry ice based on arrangement with the 
participating site PI and Dr. Luznik and upon request of the Study Chair they will be 
batch shipped to SKCCC.  Samples will be shipped or delivered to Dr. Luznik laboratory: 
1650 Orleans Street, CRB1RM 2M88, Baltimore MD 21287. Tel: (410) 955-8567. 
 
b) If a participating site does not have the capability of processing the specimens as 
detailed in Appendix E, then specimens can be shipped overnight to Dr. Luznik’s 
laboratory using cold shipping packages (boxes) provided by Fedex. Please notify the PI-
Dr. Gojo, coordinating center research nurse and Dr. Luznik’s laboratory of specimen 
shipment. 
 
9.2 
Methods 
 
The overarching goals of exploratory correlative studies are to:  a) characterize the effect of 
blinatumomab in combination with checkpoint inhibition on T cells particularly on their re-
distribution, in vivo expansion, activation, and effector differentiation in both PB and BM 
compartment over time and in relation to the response to therapy; b) identify potential predictive 
biomarker candidates to guide improved selection of ALL patients who are more likely to benefit 
from addition of checkpoint inhibitors to blinatumomab therapy in the future; c) characterize the 
mechanisms of relapse / refractoriness to blinatumomab combined with checkpoint inhibition 
such as T-cell dysfunction or to identify alternative resistance mechanisms that could be 
employed by ALL cells to evade blinatumomab/checkpoint inhibition. These studies should 
provide critical information on the selection of best immune-therapeutic combinations for futures 
studies in ALL. The proposed exploratory correlative studies are as follows: 
 
9.2.1 Flow cytometry studies 
 
9.2.1.1 
Exploratory/Ancillary Correlative Studies #1: T-cell subsets distribution (CD4+, 
CD8+, Tregs, Teffs), their differentiation status and expression of co-signaling 
molecules and canonic transcription factors, NK cells, and B cells before and 
post-blinatumomab, and immune checkpoint inhibitor(s) therapy in both 
peripheral blood and the bone marrow microenvironment (Serial PB and BM 
samples collected at all time points as indicated in Section 9.1). We will perform 
multi-parameter flow cytometry on PB and BM specimens obtained at designated 

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time points indicated in the Section 9.1 and on the Study Calendar to examine the 
effect of blinatumomab and checkpoint inhibition on T, NK and B cell dynamics in 
two different compartments in ALL patients. The analysis will be performed using 
three pre-determined panels of mAbs including but not limited to those specific for 
CD3, CD4, CD8, PD-1, CD45RA, CCR7, CD25, CD27, CD28, CD57, CD69, Ki-67, 
T-bet, CD95, CD127, FoxP3, HLA-DR, CTLA-4, TNFRII, TIM-3, LAG-3, CD160, 
2B4, BTLA, KLRG-1, Eomes, Blimp-1, CD16, and CD56. This multi-parametric 
flow cytometry approach allows examination of different CD4+ and CD8+ T-cell 
subpopulations (expressing CD45RA, CCR7, CD27, CD28 and CD57), their 
expression of co-signaling molecules, proliferation  (% Ki-67 positive cells) and 
activation status (CD69, HLA-DR and TNFRII) as well as phenotypic separation of 
human CD4+FoxP3+ T cells into three distinct subpopulations. Natural killer cells 
(NK), NK-T cells will be enumerated using CD16 and CD56 (NK/NK-T cells).  
Additionally kinetics and durability of B cell depletion (CD19) will be assessed.   
Dr. Luznik (co-investigator) and his lab have extensive experience in characterizing 
different T cell subpopulations in leukemia patients at diagnosis, during and after 
chemotherapy, after allogeneic HSCT, and in follow up as published.74 Our studies in 
AML clearly show differences in T cell distribution, activation status, and expression 
of different co-signaling molecules between the PB and BM and depending the disease 
status and response to therapy.74 
 
NOTE: See BIOASSAY TEMPLATE IN Appendix C. 
 
9.2.1.2 
Exploratory/ Ancillary Correlative Laboratory Studies #2:  Characterize the 
expression of co-signaling molecules on BM or PB ALL blasts prior to, during 
and after blinatumomab and checkpoint inhibition (Pre-treatment, week 2 Cycle 
1 if feasible, at response assessment following Cycle 1 and/or 2, BM). Flow 
cytometric studies will be performed on leukemia blasts (CD19/CD10/CD34 plus 
other leukemia specific marker) to examine for expression of co-stimulatory and co-
inhibitory molecules such as PD-L1, B7-H3, VISTA, Gal-9, CD86, PVR, PVR2, 
OX40L, ICOSL at baseline, within 10 days of blinatumomab treatment (prior to first 
administration of checkpoint inhibitors), in non-responders following combination 
treatment after cycle 1 and/or 2, and at the time of relapse.  Collected specimens will 
also serve to examine for other mechanisms of relapse or resistance such as CD19 
loss.   
 
9.2.2 Cytokine studies 
 
9.2.2.1 
Exploratory/ Ancillary Correlative Laboratory Studies #3: Cytokine 
measurement. As a part of PB and BM collection and mononuclear cell isolation we 
will collect plasma that will be used for the measurement of defined cytokines (IL-2, 
IL-6, IL-10, IFN-γ, TNF-α) to assess blinatumomab and checkpoint inhibitors-
induced global T-cell activation.  We will examine the levels of cytokines before and 
after treatment with blinatumomab and checkpoint inhibitors, including the levels of 
sCTLA-4 using a standard ELISA tests (Bio-Plex Pro Human Cytokine 8-Plex 
Immunoassay, Bio-Rad Laboratories, Inc; Human sCD152/CTLA-4 Platinum ELISA. 

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eBioscience). 
 
9.2.3 Molecular studies  
 
9.2.3.1 
Exploratory/ Ancillary Correlative Laboratory Studies #4: Immune Profiling of 
T cell Repertoire (pre-treatment, response assessment after Cycle 1 or 2 and at 
relapse, PB and BM).  The studies proposed will evaluate the TCR diversity in T 
cells isolated from PB and BM from patients before and after treatment with 
blinatumomab and checkpoint inhibitors.  We will determine TCR diversity and 
clonal composition using a molecular and computational approach based on high-
throughput DNA sequencing of rearranged TCRβ CDR3 regions from T cell genomic 
DNA from Adaptive Biotechnologies. This approach allows direct measurement of 
the TCRβ CDR3 region sequence diversity in any arbitrarily complex population of T 
cells, and also permits quantitative description of the clonal composition of the 
population. The Luznik laboratory in collaboration with the E. Warren laboratory 
from Fred Hutchinson Cancer Research Center (FHCRC) have performed extensive 
monitoring and tracking of the TCR repertoires in patients undergoing alloHSCT.99 
We are utilizing an established multiplex PCR strategy to amplify the CDR3 region 
of the TCR, spanning the variable region formed by the junction of the V, D and J 
segments and their associated non-template insertions followed by Illumina-based 
sequencing methodology, a well-characterized methodology developed by Adaptive 
Technology (http://www.adaptivebiotech.com/technology/).  Sequencing is followed 
by comprehensive bioinformatics analyses focused on determining the diversity of the 
T cell and B cell repertoires as well as the entropy and clonality of each repertoire 
consistent with previous studies.  Through these ongoing studies we have developed 
substantial experience not only in using and analyzing DNA retrieved from unsorted 
PBMCs but also from sorted T cells subpopulations (naïve vs memory vs regulatory), 
paired PB and BM samples and as well from DNA retrieved from FFPE archived 
tissues.  
 
9.2.3.2 
Exploratory/ Ancillary Correlative Laboratory Studies #5:  Characterization of 
T cell transcriptional signature before and after treatment (pre-treatment, 
response assessment after Cycle 1 or 2 and at relapse, PB and BM).  For the 
analysis of T-cell gene expression profiles we will use the Human Prime View Gene 
Expression Array (http://www.affymetrix.com). Differentially-expressed genes and 
corresponding fold-changes will be analyzed using standard statistics and through the 
use of Ingenuity pathway analysis as described previously. We predict based on our 
previous work that several key co-stimulatory signaling pathways will be 
downregulated in CD8+ T cells retrieved from patients with leukemia in comparison 
to healthy controls and that these pathways will differ after blinatumomab, nivolumab 
and ipilimumab administration. We will also examine whether there is differential-
expression of genes between CD8+ T cells in BM relative to those in circulation. 
These studies are likely to provide important insights into the T cell transcriptome in 
patients with ALL in particular as it relate to the immunomodulatory strategies to 
modulate their function.  While analysis will focus on CD8+ T cells, as part of T cell 
isolation we are routinely sorting CD8+, CD4+, B cells, NK cells and tumor cells; 

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these other populations will be stored for future analysis.  Given that recent studies 
suggest that mutant neo-epitopes provide potent targets of checkpoint inhibitors, 
stored tumor specimens may be used in the future for neo-antigen discovery studies.  
 
The workflow of specimens for TCR sequencing (Adaptive Biotechnologies) and 
gene expression analysis have been optimized in Luznik Laboratory.  Briefly, CD8+ 
T cells from serial samples (at diagnosis and at the response assessment) will be 
FACS-purified from PB and or BM and DNA/RNA will be isolated and used for TCR 
deep sequencing and gene expression studies, respectively. To determine TCR 
diversity of T cells we are utilizing an established multiplex PCR strategy followed 
by Illumina-based sequencing methodology, a well-characterized methodology 
developed by Adaptive Technology (http://www.adaptivebiotech.com/technology).  
For gene expression studies, cDNA will be synthesized and amplified from total RNA 
will be hybridized to the Human Prime View Gene Expression Array 
(http://www.affymetrix.com) at JHU Deep Sequencing and Microarray Core. 
 
