Use of Response-Adapted Hypofractionated Radiation Therapy to Potentiate the Systemic Immune Response to Checkpoint Inhibitors in Non-Small Cell Lung Cancer
Phase: NA
Conditions: Non Small Cell Lung Cancer Metastatic
Sponsor: West Virginia University

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Use of Response-Adapted Hypofractionated Radiation Therapy to Potentiate a Systemic Immune Response to 
Checkpoint Inhibitors in Non-Small Cell Lung Cancer 
 
09/09/2021 
 
NCT03035890 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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STUDY NUMBER: WVU010516 
STUDY TITLE: Use of Response-Adapted Hypofractionated Radiation Therapy to Potentiate 
the Systemic Immune Response to Checkpoint Inhibitors in Non-Small Cell Lung Cancer 
 
PRINCIPAL INVESTIGATOR: 
CO-INVESTIGATOR: 
Mohammad Shaikh, MD 
Malcolm Mattes, MD 
Department of Radiation Oncology 
Department of Radiation Oncology 
West Virginia University School of Medicine 
West Virginia University Cancer Institute 
1 Medical Center Drive 
Mary Babb Randolph Cancer Center 
Morgantown, WV 26506 
1 Medical Center Drive Morgantown, WV 26506 
304-293-4706 
304-598-4706 
mohammad.shaikh@hsc.wvu.edu 
mdmattes@hsc.wvu.edu 
CO-INVESTIGATOR: 
CO-INVESTIGATOR: 
Mohammed Almubarak, MD 
Timothy Eubank, PhD 
Department of Medicine (Hem/Oncology) 
Department of Microbiology/Immunology/ 
West Virginia University Cancer Institute 
Cell Biology 
Mary Babb Randolph Cancer Center 
West Virginia University School of Medicine 
1 Medical Center Drive Morgantown, WV 26506 
1 Medical Center Drive Morgantown, WV 26506 
304-293-4229 
304-293-0525 
malmubarak@hsc.wvu.edu 
tdeubank@hsc.wvu.edu 
CO-INVESTIGATOR: 
Matthew Smolkin, MD, HCLD 
Department of Pathology 
West Virginia University Cancer Institute 
Mary Babb Randolph Cancer Center 
1 Medical Center Drive 
Morgantown, WV 26506 
304-293-3404 
MBSMOLKIN@hsc.wvu.edu 
CO-INVESTIGATOR: 
Ann Morris, MD 
Department of Radiation Oncology 
West Virginia University Cancer Institute 
Mary Babb Randolph Cancer Center 
1 Medical Center Drive Morgantown, WV 26506 
304-293-9086 
ammoris1@hsc.wvu.edu 
CO-INVESTIGATOR: 
Geraldine Jacobson, MD, MPH, MBA 
Department of Radiation Oncology 
West Virginia University Cancer Institute 
Mary Babb Randolph Cancer Center 
1 Medical Center Drive 
Morgantown, WV 26506 
304-293-4706 
gmjacobson@hsc.wvu.edu 
CO-INVESTIGATOR: 
Todd Tenenholz, MD, PhD 
Department of Radiation Oncology 
West Virginia University Cancer Institute 
1 Medical Center Drive Morgantown, WV 26506 
304-293-4706 
todd.tenenholz@hsc.wvu.edu 
STATISTICIAN: 
STUDY COORDINATOR: 
Sijin Wen, PhD Department of Biostatistics 
Carla Ross 
West Virginia University Cancer Institute 
West Virginia University 1206 
1 Medical Center Drive 
HSC South, Floor 1 
Morgantown, WV 26506 
PO Box 9260, 64 Medical Center Drive 
304-581-1971 
Morgantown, WV 26506 
siwen@hsc.wvu.edu 
304-293-2633 
cjross@hsc.wvu.edu 

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SPONSOR: 
WVU Cancer Institute Mary Babb Randolph Cancer 
Center / WV Clinical and Translational Institute 
 
SUPPORT/FUNDING: 
WV Clinical and Translational Institute 

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Stage IV NSCLC, 
checkpoint inhibitor immune therapy 
recommended as standard of care 
Study Registration 
3-5 fraction course of 
radiation therapy to target lesion 
concurrent with immune therapy 
If progressive disease at any 
point, give one additional 3- 
5 fraction course of 
radiation therapy and then 
patient goes off-protocol 
therapy and consider 
alternative systemic therapy 
 
STUDY SCHEMA 
 
 
 
 
 
 
 
 
If complete or partial 
If stable disease, continue 
If progressive disease at any 
systemic response, 
giving additional 3-5 
point, give one additional 3- 
continue immune therapy 
fraction radiation therapy 
5 fraction course of 
until progression 
with immune therapy to 
radiation therapy and then 
different target lesion(s) 
patient goes off-protocol 
based on follow-up CT or 
therapy and consider 
PET/CT imaging until 
alternative systemic therapy 
either disease progression 
or partial/complete response 
 
 
 