 
 

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10. STUDY CALENDAR 
 
Notations/reminders for all calendars:  
• Baselines assessments are to be conducted within 7 days prior to start of protocol 
therapy unless otherwise noted. If the patient will receive pre-phase treatment, then a BM 
aspirate and biopsy within 14 days of starting treatment on this study is allowed.  
• On study physical exams to include medical history since last assessment, as 
appropriate.  
• Pregnancy test (serum or urine) is required for women of childbearing potential ≤3 days 
prior to study enrollment and must be negative to initiate treatment.  
• Correlative blood and bone marrow sample participation is mandatory.  
• Additional tests may be performed at the discretion of the treating investigator or site as 
per routine practice, or as otherwise clinically indicated.  
• The schedule should be followed as closely as is realistically possible; however, the 
schedule may be modified due to problems such as scheduling delays or conflicts (e.g., 
clinic closure, poor weather conditions, vacations, etc.) with the guidance of the Protocol 
Chair/designee, as appropriate, and will not be reportable as a deviation unless the 
endpoints of the study are affected. 
 
 

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Table 10.1 
Screening 
Cycle 1 
Cycles 2-5 
Beyond Cycle 5 
Treatment Cycle: 
Main 
Study 
Screening 
Week1 
Weeks 2-4 
Weeks 
5-6 
Week 
1 
Weeks 
2-4 
 
Weeks 
5-6 
Every 2 
weeks for up 
to 1 year 
Every 3 
months for 2 
years after 
completing 
study 
treatment 
Off 
Study 
Blinatumomab 
(D 1-28 every 42 
days) 
 
X 
X 
 
X 
(D1-
D28) 
X 
(D1-
D28 
only) 
 
 
 
 
Nivolumab (every 
2 weeks starting on 
D11 of Cycle 1)1 
 
 
X 
X 
 
X 
X 
X 
 
 
Ipilimumab (every 
6 weeks starting on 
D11 of Cycle 1)1 
 
 
X 
 
 
X  
 
X (Every 6 
weeks)  
 
 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria 
X 
 
 
 
 
 
 
 
 
 
Demographics and 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
Concurrent Meds 
X 
X------------------------------------------------------------------------X 
 
 
History/Physical 
Exam2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vital Signs 
including oxygen 
saturation2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Height/Weight2 
X 
X 
 
 
X 
 
 
X (every 6 
weeks) 
 
 
Performance 
Status2 
X 
X 
 
 
X 
 
 
X (every 6 
weeks) 
 
 
CBC with 
X 
X 
X 
X 
X 
X 
 
X 
X 
X 

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Differential3 
PT, aPTT, 
fibrinogen, D-
dimer4 
X 
X 
X 
 
X 
 
 
 
 
 
Serum chemistry5 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Amylase, lipase 6 
X 
 
X 
X 
 
X 
X 
X 
 
 
TSH (with 
reflective Free T3 
and FreeT4)6 
X 
 
X 
X 
 
X 
X 
X 
 
 
Hepatitis 
Serologies7 
X 
 
 
 
 
 
 
 
 
 
Quantitative 
Immunoglobulin8 
X 
 
 
 
X8  
(cy 2 
only) 
 
X8  
(end of 
cy 5) 
X8 
(every 3-6 
months 
X8  
(every 3-6 
months) 
 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
Serum or urine 
HCG for WOCBP 
only9 
X 
 
 
 
X 
 
 
X (every 6 
weeks) 
 
 
Writing Test10 
X 
X 
X 
 
X 
X10 
 
 
 
 
EKG11 and 
ECHOcardiogram 
X 
 
 
 
 
 
 
 
 
 
BM Aspirate and  
Biopsy12 
X 
 
X (within 3 
days prior 
to 1st 
nivolumab) 
X 
 
 
X12 
(end Cy 
2; every 
3-4 mos 
up to 1 
year) 
X12 
(every 3-4 
months up to 
1 year) 
 
X12 
(off 
treatment 
or 
relapse) 
MRD Monitoring 
12 
X 
 
X 
X 
 
 
X12 
X12 
 
X 
LP and CSF 
analysis with 
Intrathecal 
Chemotherapy13 
X 
 
 
X 
 
 
X13 
(cy 2 
only 
required) 
As per 
investigator’s 
discretion 
As per 
investigator’s 
discretion 
 

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Correlative Studies 
from BM (Section 
9.1 and Appendix E 
for instructions)14 
X 
 
X (within 3 
days prior 
to nivo) 
X 
 
 
X14 
X14 
 
X14 
Correlative Studies 
from PB (Section 
9.1 and Appendix E 
for instructions)15 
X 
X 
X 
X 
X 
X 
X 
X 
(every 3-4 
months up to 
1 year) 
 
X15 
(off 
treatment 
or 
relapse) 
 
 
 
Symptom/Toxicity 
Assessment16 
X 
X--------------------------------------------------------------------------------------------------------------X16 
See specific requirements for monitoring after last dose of nivolumab and/or ipilimumab, and after 
allo-HSCT16 
 
Follow-
up/Survival17 
 
X17 
X17 
1 Ipilimumab will be administered every 6 weeks and only to subjects treated on DL B1 (B-1) and B-2.  Both Ipilimumab and 
Nivolumab can be given ± 2 days from the scheduled time and delayed in Cycle 1 up to day 25 as defined in Section 5.3.2 and 5.3.3. 
 
2 Interim history/physical exam and vital signs (heart rate, blood pressure, temperature, respiratory rate and 02 saturation) will be 
performed prior to each cycle, weekly during cycle 1 and 2, and every 2 weeks in cycle ≥3. During cycle 1 patient are expected to be 
hospitalized for 14 days and in subsequent cycles for the first 2 days and will have daily history/physical exam/vital signs (including 
S02) as per standard of care (SOC). Vital signs (including S02) will be monitored prior to start of each nivolumab and ipilimumab 
infusion and at the end of infusion or more frequently as indicated. Height will be recorded only prior to start of treatment on the study. 
Weight and performance status will be measured/assessed prior to each cycle (every 6 weeks). 
 
3 CBC and differential will be performed on day 1 of each cycle, daily for the first 4 days of cycle 1, weekly during cycle 1 and 2, and 
every 2 weeks thereafter for the duration of therapy. CBC and diff should be performed within three days of nivolumab and ipilimumab 
administration. The frequency of CBC/diff measurements may be higher and adjusted for individual patient’s need as per the SOC 
requirements for monitoring and treatment of patients with ALL. 
 

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4 PT/PTT, fibrinogen and d-dimer will be measured prior to each cycle of blinatumomab.  In cycle 1, due to higher risk for DIC because 
of active disease, PT/PTT, fibrinogen and d-dimer should be checked at least twice a week in the first two weeks. The frequency of 
measurement may be higher and adjusted for individual patient’s need as per the SOC requirements for monitoring and treatment of 
patients with ALL. 
 
5 Serum chemistry: albumin, alkaline phosphatase, total bilirubin, bicarbonate, BUN, calcium, chloride, creatinine, glucose, LDH, 
phosphorus, potassium, total protein, SGOT [AST], SGPT [ALT], sodium, uric acid. Serum chemistry will be performed on day 1 of 
each cycle, daily for the first 4 days of cycle 1, weekly during cycle 1 and 2, and every 2 weeks thereafter for the duration of therapy. 
Serum chemistry should be performed within three days of nivolumab and ipilimumab administration. The frequency of serum 
chemistry measurements may be higher and adjusted for individual patient’s need as per the SOC requirements for monitoring and 
treatment of patients with ALL. 
 
6 Amylase, lipase, and TSH should be checked within three days prior to each nivolumab administration. If TSH is abnormal, Free T3 
(triiodothyronine) and T4 (thyroxine) should be assessed. Screening time point must be done within 28 days of registration.  
 
7 Hepatitis serologies will be performed as baseline and include: Hepatitis B surface antigen (HBV sAg), Hepatitis B core antibody 
(anti-HBc), and Hepatitis surface antibody (HBsAb).  Hepatitis C antibody (HCV Ab) and/or Hepatitis C RNA (HCV RNA). Screening 
time point must be done within 28 days of registration. 
 
8 Quantitative immunoglobulin should be measured at baseline, at the end of cycle 1, at the end of the last blinatumomab cycle and 
every 3-6 months thereafter until off study. Screening time point must be done within 28 days of registration. 
 
9 For WOCBP (women of childbearing potential) only: A serum or urine pregnancy testing is required prior to study enrollment and 
prior to each cycle.  
 
10 Writing test (Appendix G) should be performed at baseline, prior to each cycle, and then weekly during blinatumomab administration 
(week1-4) in cycle 1 and 2 and every 2 weeks during blinatumomab administration (week 1-4) in cycle ≥3 of blinatumomab. 
 
11 All patients should have baseline ECG. Baseline ECHOcardiogram is required for patients with a history of CHF, or at risk because of 
underlying cardiovascular disease (e.g history of angina, heart attack, or prior cardiovascular interventions or findings), history of 
cardiac arrhythmias, or exposure to cardiotoxic drugs (e.g anthracyclines, cyclophosphamide, or others) as clinically indicated. Any 
patient with heart arrhythmia or ischemic changes on baseline ECG should have baseline ECHOcardiogram. In addition, any patient 
who develop symptoms or signs of CHF, MI, cardiomyopathy, or myositis in the course of the study, should have repeat EKG, 
ECHOcardiogram, as well as cardiac evaluation including lab tests, CPK, troponin, and cardiology consultations as clinically indicated. 

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12 Bone marrow aspirate and biopsy to assess disease status and response to therapy will be performed at baseline (after pre-registration 
and prior to registration), at the end of cycle 1 and 2 (day 29-day 35), and every 3-4 months thereafter up to 1 yr, any time relapse is 
suspected or off treatment. Additional bone marrow aspirates for research purposes only will be performed in cycle 1 within 3 days of 
the first nivolumab/ipilimumab administration (between days 8-11 of cycle 1 but can be delayed if nivolumab and/or ipilimumab 
administration is delayed in Cycle 1 as per Section 5.3.2 and 5.3.3) prior to nivolumab administration. Each time bone marrow 
assessment is performed to assess disease status, the flow cytometry studies for MRD assessment will be performed. 
 
13 All patients should have baseline CSF assessment prior to enrollment on the study. Administration of intrathecal chemotherapy is 
required when LP is performed with a choice of agent (ara-C or MTX or both) and dose as per institutional standard of practice. 
Subsequent IT chemotherapy administration for CNS prophylaxis should be performed at the end of blinatumomab administration in 
cycles 1 and 2 (day 29-35) and the determination of need for subsequent CSF prophylaxis will be per investigator’s discretion. 
 
14 Each time bone marrow is performed for disease status assessment additional 40 cc of the bone marrow should be collected for 
research studies. Additional bone marrow aspirate for research purpose only will be performed in cycle 1 (between days 8-11) prior to 
nivolumab administration. 
 
15 Peripheral blood 100 cc (min 60 cc) for research studies will be collected at baseline (after pre-registration and prior to registration), 
prior to first dose of nivolumab / ipilimumab in cycle 1 (-3 days), at the end of cycle 1 and 2 (day 29-35), and every 3-4 months up to 1 
yr, or at the time of relapse or off treatment. Additional research peripheral blood 40 cc (min 30 cc) will be collected in cycle 1 (day 1, 
15, 22; all ±3 days), on day 1 (-3 days) of cycle 2. 
 
16 Assessments for toxicity/adverse events are to continue for 100 days after the last dose of nivolumab or ipilumimab, whichever was 
administered last. These may occur by phone for subjects no longer being seen at the institution; however, an in-person clinic visit may 
be needed to confirm event resolution and/or to effectively evaluate possible immune-related events. In addition, all patients who go 
onto allo-HSCT following the completion of treatment on the study will undergo continuous monitoring for acute grade 3-4 graft versus 
host disease and post-transplant non-relapse mortality for the first 100 post-transplant days. Subjects must be told of follow-up 
requirements at study entry.  
 
17 Subjects will be followed about every 3 months for disease status and survival. Information about subsequent treatment received and 
response will be collected.  
 
 

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110 
 
11. MEASUREMENT OF EFFECT 
 
Although the clinical benefit of nivolumab and ipilimumab has not yet been established in ALL, 
the intent of offering this treatment is to provide a possible therapeutic benefit, and thus the 
patient will be carefully monitored for leukemia response and symptom relief in addition to 
safety and tolerability.  Patients will be assessed by standard criteria.  For the purposes of this 
study, patients will be re-evaluated with a bone marrow biopsy at the conclusion of the first and 
second cycle of treatment, at the end of the last blinatumomab containing cycle, and every 3-4 
months thereafter, and off study.  A bone marrow biopsy should also be obtained at anytime 
there is clinical suspicion for relapse based on changes in symptoms, exam, or laboratory 
parameters.   
 
11.1 
Antitumor Effect – Hematologic Tumors 
 
11.1.1 Definitions 
 
Evaluable for toxicity.  All patients will be evaluable for toxicity from the time of their 
first treatment with blinatumomab. 
 
Evaluable for objective response.  Patients who have measurable disease present at 
baseline, have received at least one cycle of therapy, and have had their disease re-
evaluated will be considered evaluable for response.  These patients will have their 
response classified according to the definitions stated below.  (Note:  Patients who exhibit 
objective disease progression prior to the end of cycle 1 will also be considered 
evaluable.) 
 
11.1.2 Disease Parameters 
 
Complete Remission (CR)   
1 No circulating blasts or extramedullary disease 
o No lymphadenopathy, splenomegaly, skin/gum infiltration/testicular 
mass/CNS involvement 
2 Trilineage hematopoiesis (TLH) and <5% blasts 
3 Absolute neutrophil count (ANC) >1,000/L 
4 Platelets >100,000/L 
 
CR with incomplete blood count recovery (CRi) 
• Meets all criteria for CR except platelets and/or ANC 
 
Refractory Disease 
• Failure to achieve CR after 1-2 cycles of treatment 
 
Progressive Disease (PD) 
• Increase of at least 25% in the absolute number of circulating or bone marrow 
blasts or development of extramedullary disease 
 

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111 
 
Relapsed Disease 
• Reappearance of blasts in the blood or bone marrow (>5%) or in any 
extramedullary site after a CR 
 
Minimal Residual Disease (MRD) 
• MRD in ALL refers to the presence of leukemic cells below the threshold of 
detection by conventional morphologic methods.  Patients who achieved a CR by 
morphologic assessment alone can potentially harbor a large number of leukemic 
cells in the bone marrow. 
 
11.1.3 Methods for Evaluation of MRD 
 
The high relapse rate seen in adult ALL indicates the lack of eradication of MRD despite 
morphologic remission.  Several techniques, including monitoring of fusion gene transcripts; 
clonal immunoglobulin heavy chain gene rearrangement; or multicolor flow cytometry have 
shown reliability in estimating the risk of relapse in ALL patients.100   
 
Given the equivalence of PCR techniques and flow cytometry in monitoring MRD in ALL 
patients,101 a flow cytometric approach will be used for MRD assessment in this study.  This 
approach has been adopted for all patients with ALL in our institution and for patients with NHL 
involving the bone marrow.  Furthermore, the flow cytometry laboratory at Johns Hopkins is a 
reference laboratory for MRD monitoring in ALL for all COG studies.  Those patients with 
unique gene fusions detectable by PCR will also be monitored for MRD by specific PCR tests 
following the completion of blinatumomab treatment, and then per the institutional standard-of-
care.  Collected samples may also be used for the assessment of MRD at a molecular level by 
high-throughput sequencing of IGH as previously described,102 or by PCR for patients with a 
known fusion gene transcript. 
 
11.1.4 Response Criteria 
 
Responses will be assessed at the conclusion of cycles 1 and 2 and in follow-up given the 
response definitions provided above. 
 
11.1.5 Duration of Response 
 
Duration of overall response:  The duration of overall response is measured from the time 
criteria are met for CR or CRi (whichever is first recorded) until the first date that 
relapsed disease is objectively documented. 
 
 
11.1.6 Progression-Free Survival 
 
Progression-free survival (PFS) is defined as the duration of time from start of treatment to time 
of progression or death, whichever occurs first.  
 

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112 
 
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.   
 
For the Phase 1 portion of this study, all decisions regarding dose escalation/expansion/de-
escalation require sign-off by the Protocol Principal Investigator through the CTMS/IWRS.  In 
addition, for the Phase 1 portion, the Protocol Principal Investigator will have at least monthly, 
or more frequently, conference calls with the Study Investigators and the CTEP Medical 
Officer(s) to review accrual, progress, and adverse events and unanticipated problems.   
 
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. 
 
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, Read-Only, CRA (Lab Admin, SLA, or Site Investigator) on 
either the LPO or participating organization roster at the enrolling site. To the hold Rave CRA 
role or CRA Lab Admin role, the user must hold a minimum of an AP registration type. To hold 
the Rave Site 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 

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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 three times annually (one annual site visit and two data audits). 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. 
 
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. 

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114 
 
 
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). 
12.3 
CTEP Multicenter Guidelines 
 
N/A 
 
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 

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115 
 
shall hereinafter be referred to as "Multi-Party Data”): 
 
a. NCI will provide all Collaborators with prior written notice regarding the existence and 
nature of any agreements governing their collaboration with NCI, the design of the 
proposed combination protocol, and the existence of any obligations that would tend to 
restrict NCI's participation in the proposed combination protocol. 
 
b. Each Collaborator shall agree to permit use of the Multi-Party Data from the clinical trial 
by any other Collaborator solely to the extent necessary to allow said other Collaborator 
to develop, obtain regulatory approval or commercialize its own Agent. 
 
c. Any Collaborator having the right to use the Multi-Party Data from these trials must 
agree in writing prior to the commencement of the trials that it will use the Multi-Party 
Data solely for development, regulatory approval, and commercialization of its own 
Agent. 
 
3. Clinical Trial Data and Results and Raw Data developed under a Collaborative Agreement 
will be made available to Collaborator(s), the NCI, and the FDA, as appropriate and unless 
additional disclosure is required by law or court order as described in the IP Option to 
Collaborator (http://ctep.cancer.gov/industryCollaborations2/intellectual_property.htm).  
Additionally, all Clinical Data and Results and Raw Data will be collected, used and 
disclosed consistent with all applicable federal statutes and regulations for the protection of 
human subjects, including, if applicable, the Standards for Privacy of Individually 
Identifiable Health Information set forth in 45 C.F.R. Part 164. 
 
4. When a Collaborator wishes to initiate a data request, the request should first be sent to the 
NCI, who will then notify the appropriate investigators (Group Chair for Cooperative Group 
studies, or PI for other studies) of Collaborator's wish to contact them. 
 
5. Any data provided to Collaborator(s) for Phase 3 studies must be in accordance with the 
guidelines and policies of the responsible Data Monitoring Committee (DMC), if there is a 
DMC for this clinical trial. 
 