 
CT or PET/CT 
response assessment 

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PROTOCOL SYNOPSIS 
Protocol Number/ 
Title 
Protocol Number WVU010516 
Use of Response-Adapted Hypofractionated Radiation Therapy to 
Potentiate the Systemic Immune Response to Checkpoint Inhibitors in 
Non-Small Cell Lung Cancer 
Study Phase 
Phase II 
Brief Background/ 
Rationale 
Preclinical data suggest that radiation therapy may be uniquely suited to 
combine with immune checkpoint inhibitors, since radiation can disrupt 
a tumor’s physical barriers to T-cell infiltration and augment antigen 
presentation, thus serving as an "in situ personalized vaccine" to 
activate the immune system and potentially enhance the systemic 
response. However, the optimal way to combine immune checkpoint 
inhibitors and radiation therapy is poorly understood, and there is little 
prospective data evaluating the efficacy in patients. The rationale for 
this study is to determine the safety and efficacy of combined immune 
checkpoint inhibitors and radiation therapy in metastatic non-small cell 
lung cancer patients. 
Primary Objective 
Primary Endpoint: Best overall response rate (ORR) (complete and 
partial), measured on follow-up imaging as per immune-related 
Response Criteria (irRC) after initiation of therapy. 
Secondary 
Objective(s) 
Secondary Endpoint(s): Progression-free survival (PFS), overall 
survival (OS), toxicity using CTCAE v4.0, quality of life using FACT- 
L. 
Exploratory 
Objective(s) 
Exploratory Endpoint(s): Univariate and multivariate analysis will be 
used to correlate the presence of response with radiotherapy variables 
(biologic effective dose, number of fractions, duration of radiotherapy, 
sequence of radiation and immune therapy), tumor variables (irradiated 
tumor site, size, histology, local response, extent of prior chemotherapy 
use), and patient variables (age, smoking status, and biologic 
correlates). 
Correlative 
Objective(s) 
Correlative Endpoint(s): In consenting patients peripheral blood 
samples will be collected before initiation of radiation therapy, at the 
time of the first follow-up imaging study, and for any change in response 
status on reimaging to assess levels of circulating CD4+, CD8+ and 
Treg T-cell subsets, as well as iNOS+/CD80+ macrophages. We will 
also assess immune cell trafficking by determining levels of circulating 
cytokines (HGF, TGF-β) and chemokines (CCL2 for M1 macrophages, 
and CXCL9, CXCL10, and CXCL11 for T-cells). We will also 
determine changes of the 
circulating T-cells immune-repertoire (i-repertoire) by performing next 
generation sequencing of the CDR3 region of the T-cell receptor (TCR). 
Sample Size 
33 
Disease Sites/ 
Conditions 
Stage IV NSCLC (ICD-10 code C34.90) 
Interventions 
Radiation therapy, 3-5 fraction course over 3-21 days 
Immune therapy per standard of care physician’s discretion 

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ABBREVIATIONS 
 
3DCRT 
3-Dimensional Conformal 
Radiation Therapy 
irAE 
Immune-related Adverse 
Events 
BED 
Biologically Effective Dose 
irRC 
Immune-related Response 
Criteria 
CCL 
Chemokine (C-C Motif) Ligand 
ITV 
Internal Target Volume 
CD4 
Cluster of Differentiation 4 
MBRCC 
Mary Babb Randolph Cancer 
Center 
CD8 
Cluster of Differentiation 8 
MDSC 
Myeloid Derived Suppressor 
Cell 
CRF 
Case Report Form 
MHC 
Major Histocompatibility 
Complex 
CRP 
C-reactive Protein 
MRI 
Magnetic Resonance Imaging 
CT 
Computed Tomography 
MV 
Megavoltage 
CTCAE 
Common Terminology Criteria for 
Adverse Events 
NGS 
Next Generation Sequencing 
CTLA-4 
Cytotoxic T-lymphocyte Antigen 4 
NSCLC 
Non-Small Cell Lung Cancer 
CTRU 
Clinical Trials Research Unit 
OAR 
Organ-at-Risk 
CTV 
Clinical Target Volume 
ORR 
Overall Response Rate 
CXCL 
Chemokine (C-X-C motif) ligand 
OS 
Overall Survival 
DSTC 
Data Safety Toxicity Committee 
PD-1 
Programmed Death Receptor 1 
ESR 
Erythrocyte Sedimentation Rate 
PD-L1 
Programmed Death-Ligand 1 
ECOG 
Eastern Cooperative Oncology 
Group 
PERCIST 
PET Response Criteria in 
Solid Tumors 
FACIT 
Functional Assessment of Chronic 
Illness Therapy 
PET 
Positron Emission 
Tomography 
FACT 
Functional Assessment of Cancer 
Therapy 
PFS 
Progression Free Survival 
FDA 
Food and Drug Administration 
PRMC 
Protocol Review and 
Monitoring Committee 
Gy 
Gray 
PTV 
Planning Target Volume 
GTV 
Gross Tumor Volume 
QOL 
Quality of Life 
HGF 
Hepatocyte Growth Factor 
RECIST 
Response Evaluation Criteria 
in Solid Tumors 
ICF 
Informed Consent Form 
SBRT 
Stereotactic Body Radiation 
Therapy 
Ig 
Immunoglobulin 
SOC 
Standard of Care 
IMRT 
Intensity Modulated Radiation 
Therapy 
TCR 
T-Cell Receptor 
iNOS 
Inducible Nitric Oxide Synthase 
TGF 
Transforming Growth Factor 
Treg 
Regulatory T-cell 