6. Any manuscripts reporting the results of this clinical trial must be provided to CTEP by the 
Group office for Cooperative Group studies or by the principal investigator for non-
Cooperative Group studies for immediate delivery to Collaborator(s) for advisory review and 
comment prior to submission for publication.  Collaborator(s) will have 30 days from the 
date 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 

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116 
 
 
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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117 
 
13. STATISTICAL CONSIDERATIONS 
 
13.1 
Overall 
 
This is a multi-site, open-label, Phase 1 study of evaluating safety, tolerability, and preliminary 
antitumor activity of blinatumomab and nivolumab with or without ipilimumab in patients with 
CD19+ Pre-B ALL and CD19+ MPAL. The study consists of two parts: dose escalation for 
blinatumomab and nivolumab with and without ipilimumab and dose expansion at MTD.  The dose 
expansion cohort will only be initiated once the MTD for the combination therapy has been 
established.  In each part of the study, a ten-day run-in of blinatumomab prior to combination therapy 
will be incorporated to help determine the effect of blinatumomab on immune-related parameters of 
each patient’s leukemia. 
 
13.2 
Analysis Population 
 
• 
Safety Analysis Set: All subjects who receive at least one dose of study drug.  
• 
Dose-Limiting Toxicity Evaluation Set: A subject must meet one of the following 3 criteria 
to be evaluable for dose-escalation decisions:  receive all of the scheduled doses of 
combination therapy and has completed 6 weeks of treatment without a DLT; experience a 
DLT in the first 6 weeks of combination therapy; or withdrawn from the study prior to 
completing 6 weeks of combination treatment due to a DLT.  
• 
Efficacy Evaluable Analysis Set: All subjects who receive at least one dose of study drug, 
have an adequate baseline disease assessment and at least one post-baseline response 
assessment.  
 
13.3 
Study Design/Endpoints 
 
13.3.1 Primary Objectives 
 
13.3.1.1 
Adverse events and toxicities will be tabulated and reported by type and grade for all 
dose levels of all treatment combinations and the proportions reported with exact 95% 
binomial confidence intervals. 
 
13.3.1.2 
The maximum tolerated dose (MTD) of the combination of blinatumomab plus 
nivolumab, and blinatumomab plus both nivolumab and ipilimumab will be 
determined in subjects with poor-risk, relapsed or refractory CD19+ Pre-B cell ALL 
or CD19+ mixed phenotype acute leukemia (MPAL). 
 
13.3.2 Secondary Objectives 
 
13.3.2.1 
The frequency distribution of responses, including CR, CRi or progressive disease 
(PD) by treatment arm and dose level for all patients on study will be determined and 
reported with exact 95% confidence intervals.   
 

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13.3.2.2 
For patients who have a clinical response, the frequency of MRD+ vs. MRD- 
responses will be reported by treatment arm and dose level for all patients on study.     
   
13.3.2.3 
For patients who have a clinical response, duration of response (DOR) will be 
analyzed as a time-to-event outcome with the duration being measured as the time 
from measured response to progressive disease, death, or study end.  
 
13.3.2.4 
Overall survival will be measured from the first day of treatment on the study until 
death or last known follow up. 
 
13.3.3 Exploratory Objectives 
 
13.3.3.1 
The absolute lymphocyte count and the distribution of T cell subsets (CD4+, CD8+, 
Tregs, Teffs) and their differentiation status, NK cells, and B cells before and post-
blinatumomab, and immune checkpoint inhibitor(s) therapy in both peripheral blood 
and the bone marrow microenvironment will be determined.  
 
13.3.3.2 
Changes in T cell co-signaling receptors expression in defined T cell subpopulations 
and their canonic transcription factor expression in both peripheral blood and bone 
marrow before and post-blinatumomab, and immune checkpoint inhibitor(s) therapy 
will be recorded. 
 
13.3.3.3 
Changes in expression of co-signaling molecules on leukemia blasts 
(CD10+/CD19+/CD34+) before and after treatment with blinatumomab and 
checkpoint inhibitors will be examined. 
 
13.3.3.4 
Serum levels of cytokines before and after treatment with blinatumomab and 
checkpoint inhibitors, including the levels of sCTLA-4, will be determined. 
 
13.3.3.5 
Immune profiling of T cell repertoire and characterization of T cell transcriptional 
signature before and after treatment will be determined. 
 
13.4 
Study Design 
 
This study proposal will be a phase 1 trial of blinatumomab plus immune checkpoint inhibition 
in patients with relapsed/refractory ALL or those with a new diagnosis of ALL who cannot 
receive standard induction. The first part of the study will be a dose escalation following a 3+3 
design for the combination of blinatumomab plus nivolumab. The study will start with the 
recommended dose of blinatumomab in relapsed/refractory ALL. Nivolumab will be started at 
the recommended doses for monotherapy for metastatic melanoma. This design is being used as 
an added safety measure and a more controlled start of the study to minimize the risk of 
unexpected toxicities or other issues that may occur in the combination treatment of 
blinatumomab with either ipilimumab or nivolumab.  
 
The first three patients will be enrolled at dose level DL A1 and monitored for the first cycle of 
treatment (42 days) for DLTs before enrolling additional patients.  If less than 2 patients 

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119 
 
experience a DLT, an additional 3 patients will be enrolled at that dose level.  If 0 or 1 out of 6 
patients have a DLT, that dose level will be deemed safe.  If 2 or 3 of the first 3 patients 
experience a DLT, that study arm may de-escalate to dose level DL A-1 (only after CTEP 
approval) and another 3 patients will be enrolled.  If less than 2 patients experience a DLT in the 
de-escalated dose, an additional 3 patients will be enrolled at that dose.  If 0 or 1 out of 6 patients 
have a DLT, the de-escalated dose will be deemed safe.  If 2 or 3 patients experience a DLT, that 
study arm will be stopped for review.   
 
When the safety of blinatumomab in combination with nivolumab is confirmed, the study will 
expand to treat patients with this combination plus ipilimumab.  A standard 3+3 design will be 
used to assess the safety and tolerability of the combination.  Two dose levels (DL B1, DL B-1,) 
are available.  If DL A1 was deemed safe, then three patients will be enrolled at DL B1.  If ≤1 of 
3 patients experience a DLT during the first cycle of treatment (42 days), at DL B1, an additional 
3 patients will be enrolled at DL B1. If no more than 1 of 6 patients experience a DLT, then it 
will be defined as the MTD. If 2 or more of 3 or 6 patients experience a DLT at DL B1, then 
dose de-escalation may  be implemented BUT ONLY after CTEP approval and the next three 
patients may  be enrolled at DL B-1. If ≤1 of 3 patients experience a DLT during the first cycle 
of treatment (42 days), an additional three patients will be enrolled at DL B-1.  If 2 or more of 3 
or 6 patients experience a DLT at DL B-1, then dose escalation will be halted and the 
combination of blinatumomab, nivolumab and ipilimumab will not be further pursued in this 
patient population unless additional data become available supporting different doses or 
schedules of nivolumab and ipilimumab administration. This will require review of all toxicity, 
discussion with CTEP and official study amendment.  
 
When the MTD of blinatumomab in combination with ipilimumab and nivolumab is determined, 
an additional 6 patients will be enrolled in an expansion cohort to further characterize safety, 
tolerability and any preliminary signs of biological or clinical activity of the triplet 
blinatumomab/nivolumab plus ipilimumab.  An expansion cohort of 6 subjects will be also 
pursued at MTD for doublet of blinatumomab and nivolumab only to further characterize safety, 
tolerability and any preliminary signs of biological or clinical activity in this cohort.   
 
13.4.1 Dose Expansion 
 
Continuous monitoring of safety will be completed during the enrollment and treatment period of 
each expansion cohort.  If it becomes evident that the proportion of patients experiencing a 
treatment-related toxicity meeting DLT criteria convincingly exceeds 30%, the study will be 
halted for a safety consultation. The toxicity stopping rule will hold enrollment if the posterior 
probability of failure being larger than 0.30 is 70% or higher. The prior for this monitoring rule 
is beta (1,2). This means that our prior guess at the proportion of failures is 33%, and there is 
90% probability that this proportion is between 2.5% and 77.6%. The monitoring rule and 
operating characteristics are given below.  
- Stop if 2 out of 2 patients experience a DLT: Pr(Risk>0.3 | Data) = 0.916 
- Stop if 2 out of 3 patients experience a DLT: Pr(Risk>0.3 | Data) = 0.837 
- Stop if 2 out of 4 patients experience a DLT: Pr(Risk>0.3 | Data) = 0.744 
- Stop if 3 out of 5 patients experience a DLT: Pr(Risk>0.3 | Data) = 0.874 
- Stop if 3 out of 6 patients experience a DLT: Pr(Risk>0.3 | Data) = 0.806 

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120 
 
 
Operating Characteristics of stopping rule for toxicity, based on 5000 simulations: 
True Toxicity 
Rate 
Probability of declaring 
treatment too toxic 
Average sample size 
20% 
25% 
30% 
35% 
40% 
45% 
50% 
17% 
26.8% 
34.6% 
43.1% 
52.7% 
61% 
68.8% 
3.9 
3.8 
3.7 
3.6 
3.5 
3.4 
3.2 
 
13.4.2 Early Stopping for Safety in the Post-Transplant Setting 
 
Because many patients enrolled in this protocol will be candidates for a subsequent allo-HSCT, 
and there have been recent reports of increased toxicity among patients who undergo allo-HSCT 
following treatment with PD-1 inhibitors, all patients who go onto allo-HSCT following the 
completion of the clinical protocol will undergo continuous monitoring.  The clinical failures of 
acute grade 3-4 graft versus host disease and post-transplant non-relapse mortality will be 
monitored continuously for the first 100 post-transplant days. If it becomes evident that the 
proportion of acute grade 3-4 graft versus host disease is greater than 25% or the proportion of 
non-relapse mortality is greater than 20% then the study would be held for a safety consultation.  
 
Acute Grade 3-4 GVHD 
 
The acute GVHD grade 3-4 stopping rule will hold enrollment if the posterior probability of 
failure being larger than 0.25 is 70% or higher. The prior for this monitoring rule is beta(1,3).   
This means that our prior guess at the proportion of failures is 25%, and there is 90% probability 
that this proportion is between 1.7% and 63.2%. The following table shows the resulting rules. 
 
Safety review triggered 
if number of patients 
with grade 3-4 GVHD 
is: 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
Number of patients is 
between: 
2-4 
5-8 
9-11 
12-15 
16-18 
19-22 
23-26 
27-30 
31-33 
34-36 
 
For example, the rule will call for a safety review if 3 out of the first 5 patients experience acute 
grade 3-4 GVHD.  The table below shows the percent of times the stopping rule will halt the 
study for a safety review and the average sample size under different hypothetical risks of grade 
3-4 acute GVHD. 
 
 
 
 
 

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121 
 
Operating Characteristics of stopping rule for GVHD, based on 5000 simulations: 
True acute or chronic GVHD 
grade 3-4 rate 
Probability of stopping 
for excess GVHD grade 3-4 
Average 
Sample Size 
10% 
15% 
20% 
25% 
30% 
35% 
40% 
8.0% 
20.7% 
37.1% 
58.5% 
77.3% 
89.2% 
95.9% 
31.7 
28.4 
24.6 
19.4 
14.9 
11.3 
8.4 
 
Non-Relapse Mortality 
 
The non-relapse mortality safety stopping rule will hold enrollment if the posterior probability of 
failure being larger than 0.20 is 70% or higher. The prior for this monitoring rule is beta(1,4).   
This means that our prior guess at the proportion of failures is 20%, and there is 90% probability 
that this proportion is between 0.60% and 60.2%. The following table shows the resulting rules. 
 
Safety review triggered if 
number of patients with 
non-relapse mortality is: 
2 
3 
4 
5 
6 
7 
8 
9 
Number of patients is 
between: 
2-5 
6-9 
10-14 
15-18 
19-23 
24-27 
28-32 
34-36 
 
For example, the rule will call for a safety review if 4 out of the first 10 patients die without 
relapse.  The table below shows the percent of times the stopping rule will halt the study for a 
safety review and the average sample size under different hypothetical risks of non-relapse 
mortality. 
 
Operating Characteristics of stopping rule for non-relapse mortality, based on 5000 
simulations: 
True Non-Relapse Mortality 
Rate 
Probability of stopping 
for too much  
non-relapse mortality 
Average 
Sample Size 
10% 
15% 
20% 
25% 
30% 
35% 
13.0% 
31.0% 
53.7% 
74.3% 
89.6% 
96.2% 
30.5 
26.3 
21.0 
16.1 
11.6 
8.9 
 
13.4.3 Statistical Analysis Plan 
 
The primary objective of this study is to evaluate the safety and tolerability of blinatumomab 
given in combination with nivolumab, or in combination with both nivolumab and ipilimumab in 
subjects with poor-risk, relapsed or refractory CD19+ Pre-B cell ALL or CD19+ biphenotypic 

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122 
 
leukemia.  All adverse events and toxicities will be tabulated and reported by type and grade for 
all dose levels of all treatment combinations and the proportions reported with exact 95% 
binomial confidence intervals.  Any patient who receives at least one dose of any treatment will 
be included in toxicity reporting, regardless of eligibility or study drop out. 
 
13.5 
Sample Size/Accrual Rate 
 
In the dose escalation phase of this study, the sample size is determined by the number of DLTs 
observed.  The minimum sample size for this first part of the study will be 6 patients at DL1 and 
DL-1 (if necessary), and a maximum sample size of 12 patients.  During the dose escalation 
phase of the combination arm, the minimum number of patients treated will be 3 and maximum 
will be 6 at each dose level.  If the combination is deemed safe and the expansion cohort is 
enrolled, the sample size will be either 9 or 12 at that dose level.  The maximum total sample for 
the entire study will be 36 patients. 
 
The anticipated complete response (CR) rate in this patient population is approximately 40%.  
With a minimum sample size of 12 subjects in the combination arm, the probabilities of 
observing at least 5 responses out of 12 patients (41.7% CR rate) would be 0.42, 0.56, and 0.70 if 
the true CR rate is 35%, 40%, and 45%, respectively. If the true CR rate is less than 15%, the 
chance of observing 5 responses out of 12 would be 0.024 or less. This sample size also allows 
for estimation of the CR rate with precision (half the width of the 95% exact binomial confidence 
interval) being no wider than 25.5%. 
 
PLANNED ENROLLMENT REPORT 
Racial Categories 
Ethnic Categories 
Total 
Not Hispanic or Latino 
Hispanic or Latino 
 
Female 
Male 
Female 
Male 
 
American Indian/ Alaska 
Native 
0 
0 
0 
0 
0 
Asian 
1 
0 
0 
0 
1 
Native Hawaiian or 
Other Pacific Islander 
0 
0 
0 
0 
0 
Black or African 
American 
1 
2 
0 
0 
3 
White 
7 
13 
3 
3 
26 
More Than One Race 
0 
0 
0 
0 
0 
Total 
9 
15 
3 
3 
30 
PHS 398 / PHS 2590 (Rev. 08/12 Approved Through 8/31/2015)  
OMB No. 0925-0001/0002 
 

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123 
 
13.6 
Stratification Factors 
 
Not Applicable   
 
13.7 
Analysis of Secondary Endpoints 
 
The secondary objectives of this study include describing preliminary antileukemia activity of 
blinatumomab and nivolumab, and blinatumomab plus both nivolumab and ipilimumab, 
including the effects on MRD, and assessing preliminary antileukemia activity in an expansion 
cohort of patients with poor-risk, relapsed or refractory CD19+ Pre-B cell ALL.  The frequency 
distribution of responses, including CR, CRi or progressive disease (PD) will be reported by 
treatment arm and dose level for all patients on study and reported with exact 95% confidence 
intervals.  For patients who have a clinical response, duration of response (DOR) will be 
analyzed as a time-to-event outcome using the Kaplan Meier method with the duration being 
measured as the time from measured response to progressive disease, death, or study end. A 
sensitivity analysis may be performed to evaluate DOR while excluding patients who go on to 
have an allo-HSCT. Overall survival will be measured using the Kaplan Meier method as the 
time from the first day of treatment on the study until death or last known follow up. 
 
13.8 
Analysis of Exploratory Endpoints  
 
13.8.1 Characterizing T cell populations 
 
The analyses of pre- and post-treatment PB and BM specimens for immune parameters will be 
descriptive and graphical in nature. Data will be summarized for each patient group separately 
(blinatumomab plus nivolumab; blinatumomab plus nivolumab and ipilimumab). Flow values at 
each time point will be summarized using geometric means and standard deviation. Differences 
in baseline values between patient subgroups will be explored using linear regression models.  
We are specifically interested in determining what pretreatment signature is associated with 
outcome, such as having a complete response or becoming refractory. To this end, we will use 
logistic regression models with ROC analysis to describe which pretreatment parameters are 
potential predictors of outcomes following treatment. Values will be checked for skewness and 
log-transformed as appropriate. The change in flow values at each time point after blinatumomab 
and blinatumomab plus checkpoint inhibitor(s) relative to the baseline value will be modeled 
using mixed-effects, linear regression models that include fixed effects for time point and a 
random effect for the patient to account for within-patient correlation of measurements.  Post-
treatment changes in T cell populations will be correlated with clinical outcomes such as CR vs. 
No CR or MRD vs. No MRD using interaction tests. T cell subsets in the PB and BM defined by 
multicolor flow cytometry will be summarized before and after treatment with blinatumomab 
alone or plus checkpoint inhibitors by treatment group using summary statistics. Differences in T 
cells before and after treatment will be explored using non-parametric Wilcoxon signed rank 
tests or paired t tests as appropriate. The expression of co-inhibitory/-stimulatory molecules will 
also be examined in the same way. 
 
 

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124 
 
13.8.2 Characterization of T cell transcriptional signature before and after treatment. 
 
Expression levels will be summarized at pre-treatment and post-treatment using standard 
descriptive statistics. Differentially-expressed genes and corresponding fold-changes will be 
analyzed using standard statistics and through the use of Ingenuity pathway analysis as described 
previously. We will identify differentially-expressed genes by patient subgroups such as CR v. 
NR and MRD v. No MRD using interaction tests. 
 
13.8.3 Leukemia Blasts 
 
The analyses for changes in expression of co-signaling molecules on leukemia blasts 
(CD10+/CD19+/CD34+) before and after treatment with blinatumomab and checkpoint inhibitors 
will be summarized using descriptive statistics and either Wilcoxon rank sum tests or paired t 
tests, as appropriate for a single time point, or using the mixed effects linear regression models 
for simultaneously modelling data from multiple time points as previously described for 
analyzing the T cell population data. We will explore the changes in blasts in terms of expression 
of co-signaling molecules over time and summarize any correlation in the pattern of blast 
changes over time using the regression models and interaction tests described above. 
 
 
13.8.4 Cytokine Profiling  
 
Changes in cytokine levels for all patients and within patient subgroups will be summarized 
using descriptive statistics and either Wilcoxon rank sum tests or paired t tests, as appropriate for 
a single time point, or using the mixed effects linear regression models previously described for 
simultaneously modelling data from multiple time points for the T cell population data.  
13.8.5 Immune Profiling 
 
Immune profiling of T cell repertoire and characterize T cell transcriptional signature before and 
after treatment will be analyzed using the approach outlined in a prior study.99  Specifically, two 
distinct measures, clonality and Gini coefficient, will assess the degree of clonal skewing in the 
TRB repertoires.  Clonality is a metric derived from the Shannon entropy of the frequency 
distribution of TRB sequences normalized by the log2(number of unique TRB sequences); it 
captures the clonal composition of a T cell population and has an adjustment for sequencing 
depth, thus making it less sensitive to this critical variable.103    The Gini coefficient is a 
graphically defined metric of repertoire diversity in the sequence frequency distribution.   
These measures will be used to define clonality, which will be correlated with patient outcomes, 
such as CR v No CR and MRD v No MRD. 
 