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TABLE OF CONTENTS 
 
1. 
OBJECTIVE.................................................................................................................8 
1.1. 
Primary Objective ..................................................................................................8 
1.2. 
Secondary Objective(s) ..........................................................................................8 
1.3. 
Correlative Objective(s) .........................................................................................8 
2. 
BACKGROUND ..........................................................................................................8 
2.1. 
Background of Study Disease ................................................................................8 
2.2. 
Checkpoint Inhibitor Immune therapy for Stage IV NSCLC ................................8 
2.3. 
Rationale for Combining Radiation Therapy with Immune therapy .....................9 
2.4. 
Approach to Radiation Therapy Delivery..............................................................9 
2.5. 
Background and rationale of correlative studies .................................................10 
3. 
STUDY DESIGN .......................................................................................................11 
3.1. 
Study Design .......................................................................................................11 
3.2. 
Number of Subjects .............................................................................................11 
3.3. 
Expected Duration of Treatment and Subject Participation ................................11 
3.4. 
Duration of Follow-Up ........................................................................................12 
3.5. 
Overall Duration of the Study .............................................................................12 
3.6. 
Study Termination ...............................................................................................12 
4. 
SUBJECT SELECTION AND REGISTRATION .....................................................12 
4.1. 
Inclusion Criteria .................................................................................................13 
4.2 
Exclusion Criteria ................................................................................................13 
4.3 
Inclusion of Women and Minorities ....................................................................14 
4.4 
Registration ..........................................................................................................15 
5. 
TREATMENT PLAN ................................................................................................15 
5.1. 
Initial Radiation Therapy .....................................................................................15 
5.2. 
Standard of Care Immune Checkpoint Inhibitors ................................................16 
5.3. 
Subsequent Response-Adapted Radiation Therapy .............................................16 
5.4. 
General Concomitant Medications and Supportive Care Guidelines ..................17 
6. 
DOSE DELAYS/DOSE MODIFICATIONS .............................................................17 
6.1. 
Radiation Therapy ...............................................................................................17 
6.2. 
Immune therapy ...................................................................................................17 
7. 
ADVERSE EVENTS .................................................................................................18 
7.1. 
Definitions ...........................................................................................................18 
7.2. 
Adverse Event Evaluation ...................................................................................19 
7.3. 
Adverse Event Reporting Procedures ..................................................................22 
7.4. 
Serious Adverse Event Reporting Procedures .....................................................22 
7.5. 
SAEs and OnCore ................................................................................................23 
7.6. 
Data Safety and Toxicity Committee...................................................................23 
7.7. 
Data and Safety Monitoring Plan (DSMP) ..........................................................23 
8. 
PHARMACEUTICAL INFORMATION ..................................................................23 
8.1. 
Commercial Agent #1 ..........................................................................................23 
8.2. 
Commercial Agent #2 ..........................................................................................24 
8.3. 
Commercial Agent #3 ..........................................................................................26 
9. 
CORRELATIVE STUDIES .......................................................................................27 
9.1. 
Correlative Study #1 ............................................................................................27 

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9.2. 
Correlative Study #2 ............................................................................................29 
9.3. 
Correlative Study #3 ............................................................................................31 
10. STUDY PARAMETERS AND CALENDAR ...........................................................32 
10.1. 
Study Parameters ..............................................................................................33 
10.2. 
Study Calendar .................................................................................................35 
11. MEASUREMENT OF EFFECT ................................................................................37 
11.1. 
Antitumor Effect ..............................................................................................37 
11.2. 
Response Criteria .............................................................................................38 
12. DATA REPORTING / REGULATORY CONSIDERATIONS ................................40 
12.1. 
Data Reporting ................................................................................................ 39 
12.2. 
Regulatory Considerations ...............................................................................40 
13. STATISTICAL CONSIDERATIONS .......................................................................42 
13.1. 
Study Design/Endpoints ...................................................................................42 
13.2. 
Sample Size/Accrual Rate ................................................................................42 
13.3. 
Methods for Analysis .......................................................................................42 
13.4. 
REFERENCES ................................................................................................43 
14. APPENDICES ............................................................................................................47 
Appendix A ................................................................................................................47 
Appendix B ................................................................................................................48 
Appendix C ................................................................................................................49 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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1. 
OBJECTIVE 
The overall objective of this study is to determine the safety and efficacy of combined 
immune checkpoint inhibitors and radiation therapy in metastatic non-small cell lung 
cancer patients. 
 
1.1. 
Primary Objective 
To determine the best overall response rate (ORR) (complete and partial), as measured on 
follow-up CT or PET/CT imaging after initiation of radiation therapy. 
 
1.2. 
Secondary Objective(s) 
To determine 1-year progression-free survival (PFS); 1-year overall survival (OS); 
safety/toxicity using CTCAE v4.0 until 30 days after the last dose of immune therapy or 
until the patient begins a new cancer-directed therapy, or death, whichever comes first; 
quality of life using FACT-L and FACIT Fatigue Scale at 3 month intervals until the time 
of systemic disease progression. In order to determine factors predictive of response to 
therapy, we will correlate the presence of response with radiotherapy variables (biologic 
effective dose, number of fractions, duration of radiotherapy, sequence of radiation and 
immune therapy), tumor variables (irradiated tumor site, size, histology, PD-L1 status, 
local response, extent of prior chemotherapy use), and patient variables (age, smoking 
status, and biologic correlates). 
 
1.3. 
Correlative Objective(s) 
Peripheral blood samples will be collected before initiation of radiation therapy, at the 
time of the first reimaging study, and with each subsequent change in response status to 
assess levels of circulating CD4+, CD8+ and Treg T-cell subsets, iNOS+/CD80+ 
macrophages, cytokines (HGF, TGF-β) and chemokines (CCL2, CXCL9, CXCL10, 
CXCL11). We will also determine changes of the circulating T-cells immune-repertoire 
(i-repertoire) by performing next generation sequencing of the CDR3 region of the T-cell 
receptor (TCR). 
 