 
 

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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 DRUG INFORMATION HANDOUT AND WALLET CARD 
 
Information for Patients, Their Caregivers, and Non-Study Healthcare Team on Possible 
Interactions with Other Drugs and Herbal Supplements  
 
The patient ____________________________ is enrolled on a clinical trial using the 
experimental study drugs, blinatumomab and nivolumab with or without ipilimumab.  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.  
 
These are the things that you as a healthcare provider need to know: 
  
Blinatumomab, nivolumab, and ipilimumab are not known or expected to interact with certain 
enzymes in the body, the heart’s electrical activity, or with other medications; however, there is 
the possibility of interactions.  
 
To the patient: Take this paper with you to your medical appointments and keep the 
attached information card in your wallet.   
 
Blinatumomab, nivolumab, and ipilimumab may interact with other drugs which can cause side 
effects. For this reason, 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, as needed, to review any medicines and herbal supplements that you are taking or 
may start during the study. 
 
• 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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136 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
STUDY DRUG INFORMATION WALLET CARD 
You are enrolled on a clinical trial using the experimental study  
drugs blinatumomab and nivolumab with or without ipilimumab.  
This clinical trial is sponsored by the NCI.  Blinatumomab, nivolumab, 
and ipilimumab may interact with other drugs.  Because of this, 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. 
 
Blinatumomab, nivolumab, and ipilimumab must be used very 
carefully with other medicines.  
➢ 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 that you are taking or may 
start during the study. 
➢ 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 
 
Exploratory/Ancillary Biomarkers for the Assessment of T-cell Subset Distribution, 
Differentiation Status, and the Expression of Co-signaling molecules and Canonic 
Transcription Factors in both the peripheral blood and bone marrow microenvironment 
 
1) Name of Marker:  Surface expression of cluster of differentiation (CD) markers and 
intracellular transcription factors in peripheral blood and bone marrow T cells 
 
2) Role of the Biomarker Assay in the Trial:  Exploratory Assay. 
 
➢ Assay purpose:  
a) To determine phenotypic correlates of effective response to blinatumomab and 
checkpoint inhibitors (nivolumab with or without ipilimumab) 
b) To assess phenotypic predictors of responsiveness to blinatumomab and checkpoint 
inhibitors (nivolumab with or without ipilimumab) 
c) To determine which T cell populations are the targets of checkpoint inhibitors in 
combination with blinatumomab 
 
➢ Assay type: Flow cytometry. 
 
3) Laboratory conducting study for the trial:  Dr. Leo Luznik’s research laboratory. 
 
4) Assay: Standardized tubes and procedures will be used for specimen collection, 
processing, cryopreservation and storage (Appendix E). Our workflow has been 
specifically designed to maximize information yield from smaller samples and is based 
on well developed and implemented standard operating procedures (SOPs). In our 
analysis we will utilize standardized pre-determined multi parametric flow-cytometry 
mAb panels that interrogate dynamic changes across comprehensive immune cell 
populations. In the development and use of the integrated biomarker assay in the context 
of clinical trial we have followed guidelines from the Biomarkers Taskforce of the NCI 
Investigational Drug Steering Committee (Dancey JE et al. Clin Cancer Res 
2010;16:1745-55). We will also follow all recommendations and protocols for 
standardizing immunologic readouts such as published by SITC/FDA/NCI Workshop on 
Immunotherapy Biomarkers (Butterfield LH et al. Clin Cancer Res 2011;17(10):3064-
76). All multicolor flow-cytometry panels will follow standard principles of panel design 
and follow recommendation published by the “Human Immune Phenotyping 
Consortium” on the standardization of flow cytometry immunophenotyping in clinical 
studies (Maecker HT et al. Nat Rev Immunol 2012, 12:191–200). 
 

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➢ Analyte(s) and sources of assay components:  The directly conjugated monoclonal 
antibodies outlined in the Table 1 below. All antibodies will be obtained from commercial 
vendors. 
Table. 1 
Antigen 
Fluorochrome 
Clone  
Antibody type 
Cat No. 
Company  
CD3 
AF700 
HIT3a 
Mouse IgG2a, κ 
300324 
BioLegend 
CD3 
APC 
OKT3 
Mouse IgG2a, κ 
17-0037-42 
eBioscience 
CD3 
evolve 605 
OKT3 
Mouse IgG2a, κ 
83-0037-42 
eBioscience 
CD4 
PerCP Cy5.5 
OKT4 
Mouse IgG2b, κ 
45-0048-42 
eBioscience 
CD4  
BV605  
OKT4 
Mouse IgG2b, κ 
317438 
Biolegend 
CD8 
PerCP-Cy5.5  
RPA-T8 
Mouse IgG1, κ 
45-0088-42 
eBioscience 
CD8  
pacorange 
3B5 
Mouse IgG2a 
MHCD0830 
Thermo Fisher 
(Invitrogen) 
CD45RA 
APC-Cy7 
HI100 
Mouse IgG2b, κ 
304128 
BioLegend 
CCR7 
BV650 
G043H7 
Mouse IgG2a, κ 
353234 
BioLegend 
CD25 
PE-Cy7  
BC96 
Mouse IgG1, κ 
302612 
BioLegend 
CD27 
BV605 
O323 
Mouse IgG1, κ 
302830 
BioLegend 
CD27  
AF700 
M-T271 
Mouse IgG1, κ 
560611 
BD 
CD28 
PE-Cy7  
CD28.2 
Mouse IgG1, κ 
25-0289-42 
eBioscience 
CD127 
e-fluor 450 
eBioRDR5 
Mouse IgG1, κ 
48-1278-42 
eBioscience 
BTLA (CD272) 
AF647 
MIH26 
Mouse IgG2a, κ 
344510 
Biolegend 
BTLA (CD272) 
PE 
MIH26 
Mouse IgG2a, κ 
344506 
Biolegend 
CD160 
AF488 
BY55 
Mouse IgM 
53-1609-42 
eBioscience 
CD244 (2B4) 
FITC 
C1.7 
Mouse IgG1, κ 
329506 
Biolegend 
CD57 
pacblue 
HCD57 
Mouse IgM, κ 
322316 
BioLegend 
KLRG1  
APC 
REA261 
Mouse IgG1, κ 
130-103-639 
Miltenyi 
CTLA-4 (CD152) 
AF647 
BNI3 
Mouse IgG2a, κ 
555855 
BD 
PD1 (CD279) 
PE 
EH12.1 
Mouse IgG1, κ 
560795 
BD 
TIM3 (CD366) 
PE 
344823 
Rat IgG2A 
FAB2365P 
R&D Systems 
PDL1 
Alexa Fluor 700 
MIH1 
Mouse IgG1, κ 
565188 
BD 
CD56 
PECF594 
B159 
Mouse IgG1, κ 
562289 
eBioscience 
Ki-67 
PerCP Cy5.5 
B56 
Mouse IgG1, κ 
561284 
BD 
CD69 
PE 
FN50 
Mouse IgG1, κ 
12-0699-42 
eBioscience 
T-bet 
PE-CF594 
04-46 
Mouse IgG1, κ 
562467 
BD 
FoxP3 
V450 
259D/C7 
Mouse IgG1, κ 
560459 
BD 
HLA-DR 
FITC 
G46-6 
Mouse IgG2a, κ 
555811 
BD 
TNFR2 
(CD120b) 
PE 
3G7A02 
Rat IgG2a, κ 
358404 
Biolegend 
LAG-3 (CD223) 
PE-Cy7 
3DS223H 
Mouse IgG1, κ 
25-2239-42 
eBioscience 
Eomes 
PE 
WD1928 
Mouse IgG1, κ 
12-4877-42 
eBioscience 
Blimp-1 
PE-CF594 
6D3  
Rat IgG2a, κ 
565274 
BD 
CD16 
PerCP Cy5.5 
3G8 
Mouse IgG1, κ 
302028 
Biolegend 
CD95 
Pacific Blue (V450) 
DX2 
Mouse IgG1, κ 
305619 
Biolegend 
LIVE/Dead fixable 
Aqua Dead stain 
kit 
405 nm 
 
 
L34957 
Life Technologies  

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139 
 
 
➢ Technical platform: The Cancer Center flow cytometry facility is equipped with two 
Becton Dickinson (BD) FACSAria II cell sorters, a BD LSR Fortessa with capability of 
simultaneous analysis of up to 18 colors, and a BD LSR II with capability of simultaneous 
analysis of up to 15 colors are available for use in this project. 
 
➢ Specimens: Peripheral blood samples will be obtained via phlebotomy while bone 
marrow will be collected through standard access to iliac crest. Peripheral blood should 
be drawn in 4-10 10 ml green-top vacutainer tube (sodium heparin) as per schedule 
defined in the protocol Section 9.1 and the Study Calendar (Table 10.1). Aspirated bone 
marrow cells will be collected in a 4-10 ml green-top vacutainer tube (sodium heparin). 
All collected specimens will be labeled with the patient’s study number, sample 
collection date and time, and sample source (PB or BM). Specimen collection will be 
recorder on Correlative Studies Collection Worksheet (Appendix F). All data should be 
kept in laboratory log. 
 
➢ Anticipated methods for specimen processing: At each sampling interval, BM and PB 
mononuclear cells (PBMC) will be processed by Ficoll density gradient centrifugation. 
Please refer to Appendix E: Protocol for Plasma/PBMC isolation (Ficoll Hypaque). Each 
sample is aliquoted in multiple vials of 5-20 x 106 cells/vial for PBMC and 25-75 x 106 for 
BM samples. This strategy for sample processing enables purification of PBMCs and the 
corresponding mononuclear cell fraction from BM, and of plasma, for separate 
experimental uses. Freezing enables sample collection over time, which allows analysis of 
multiple samples simultaneously in a single experiment (batching) for increased 
reproducibility and comparability of results. The cell viability upon freeze and subsequent 
thaw is >85% for the majority of the samples (lower viability can be seen in samples from 
patients with uncontrolled leukemia). The function and numbers of the lymphocyte 
populations of interest have been found to be mostly unaffected by freezing and thawing 
in recent study (small changes in the numbers of CD8+ T cells, naïve T cells and central 
memory T cells have been described, but are generally assessed as being of minor 
importance) (Riedhammer et al. Methods in Molecular Biology 2015: 1304: 53–61). 
Thawed cells will be washed in phosphate-buffered saline (PBS) before staining with 
appropriate concentrations of fluorochrome-conjugated monoclonal antibodies. We are 
also routinely allowing a short rest period before staining and closely follow the literature 
on optimal use of the markers on cryoprocessed specimens (Ogunjimi B et al. J Immunol 
Methods 2013;392:63-67; Lemieux J et al. J Immunol Methods 2016;434:73-82). Staining 
for extracellular antigens is performed directly after wash, while fixation and 
permeabilization is performed before staining for intracellular antigens, such as 
transcription factors and cytokines. For intracellular staining we are using commercially 
available reagents and protocols (BD and eBioscience) 

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➢ Data acquisition: Consistency of data acquisition will be ascertained by calibrating the 
flow cytometer with calibrating beads daily. For compensation of flow cytometry data we 
will prepare single stain controls with the appropriate antibodies (mainly using PBMCs, 
but commercially available compensation beads will be utilized for weakly expressed 
antigens), and perform compensation of fluorescent spillover with the compensation 
applications included in the flow cytometry analysis softwares DIVA (Becton Dickinson) 
and FlowJo (TreeStar). At least 10,000 cell events will be collected including appropriate 
isotype controls for cell surface markers and intracellular proteins. Viability dyes will be 
used to facilitate the gating of “live” cell populations.  
 
➢ Data analysis: We will utilize standardized analysis and gating strategies for multi 
parametric flow-cytometry mAb panels (Herzenberg LA et al. Nat Immunol 
2006;7(7):681-5; Lugli E et al. Cytometry A 2010;77(7):705-713). All samples will be 
analyzed by setting appropriate side and forward scatter gates to exclude cell clumps and 
debris, and to include the population of interest: lymphocytes. A “live” gate in the 
fluorescence channel containing the viability stain will be used to exclude dead cells. 
Fluorescence minus one (FMO, samples that include all antibodies but the one of interest) 
and isotype controls will be used to distinguish positive and negative populations for 
studied antigens. The results will be reported as percent of gated cells positive for each 
antibody. A BD FACSAria or BD LSR II flow cytometer with DIVA software (BD) will 
be used for data acquisition. The quantitative, continuously distributed data generated by 
this procedure will be analyzed using DIVA and/or FlowJo. Additional analysis with 
softwares for complex statistical and visual multivariable analysis, (available as freeware 
or at https://www.cytobank.org/platform.html) such as SPICE, bh-SNE and CITRUS will 
be performed to the best advantage. These novel and powerful analysis tools are especially 
suited for presentation of high-dimensional data sets, identifying rare biological subsets, 
and gating single-cell events across different samples (Saeys Y et al. Nat Rev Immunol 
2016; 16:449-62). 
 
5.  Analytical performance of the assay and the metrics to determine the level of the 
change following the treatment: These studies exploring T cell populations have been 
extensively studied in Luznik’s laboratory. All samples are coded and assays are performed 
in blinded fashion. Assays are batched and contain both positive and negative biological 
controls. Luznik laboratory routinely include PBMCs and BM mononuclear cells from 
healthy individuals as controls for all the flow-cytometry runs. The results from controls 
are stored and averaged to generate a range for normal individuals. In our analysis we are 
achieving a high reproducibility in measuring the effects of the treatment under 
investigation in regard to T cell subset(s) numbers and/or other measurable markers (co-
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repeated measurements from the same patients. Based on our performance analysis the 
correlation between repeatedly measured subsets is very high (>90%) with the lower 
bounds of the 95% confidence limits higher than 80% for majority of the  markers 
measured, implying the high reproducibility of our assay. We have also developed criteria 
for measuring the magnitude of markers changes that take into the account differences 
between the baseline and post-treatment values (unpublished data). Specifically, for each 
marker, we modeled the log-scale percentage of cells expressing specific markers as a 
function of time and clinical effect.  A linear mixed effects regression model with a random 
intercept for each patient was then used to estimate the differences between time points for 
each marker while accounting for the patient clustering.  Standard linear regression models 
were used to estimate differences in log-scale percentages between patients at pre-
treatment and healthy controls.  For each marker and each model, we extracted the test 
statistic associated with the difference between time points (or groups) and plotted them 
using standard visualization approaches such as plots and heatmaps. 
 
6. Clinical utility of the integrated assay: Flow values at each time point will be 
summarized using geometric means and standard deviation. Differences in baseline values 
between patient subgroups will be explored using linear regression models.  We are 
specifically interested in determining what pretreatment signature is associated with 
outcome, such as having a complete response or becoming refractory. To this end, we will 
use logistic regression models with ROC analysis to describe which pretreatment 
parameters are potential predictors of outcomes following treatment.  Values will be 
checked for skewness and log-transformed as appropriate.  The change in flow values at 
each time point after blinatumomab and blinatumomab plus checkpoint inhibitor(s) relative 
to the baseline value will be modeled using mixed-effects, linear regression models that 
include fixed effects for time point and a random effect for the patient to account for within-
patient correlation of measurements.  Post-treatment changes in T cell populations will be 
correlated with clinical outcomes such as CR vs. No CR or MRD vs. No MRD using 
interaction tests.  T cell subsets in the PB and BM defined by multicolor flow cytometry 
will be summarized before and after treatment with blinatumomab alone or plus checkpoint 
inhibitors by treatment group using summary statistics.  Differences in T cells before and 
after treatment will be explored using non-parametric Wilcoxon signed rank tests or paired 
t tests as appropriate.  The expression of co-inhibitory/-stimulatory molecules will also be 
examined in the same way.  
 
References: 
1) Dancey JE, Dobbin KK, Groshen S, Jessup JM, Hruszkewycz AH, Koehler M et al. Guidelines 
for the Development and Incorporation of Biomarker Studies in Early Clinical Trials of Novel 
Agents. Clin Cancer Res 2010;16:1745-55. 
2) Butterfield LH, Palucka AK, Britten CM, Dhodapkar MV, Håkansson L,  Janetzki S et al. 
Recommendations from the iSBTc-SITC/FDA/NCI Workshop on Immunotherapy 
Biomarkers. Clin Cancer Res 2011;17(10):3064-76. 

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3) Riedhammer C, Halbritter D, Weissert R. Peripheral Blood Mononuclear Cells: Isolation, 
Freezing, Thawing, and Culture. Methods in Molecular Biology 2015: 1304: 53–61. 
4) Ogunjimi B, Hens N, Malfait R, Van Tendeloo V, Smitset E. Creating a robust framework for 
the analysis of cryopreserved samples in quantitative immunological experiments. J Immunol 
Methods 2013;392:63-67. 
5) Lemieux J, Jobin C, Simard C, Néron S. A global look into human T cell subsets before and 
after cryopreservation using multiparametric flow cytometry and two-dimensional 
visualization analysis. J Immunol Methods 2016;434:73-82. 
6) Herzenberg LA, Tung J, Moore WA, Herzenberg LA, Parkset DR. Interpreting flow cytometry 
data: a guide for the perplexed. Nat Immunol 2006;7(7):681-5. 
7) Lugli E, Roederer M, Cossarizza A. Data analysis in flow cytometry: the future just started. 
Cytometry A 2010;77(7):705-713. 
8) Saeys Y, Gassen SV, Lambrecht BN. Computational flow cytometry: helping to make sense 
of high-dimensional immunology data. Nat Rev Immunol 2016; 16:449-62. 
9) Maecker HT, McCoy JP, Nussenblatt R. Standardizing immunophenotyping for the Human 
Immunology Project. Nat Rev Immunol 2012, 12:191–200. 
 
 
 

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APPENDIX D:  MANAGEMENT ALGORITHMS FOR NIVOLUMAB-/IPILIMUMAB- 
RELATED ADVERSE EVENTS: ENDOCRINOPATHY, GASTROINTESTINAL, 
HEPATIC, NEUROLOGICAL, PULMONARY, RENAL, AND SKIN ADVERSE 
EVENTS 

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APPENDIX E: OPERATING PROCEDURES FOR SPECIMEN COLLECTION  
 
Peripheral blood and bone marrow specimen collection will be performed as delineated in the 
study calendar and in Section 9.1. 
 