 
2. 
BACKGROUND 
2.1. 
Background of Study Disease 
An estimated 221,000 new cases of lung cancer were diagnosed in 2015, making it the 
second most common malignancy in men and women. It is also the leading cause of 
cancer death in the United States.1 Non-small cell lung cancer (NSCLC) accounts for 
approximately three-fourths of new lung cancer diagnoses, the majority of which are 
locally advanced or metastatic at presentation. Patients with metastatic NSCLC often 
decline relatively rapidly, with one-year overall survival on the order of only 15-20%.2 
 
2.2. 
Checkpoint Inhibitor Immune therapy for Stage IV NSCLC 
The immune system normally functions to prevent and fight against invasive organisms 
and diseases. However, a dysregulated immune response can also be detrimental in the 
form of autoimmunity or excessive inflammation. As such, several immune checkpoints 

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have evolved in order to maintain homeostasis. Cancer has been shown to co-opt these 
checkpoints, leading to immune tolerance and subsequent progression of malignancy.3-5 
In recent years immune checkpoint inhibitors have emerged as a novel therapy for a 
variety of human malignancies.6-11 One well characterized checkpoint being targeted in 
metastatic NSCLC clinical trials is PD-1/PD-L1, with monoclonal antagonist antibody 
pharmaceuticals, such as Nivolumab, Pembrolizumab, and Atezolizumab, resulting in 
response rates of 19-25% and median response duration of 12.5-17.0 months.8-11 To date, 
Nivolumab, Pembrolizumab, and Atezolizumab have been approved by the U.S. Food 
and Drug Administration for treatment of advanced NSCLC in second line therapy and 
beyond. Promising clinical outcome data continue to emerge from clinical trial studies 
suggesting activities of PD-1 blockade in small cell lung cancer (SCLC) and 
mesothelioma as well. 
 
2.3. 
Rationale for Combining Radiation Therapy with Immune therapy 
While these findings are encouraging, the fact that only a minority of patients will 
respond to checkpoint inhibitors alone highlights that other barriers to immune 
stimulation exist. Radiation therapy has been combined with immune therapy to 
overcome some of these barriers in both preclinical and clinical studies.12-14 Radiation 
may help to break up the dense stromal barrier and acidic microenvironment surrounding 
tumors that is hostile to T-cell function, thus better mobilizing antigens and immune 
effector cells and activating the immune system. These benefits are not only restricted to 
the local area of irradiation, but also have an abscopal/systemic effect on cancer outside 
of the irradiated area.13-17 Radiation is in many ways uniquely suited to combine with 
immune therapy, since surgery removes the tumor and thus the antigenic source, and 
many chemotherapeutic agents are toxic to the host immune system. Radiation can 
upregulate targets of the immune system, augment their antigen presentation, and cause 
immune cell infiltration into the tumor.15-17 Altogether, these radiation-induced changes 
could lead to activation and proliferation of cytotoxic T-cells in an antigen-specific 
fashion in draining lymph nodes.18-21 The evolution of radiation therapy from serving as a 
purely locoregional therapy to a modality that can also stimulate a systemic cancer 
response represents an important innovation in oncology. However, the optimal way to 
combine immune checkpoint inhibitors and radiation therapy is poorly understood, and 
there is little prospective data evaluating its efficacy in patients, which is the rationale for 
performing this study. We hypothesize that this combination therapy will result in higher 
response rates, longer duration of response, and lengthened overall survival compared 
with previous studies utilizing immune checkpoint inhibitors alone. 
 
2.4. 
Approach to Radiation Therapy Delivery 
In standard clinical practice, the goal of radiotherapy in a patient with metastatic lung 
cancer is predominantly palliative for relief of symptoms. Quality of life is as important 
as longevity of life, and as such the radiation therapy administered in this trial will take 
into account quality of life, symptom relief, and minimizing morbidity along with the 
primary study goal of inducing an enhanced systemic immune response. We believe that 
these objectives will be best achieved by giving the treating physician discretion over the 
treated tumor site and choice of dose-fractionation used, within a set of guidelines. 
Preclinical data suggest that a shorter course of hypofractionated radiation therapy in 5 

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fractions or fewer is more immune-stimulatory, whereas a longer course of 
conventionally fractionated radiation is more immunosuppressive, through their 
differential effects on the up- and down-regulation of CD8 T-cells, Treg and MDSC cells, 
and expression of OX40, PD-L1, and MHC-1.22-24 Fractionated courses are also superior 
to a single fraction treatment in stimulating an abscopal effect.22 As such, for the 
purposes of this study, we will use a dose of 6-12Gy per fraction in 3 fractions (total dose 
18-36 Gy) or 4-10 Gy per fraction in 5 fractions (total dose 20-50 Gy) to be completed 
over the course of 3-21 days. This variety of regimens offers a biologically effective dose 
(BED) range of 28-100 for early responding tissue (which correlates with tumor control) 
and 47-217 for late responding tissue (which correlates with side effects). This will give 
the treating physician a full range of options, such that an adequate dose can be given to 
the tumor while meeting all dose constraints of normal organs. The optimal 
hypofractionated radiation regimen is unknown, and there is some evidence that lower 
dose (and thus less ablative) regimens that would result in inferior local control may 
actually be more systemically immune-stimulating.24 As such, regimens with a lower 
BED will be favored for this study, with the exception of situations in which improved 
local control to palliate symptoms is also a priority. Higher BED regimens may also be 
considered for larger size tumors and more rapidly growing tumors. This general 
preference for lower dose regimens will also have the favorable consequence of reducing 
the morbidity of therapy. Visceral metastases or metastases in organs involved in the 
immune system (e.g. liver) will be targeted preferentially over bone metastases due to the 
increased likelihood of an abscopal effect that has been previously reported for tumors in 
these sites.13-14, 25 If a bone metastasis requires treatment for palliative purposes we advise 
also treating a visceral metastasis concurrently. Brain metastases will be treated 
according to standard of care if they develop during the period of trial enrollment, but 
because there is little evidence to suggest that treating a brain metastasis can elicit an 
extracranial systemic response, we advise also treating a visceral metastasis concurrently 
to increase the likelihood of an abscopal effect. 
 
Finally, subsequent courses of radiation will also be delivered as part of this study in 
patients who are not having a systemic response to immune therapy or who are 
experiencing progressive disease. The rationale for these subsequent courses of radiation 
is to provide a frequent source of antigenic stimulation to potentially elicit an enhanced 
immune response. There is evidence to suggest that treatment of multiple lesions with 
SBRT in the metastatic setting has a survival benefit in lung cancer,26 and scheduled 
radiation therapy has improved survival in other malignancies as well.27 
 
2.5. 
Background and rationale of correlative studies 
In consenting patients, peripheral blood samples will also be collected at the time of any 
change in response status as assessed on follow-up imaging studies in order to correlate 
the biological effects of treatment to response, and potentially help characterize optimal 
treatment delivery. Preclinical data suggests that immune checkpoint inhibitors increase 
the quantity of the activated cytotoxic T-cell subpopulation, with a higher CD8/Treg ratio 
correlating with more robust immune activation.28-29 Additionally, M1/TH1 pro- 
inflammatory iNOS+ macrophages may also be recruited to a tumor and involved in cell- 
killing in this clinical context.30-31 As such, we will use flow cytometry to characterize 

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levels of circulating CD4+, CD8+ and Treg T-cell subsets, as well as iNOS+/CD80+ 
macrophages. Changes in cytokine and chemokine levels specific for immune cell 
trafficking have not been well studied in patients receiving immune checkpoint inhibitors 
or radiation, so we will also evaluate for levels of circulating cytokines (HGF, TGF-β1, 
TGF-β2, TGF-β3) and chemokines (CCL2 for M1 macrophages, and CXCL9, CXCL10, 
and CXCL11 for T-cells). Finally, the clonality and diversity of the T-cell receptor (TCR) 
CDR3 region may help determine the specific lung cancer antigens and host immune 
response that was triggered by immune therapy and radiation. We will use next 
generation sequencing of the circulating T-cells immune-repertoire (i-repertoire) to better 
understand the evolution of tumor response during the course of treatment. 
 
 
3. 
STUDY DESIGN 
3.1. 
Study Design 
This will be a Phase II prospective non-randomized clinical trial, with the primary 
objective being to assess the efficacy of combined checkpoint inhibitor immune therapy 
and hypofractionated radiation therapy in patients with Stage IV NSCLC. Toxicity is a 
secondary endpoint since the doses of radiotherapy to be used are within the realm of 
standard of care, and available medical literature suggests that the combination of 
radiation therapy with various immunomodulatory agents does not lead to excessive 
safety issues that would warrant a Phase I study. 14, 20, 23, 32-37 Since there is limited 
prospective clinical data on this approach in patients we felt that a randomized Phase III 
approach is not justifiable at present. Patients may be enrolled into this study before 
initiation of immune therapy (with radiation administered to one target lesion, starting at 
any time between the first and second cycles of immune therapy). 
 
3.2. 
Number of Subjects 
Approximately 33 subjects will be enrolled in this trial. 
 
3.3. 
Expected Duration of Treatment and Subject Participation 
Each course of radiation therapy will be 3-5 fractions delivered over 3-21 days. The first 
course of radiation will be initiated at any time point between the date of cycle 1 of 
immune therapy through the date of cycle 2 of immune therapy. The duration of immune 
therapy administration and the number of courses of radiation therapy that a subject 
receives will be dependent upon the subject’s response to prior treatment. There is no 
specific maximum number of cycles of immune therapy if a patient continues to respond 
to treatment, or courses of radiation therapy if a patient has persistent stable disease on 
imaging. Progressive disease will be defined per irRC criteria as assessed by two imaging 
studies > 4 weeks apart. Because abscopal responses have been reported even when the 
radiation is given after the immune therapy was completed, a final course of radiation 
therapy will be offered to patients at the time of progressive disease on imaging.38-39 
Subsequent therapy decisions will be at the discretion of the treating physicians, 
including the option of continuing the immune therapy past progression if clinically 
indicated. 

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The radiation therapy or immune therapy may be cancelled or discontinued at any point if 
no longer medically advisable due to intercurrent illness, toxicity/adverse event, decline 
in performance status, pregnancy, the best interests of the patient, or death. Subjects may 
also withdraw consent from treatment (partial consent) or from the study (full consent). 
 
3.4. 
Duration of Follow-Up 
Follow-up of subjects should continue for 30 days after systemic disease progression or 
initiation of an alternate systemic therapy (whichever comes first). After the study period, 
the sponsor-investigator may still obtain data from a subject’s medical records or by 
phone call in order to document overall survival per patient agreement. Any adverse 
events experienced after a patient has discontinued the study treatment will be followed 
until resolution, stabilization, or until it has been determined that the study treatment or 
participation is not the cause. Serious adverse events that are still ongoing at the end of 
the study period will necessitate follow-up to determine the final outcome. Any serious 
adverse event that occurs after the study period and is considered to be possibly related to 
the study treatment or study participation will be recorded and reported immediately. 
 
3.5. 
Overall Duration of the Study 
The study begins when the first subject signs the ICF. The primary analysis will occur 
when all subjects have completed the surveillance period and the last subject experiences 
progressive disease. Complete enrollment is expected over a 2 year period. 
 
3.6. 
Study Termination 
The investigator and sponsor retain the right to temporarily suspend or terminate study 
participation at any time. The date and reason for discontinuation must be documented. 
The investigator is to notify the institutional review board (IRB)/independent ethics 
committee (IEC) in writing of the study's completion or early termination, send a copy of 
the notification to the sponsor or sponsor's designee, and retain 1 copy for the site study 
regulatory file. Every effort should be made to complete the appropriate assessments. 
 