Bone marrow: 4 x 10 mL will be collected in green top (sodium heparin) tubes (~40 mL). Re-
adjustment of the direction of bone marrow aspirate needle should take a place after each 10 cc is 
collected to prevent hemodilution. At the time of collection, green top tubes must be thoroughly 
mixed to prevent clotting. 
Peripheral blood: 10 x 10 mL green top (sodium heparin) tubes of blood (~100mLs, minimum 
60mLs) or 4 x 10 mL green top tubes (~40 mL, minimum 30 mL) will be collected at specific time 
points as indicated in Section 9.1 and the Study Calendar. 
Specimens should be labeled with the patient’s study number (given at the time of registration), 
study number, sample collection date and time, and sample source (PB or BM). Sample 
collection date and time, and sample source (PB or BM) will be recorded on the correlative 
collection worksheet and copy included with delivery. All data should be kept in the laboratory 
log. At each sampling time, BM and PB mononuclear cells (PBMC) will be processed via Ficoll 
density gradient centrifugation. The washed cells will be counted, and viably cryopreserved 
using a controlled-rate freezer with transfer to the vapor phase of liquid nitrogen for long-term 
storage. 
 
The Sidney Kimmel Comprehensive Cancer Center (SKCCC) specimens should be delivered to 
the Luznik laboratory immediately after collection.  
 
Specimen collection / processing (Participating Sites).  
Participating sites should collect PB and BM specimens as outlined in the study calendar and 
Section 9.1. Participating sites have two options: 
 
1) Process specimens following the SOP described below. Samples will be stored at each study 
site. Any samples collected under the clinical protocol will be batch shipped on dry ice based on 
discussions with the participating site PI, Study Chair and Dr. Luznik. 
 
2) If the participating site does not have capability of processing the specimens as described 
below, then specimens can be shipped overnight to Dr. Luznik’s laboratory using cold shipping 
packages (boxes) provided by Fedex. Please notify PI (Study Chair), study coordinator and Dr. 
Luznik’s laboratory of specimen shipment. 
 
Shipping of Specimen(s) 
The samples will be processed, stored and analyzed in Dr. Luznik’s laboratory at the SKCCC at 
Johns Hopkins University. Upon request of the Study Chair they will be batch shipped to 
SKCCC. Samples will be shipped or delivered to Dr. Luznik laboratory: 1650 Orleans Street, 
CRB1 Rm 216, Baltimore MD 21287. Tel: (410) 955-8567 
 
 

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Freezing Protocol (SOP) 
 
1. Prepare 50mL falcon tubes with Ficoll density grade media (Histopaque) 
• Ratio Ficoll : blood should be 1:1 
• Do not exceed 20mL Ficoll to 20mL blood (i.e. total volume of 40mL) 
 
2. Slowly layer blood on top of Ficoll 
• Use whole blood or marrow aspirate, do not dilute with PBS or anything else 
• Be careful not to mix the two 
layers 
 
3. Centrifuge: spin at the following settings: 
• 1240rpm (=364G) 
• 20 Celsius 
• Break off 
• 30min 
 
4. Prepare 6 small Eppendorf tubes 
• Take off 6 x 500ul of plasma (top layer; blood only; not for BM aspirate) and put 
it into Eppendorf tubes (this is for cytokine studies); label tubes with the study #, 
patient ID #, and timepoint. 
• Be careful not to get into any layer but the plasma layer 
• Long term storage in -80 Celsius freezer 
 
5. Soak up PBMC layer with transferring pipette and put it into a new 50mL Falcon tube 
• Fill up with PBS up to 45mL, vortex 
• Centrifuge: Spin at 1240 rpm (=364G), 4 Celsius, break high, for 5 minutes 
 
6. First wash 
• Dump supernatant 
• In case of visible RBC contamination add 1Ml of lysing buffer to the cell pellet, 
vortex, and leave for 1 minute. Then add 20mL of PBS 
• If there is no RBC contamination only add 20mL of PBS and vortex 
• Centrifuge: Spin at 1240 rpm (=364G), 4 Celsius, break high, for 5 minutes 
 
7. Second wash 
• Dump supernatant 
• just add 20mL of PBS and vortex 
• Centrifuge: Spin at 1240 rpm (=364G), 4 Celsius, break high, for 5 minutes 
 

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8. Count cells 
• Dump supernatant 
• add 1mL of PBS and vortex thoroughly 
• take 10ul out and mix with 90ul of trypan blue 
• count in hematocytometer  
 
9. Prepare freezing tubes and media 
• Put cells in the meantime on ice 
• Freezing media: FBS containing 10% DMSO 
• Prepare 4 - 6 x 1.8mL vials labeled with 
study #, timepoint, cell count, date, type of 
specimen, 
 
10. Final spin 
• Add 20ml of PBS to the cells, vortex  
• Centrifuge: Spin at 1240 rpm (=364G), 4°C, break high, for 5 minutes 
 
11. Freeze cells - General rules 
• PBMCs: 1.5mL freezing media per 10 -20 million cells (=1 vial) 
• BMMCs: 1.5mL freezing media per 30 million cells (=1 vial) 
 
12. Freezing 
• Put vials into Mr. Frosty® (container with Ethanol, that gradually cools down 
samples) and put into -80 Celsius fridge for about 24 hours 
• After 24 hrs (up to 48hrs) transfer vials into liquid nitrogen tanks (to minimize 
temperature fluctuations make sure you transport them there on dry ice) 
 
Considerations regarding freezing and shipping 
 
• 
Samples should optimally be processed the same day  
• 
If there is a sample coming in late, keep it in the fridge (in 4◦C) overnight and process them 
early the next morning.  
• 
Samples processed should be stored in -80 Celsius for 24-48 hours and get transferred into 
liquid nitrogen thereafter 
• 
Samples should be shipped (Fedex) in batches on dry ice to:  
 
Luznik Lab 
Hopkins CRB1, Room 216 
1650 Orleans Street 
Baltimore, MD 21287 
  
Study # _________ 
Pt ID#   _________     
Timepoint: ______   
Cell count: ______ 
Date(time): 

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• 
If there are no liquid nitrogen tanks available, samples can be kept in -80 Celsius for up to 
2 weeks, but no longer. Shipments to Hopkins should then be done more frequently. 
Important considerations: 
1. All work should be done using standard BSL2 procedures (blood and body fluid precautions). 
2. Maintain a clean workspace and use a containment laminar airflow hood when possible. 
3. Minimize the chance of contamination. 
4. Work quickly but methodically. 
5. Keep tubes closed as much as possible and work quickly. 
6. Change gloves frequently and maintain situational awareness. 
 
 
 
 
 

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APPENDIX F:  CORRELATIVE STUDIES COLLECTION WORKSHEET 
 
 
 
 
Protocol  
Sample 
Time 
Sample 
Due Date 
Actual 
Sample 
Date 
Peripheral 
Blood 
Draw 
initials PB 
Bone 
Marrow 
Draw 
Initials 
(BM)
Comments 
Shipped/D
elivered 
Baseline (within 7-14d  
of Day 1) 
 
 
60-100 cc 
 
40 cc 
 
 
 
C1 D1 (-3 d) 
 
 
30-40 cc 
 
 
 
 
 
 
C1 D8 (+ 3 d) 
 
 
60-100 cc 
 
 
40 cc 
 
 
 
C1 D15 (±3 d) 
 
 
30-40 cc 
 
 
 
 
 
 
C1 D22 (±3 d) 
 
 
30-40 cc 
 
 
 
 
 
 
C1 D 29-35 (±3d) 
 
 
60-100 cc 
 
 
40 cc 
 
 
 
C2 D1 (-3 d) 
 
 
30-40 cc 
 
 
 
 
 
 
C2 D 29-35 (±3d) 
 
 
60-100 cc 
 
 
40 cc 
 
 
 
3 months later  
 
 
60-100 cc 
 
 
40 cc 
 
 
 
6 months later 
 
 
60-100 cc 
 
 
40 cc 
 
 
 
9 months later or at 1 
yr 
 
 
60-100 cc 
 
 
40 cc 
 
 
 
Off study treatment 
 
 
60-100 cc 
 
 
40 cc 
 
 
 
Relapse 
 
 
60-100 cc 
 
 
40 cc 
 
 
 

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APPENDIX G: WRITING TEST 
 
Subject ID ____________ 
Instructions for the Subject:  Enter the date and time of day. Please write the simple phrase 
as indicated below. Rewrite the initial phrase at subsequent days. 
 
Study Day 
Date 
Time 
Sweet as apple pie 
Study Staff- 
Initial & Date 
 
 
 

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APPENDIX H:  SHIPMENT OF BLINATUMOMAB IV BAG FROM SITE/PHARMACY 
TO PATIENT’S HOME 
To be completed by Site/Pharmacy: 
From: (Investigator Name, Address) 
To Patient: (Patient Initials, Study ID No) 
_________________ ;  
____________________ 
Protocol No.: 
Site Pharmacy contact 
Prepare shipment of IV bag at 2°C to 8°C in validated/pre-qualified insulated shipper as 
per manufacturer instructions (see shipping container instructions). Please take care to use 
the applicable instructions for summer or winter package preparation, respectively. 
IV Bag number 
Date of packaging 
[DD/MMM/YYYY] 
Time of packaging 
[hh:mm] 
packed by 
(initials) 
Please tick the boxes and fill in the information below when preparing the IV bag shipment! 
□ Validated/pre-qualified shipping container duration of time 2°C to 8°C temperature 
is maintained: ___________________________ hours 
□ Cooling elements for provided box used according to manufacturer’s instruction 
Confirmed by: 
 
 
 
(print name, signature) 
(date) 
 
To be completed by Ambulant/Home Care Service Provider: 
Shipment box unopened and content intact? 
YES 
 
NO 
 
IF NO, please comment  
 
Date and time shipment box opened: _________________  _________________ 
 
(date) 
(time) 
Confirmed by: 
  
    
 
(print name, signature) Amb. Care Service 
(date) 
NOTE: 
If content is not intact, please do not use IV bag and inform site pharmacy 
immediately! If time box opened minus time of packaging exceeds the time duration 
the shipping container maintains 2°C to 8°C, please do not use IV bag and inform site 
pharmacy immediately!