 
4. 
SUBJECT SELECTION AND REGISTRATION 
Each of the criteria in the sections that follow must be met in order for a subject to be 
considered eligible for this study. Use the eligibility criteria to confirm a subject’s 
eligibility. 
 
Patient’s Name  
 
 
Medical Record #  
 
 
Research Nurse / 
Study Coordinator Signature: 
Date  
 
 
Treating Physician [Print]  
 

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Treating Physician Signature: 
Date 
 
 
4.1. 
Inclusion Criteria 
Subjects must meet all of the following inclusion criteria to be eligible for enrollment: 
 
 
 4.1.1 Subjects must have Stage IV (metastatic) histology- or cytology-confirmed 
NSCLC. The tumor type must be confirmed by biopsy but the stage may be based 
on biopsy or imaging. 
 
 4.1.2 Subjects must have measurable disease of at least 1.0 cm in greatest 
dimension in at least 2 previously non-irradiated sites (except for lymph nodes, in 
which the short-axis dimension must be at least 1.5cm). 
 
 4.1.3 Subjects must be planned to receive standard of care checkpoint inhibitor 
immune therapy. 
     4.1.4 Subjects must be age > 18 years since lung cancer is uncommon in children 
and likely to have different biologic properties and response to therapy in this age 
group. 
     4.1.5 Subjects must have ECOG Performance status 0-2 [See Appendix A]. 
     4.1.6 Subjects must have life expectancy greater than 3 months 
   4.1.7 Subjects must have adequate organ and marrow function as defined below 
within one month of study entry: 
• Hemoglobin ≥ 8.0 g/dl 
• Leukocytes ≥ 2,000/mcL 
• Absolute neutrophil count ≥ 1,000/mcL 
• Platelet count ≥ 50,000/mcL 
• Total bilirubin ≤ 3.0 X institutional upper limit of normal, with the exception that 
patients with Gilbert disease may have a serum bilirubin ≤ 6 X upper limit of 
normal 
• AST (SGOT) and ALT (SGPT) ≤ 3 X institutional upper limit of normal (or ≤ 5 X 
institutional upper limit of normal if liver metastases are present) 
• Serum Creatinine ≤ 3.0 X institutional upper limit of normal 
 
 4.1.9 Subjects must have the ability to understand and the willingness to sign a 
written informed consent document. 
 
4.2 
Exclusion Criteria 
The presence of any of the following will exclude a subject from study enrollment. 
 
 
 4.2.1 Subjects with active autoimmune disease (e.g. inflammatory bowel disease, 
rheumatoid arthritis, scleroderma, systemic lupus erythematosus, or autoimmune 
vasculitis), primary immunodeficiency syndrome, HIV/AIDS, or hepatitis B or C. 
Acknowledgement of any of these conditions is sufficient to exclude the patient 
from the study and no specific testing to exclude these conditions is required 
unless the patient expresses uncertainty about their presence. 
 
 4.2.2 Subjects with oral corticosteroid dependency. Use of immunosuppressive 
doses of systemic medications within 7 days prior to starting study drug. Subjects 
are permitted to enroll if lower doses of systemic corticosteroids (< 10 mg/day 

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prednisone equivalents) are used within 7 days prior to 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. Short-term steroids used to enable the use of IV contrast for an imaging 
study are permitted. 
 
 4.2.3 Prior treatment with any antibody or drug targeting T-cell costimulation or 
immune checkpoint pathways (anti-PD-1, anti-PD-L1, anti-PD-L2, anti-CTLA-4, 
etc), or subjects actively receiving any other investigational cancer-directed agent, 
Interleukin-2, or immunosuppressive agents. 
 
 4.2.4 Subjects with uncontrolled or untreated active brain metastases/CNS disease 
will be excluded from this clinical trial because of their poor prognosis and 
because they often develop progressive neurologic dysfunction that would 
confound the evaluation of neurologic and other adverse events. Patients with 
previously treated brain metastases (by whole brain radiation and/or stereotactic 
radiosurgery) are eligible if the treatment was greater than 7 days from 
enrollment. In this case, imaging to confirm intracranial response to therapy is not 
required as long as the patient does not have any worsening neurologic symptoms. 
Of note, if brain metastases develop while the patient is enrolled on this study and 
they are treated, the patient may continue participation in this study at the 
discretion of the treating physicians. 
 
 4.2.5 Subjects with uncontrolled intercurrent illness including, but not limited to, 
ongoing or active infection, symptomatic congestive heart failure, unstable angina 
pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would 
limit compliance with study requirements. 
 
 4.2.6 Subjects who are pregnant are excluded from this study because radiation 
therapy has the potential for teratogenic or abortifacient effects. Women of 
childbearing potential must be using an adequate method of contraception to 
avoid pregnancy throughout the study and for up to 8 weeks after the last 
treatment. 
 
4.3 
Inclusion of Women and Minorities 
Both men and women of all races and ethnic groups are eligible for this trial. It is the 
policy of the Mary Babb Randolph Cancer Center to strive for gender and minority 
patient participation that represents the population of West Virginia in all clinical 
investigations. Between January 2015 and December 2015, 233 patients were enrolled 
onto clinical trials at the Mary Babb Randolph Cancer Center. Of these patients 55% 
percent were female and 3% percent were members of minority ethnic groups. It is 
anticipated that a similar or greater proportion of patients on this study will be female 
and/or members of ethnic minorities. It is important to recognize that according to the 
2014 US Census Bureau (available at http://quickfacts.census.gov) that the State of West 
Virginia minority ethnic group (e.g., not limited to African American and Hispanic) 
population is 3.6% Black (national average 13.2%) and 1.5% Hispanic (national average 
17.4%). The majority of Black West Virginians live in the central and southern part of 
the state and Gilmer County is the only county in WV whose Black population 
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4.4 
Registration 
At the point of registration, the study coordinator will complete registration in the 
OnCore database, including demographic, consent and on-study information. 
 
The patient will be assigned a unique sequence number for the study prior to the initiation 
of the study treatment. 
 
For those subjects who are consented, but not enrolled, the reason for exclusion must be 
recorded. 
 
All source documents that support eligibility, signed informed consent/HIPAA and 
signed eligibility checklist must be available for review and verification by the quality 
coordinator prior to starting therapy. 
 
Patient Travel Reimbursement 
Travel reimbursement may be offered to patients on trial. Due to the limited travel funds 
available, travel reimbursement will be reviewed on case by case basis by the Principal 
Investigator. 
 
5. 
TREATMENT PLAN 
5.1. 
Initial Radiation Therapy 
5.1.1 
Dose-fractionation: The initial course of radiation therapy will be 
administered in 3 or 5 fractions over 3-21 days, at a recommended dose of 6-12 Gy per 
fraction for 3 total fractions (total dose 18-36 Gy) or 4-10 Gy per fraction for 5 total 
fractions (total dose 20-50 Gy). Dose-fractionation schemes with a lower BED will be 
favored, with the exception of situations in which improved local control to palliate 
symptoms is also a priority for a given patient. Higher BED regimens may also be 
considered for larger size tumors and more rapidly growing tumors. 
5.1.2 
Targeted Site: Visceral metastases or metastases in organs involved in the 
immune system (e.g. liver, lymph nodes) will be targeted preferentially. If a bone or brain 
metastasis develops while the patient is enrolled in this trial and requires treatment for 
palliative purposes, we advise also treating a visceral metastasis. 
5.1.3 
Radiotherapy Technique: Stereotactic body radiation therapy (SBRT) will 
be the favored treatment delivery technique due to its high conformality to a target 
volume and avoidance of organs-at-risk (OAR) of toxicity. Other techniques, like 3- 
dimensional conformal radiotherapy (3DCRT) and intensity modulated radiation therapy 
(IMRT), will be permitted with the caveat that the patient will, irrespective of technique, 
undergo CT simulation for treatment planning using SBRT immobilization devices, 
undergo daily image guidance to confirm the positioning of the tumor prior to treatment, 
and the plans must meet standard 3 or 5 fraction SBRT dose constraints to normal tissues. 
The use of 4D-CT and respiratory motion management for treatment planning and 
delivery are encouraged as necessary. 
5.1.4 
Treatment Planning: All patients will undergo CT simulation using SBRT 
immobilization devices. Target volumes (i.e. GTV, CTV, ITV, PTV) will be delineated at 
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for microscopic disease extension in this setting, with the focus on covering gross disease 
plus an appropriate margin to encompass tumor motion and any physical setup 
uncertainties. OARs should be contoured according to standard guidelines provided by 
NRG Oncology for clinical trials.40 Megavoltage photons of at least 6MV will be used for 
all treatment plans. Ideally 95% of the planning target volume (PTV) should receive 
100% of the prescribed dose, and all OAR constraints detailed in Appendix B must be 
achieved in order to minimize the risk of toxicity. In patients receiving multiple courses 
of radiation therapy, there will be an assumption of no tissue recovery, and the total dose 
to any organ from the sum of all radiotherapy courses will need to achieve the dose limits 
for a single course of hypofractionated radiation therapy as described in Appendix B. 
5.1.5 
Treatment Delivery: The thoracic radiation oncologist or his/her 
designated physician is required to be present at the console to review the daily CT and 
projection images prior to each treatment. A brief documentation of the patient set up is 
required in the treatment monitoring system of each institution by the treating physician. 
5.1.6 Coordination of Radiation with Immune Therapy: The first course of 
radiation will be initiated at any time point between the date of cycle 1 of immune 
therapy through the date of cycle 2 of immune therapy. 
 
5.2. 
Standard of Care Immune Checkpoint Inhibitors 
Immune checkpoint inhibitors that are FDA approved for use in patients with metastatic 
NSCLC will be acceptable for use concurrently with radiotherapy in this trial. The choice 
of agents will be at the treating medical oncologist’s discretion, and include: 
- 
Nivolumab 240 mg once every 2 weeks (14 day cycle) or 480 mg once every 4 
weeks (28 day cycle) 
- 
Pembrolizumab 200 mg once every 3 weeks (21 day cycle) 
- 
Atezolizumab 1200 mg once every 3 weeks (21 day cycle) 
These agents should be continued per standard of care until either disease progression or 
unacceptable toxicity. In the case of Pembrolizumab, it is also recommended that patients 
should be on the drug for no more than 24 months even if there is no evidence of disease 
progression. Pembrolizumab may also be used in combination with Pemetrexed and 
Carboplatin for the first-line treatment of metastatic non-squamous NSCLC. If any of the 
immune therapy agents are permanently discontinued at any point, a final course of 
radiation therapy should be offered to the patient before switching to an alternative 
therapy. While the patient is receiving immune therapy, no other investigational or 
commercial agents or therapies may be administered with the intent to treat the subject's 
malignancy. 
 
5.3. 
Subsequent Response-Adapted Radiation Therapy 
Any patient who completes the initial course of radiation therapy and continues on one of 
the immune checkpoint inhibitors described above will be eligible for subsequent 
course(s) of radiation therapy to a different lesion that was not previously irradiated 
based on the results of follow-up imaging studies detailed below and in section 11. 
- 
Patients with a partial or complete response per irRC criteria will be observed 
without any further radiation therapy until progression. 
- 
Patients with stable disease per irRC criteria will undergo an additional course of 
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therapy, and then continue the immune therapy as above. Each subsequent course 
of radiation therapy should ideally be at least 2 months after completion of the 
prior course of radiation therapy, but is left at the discretion of the treating 
physician depending on the patient’s palliative needs. Day 1 of radiation should 
be on Day 1 of the next cycle of immune therapy. 
- 
Patients with progressive disease at any time per irRC criteria will undergo a final 
course of radiation therapy. This may be given concurrently with a final cycle of 
immune therapy or as stand-alone treatment within 6 weeks after discontinuation 
of immune therapy but before an alternative systemic therapy is initiated. 
Please see Section 5.5 below regarding situations in which these subsequent courses of 
radiation therapy may be withheld. Each subsequent course of radiation therapy should 
be given in a similar style as detailed for the initial course of radiation therapy above. In 
patients with a mixed response to therapy, preference will be given to an enlarging tumor 
(rather than one that is stable or decreasing in size) as the site of treatment. Reimaging 
will again be obtained after completion of the radiation therapy with timing at the 
discretion of the treating physicians, and the same response-adapted approach to decision 
making for further courses of radiation therapy will be carried out as described above. 
 
5.4. 
General Concomitant Medications and Supportive Care Guidelines 
Subjects should receive full supportive care, including transfusions of blood and blood 
products, antibiotics, antiemetics, corticosteroids (see section 6.2), etc when appropriate. 
 
 
 
6. 
DOSE DELAYS/DOSE MODIFICATIONS 
6.1. 
Radiation Therapy 
A range of dose-fractionation schemes is available to the treating radiation oncologist as 
part of this study. Most treated lesions will not require deviations in dose from the stated 
ranges, with some exceptions: 
• Brain metastases that develop while the patient is enrolled in this study may be 
treated with single fraction stereotactic radiosurgery or 3 Gy X 10 fractions as 
indicated. 
• If only less conformal techniques are available to a patient for the treatment of 
vertebral lesions and the spinal cord will receive the full prescription dose, lower 
dose regimens of 4 Gy in 5 fractions or 3 Gy in 10 fractions are permissible in 
order to avoid toxicity. 
For every patient, the total dose, dose per fraction, and number of fractions in every 
course of radiation therapy that the subject receives will be recorded. 
 
6.2. 
Immune therapy 
Appropriate dose modifications for immune therapy agents are at the discretion of the 
treating medical oncologist, and will be managed according to standard of care. All dose 
modifications or missed treatments should be recorded for analysis but no specific dose 
modification parameters will be used since the immune therapy is not the experimental 
component in this study. For treatment of moderate or severe immune related adverse 

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events (irAEs), we advise interruption of the checkpoint inhibitor and the use of 
corticosteroid immunosuppression. For grade 2 (moderate) immune-mediated toxicities, 
treatment with the checkpoint inhibitor should be withheld and should not be resumed 
until symptoms or toxicity is grade 1 or less. Prednisone 0.5 mg/kg/day or equivalent 
should be started if symptoms do not resolve within a week. For grade 3 or 4 (severe or 
life-threatening) immune-mediated toxicities, treatment with the checkpoint inhibitor 
should be permanently discontinued. Prednisone 1-2 mg/kg/day or equivalent should be 
given immediately. When symptoms subside to grade 1 or less, steroids can be gradually 
tapered over at least one month. If symptoms do not improve within 3 days of starting 
steroids, administer infliximab 5 mg/kg (may repeat 2 weeks later if no improvement in 
symptoms). If the immune therapy is withheld for a period of greater than 14 days at a 
time when a course of radiation therapy was planned to be given, the course of radiation 
therapy may be initiated prior to resuming the immune therapy. 
 
 
7. 
ADVERSE EVENTS 
7.1. 
Definitions 
7.1.1. 
Adverse Event 
An adverse event (AE) is any unfavorable or unintended event, physical or 
psychological, associated with a research study, which causes harm or injury to a 
research participant as a result of the participant’s involvement in a research study. The 
event can include abnormal laboratory findings, symptoms, or disease associated with the 
research study. The event does not necessarily have to have a causal relationship with the 
research, any risk associated with the research, the research intervention, or the research 
assessments. 
 
Adverse events may be the result of the interventions and interactions used in the 
research; the collection of identifiable private information in the research; an underlying 
disease, disorder, or condition of the subject; and/or other circumstances unrelated to the 
research or any underlying disease, disorder, or condition of the subject; and/or other 
circumstances unrelated to the research or any underlying disease, disorder, or condition 
of the subject. 
 
7.1.2. 
Serious Adverse Events 
Serious adverse event (SAE) or serious suspected adverse reaction: An adverse event 
or suspected adverse reaction is considered “serious” if, in the view of the investigator or 
sponsor, it results in any of the following outcomes: 
 
• Death 
 
• A life-threatening adverse experience. The term life-threatening in the 
definition of serious refers to an adverse event in which the subject was at 
immediate risk of death at the time of the event. It does not refer to an adverse 
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• Requires inpatient hospitalization or prolongation of existing 
hospitalization. Any adverse event leading to hospitalization or prolongation 
of hospitalization will be considered as Serious, UNLESS at least one of the 
following expectations is met: 
o The admission results in a hospital stay of less than 24 hours OR 
o The admission is pre-planned (e.g., elective or scheduled surgery 
arranged prior to the start of the study) OR 
o The admission is not associated with an adverse event (e.g., social 
hospitalization for purposes of respite care. 
However it should be noted that invasive treatment during any hospitalization 
may fulfill the criteria of “medically important” and as such may be reportable as 
a serious adverse event dependent on clinical judgment. In addition where local 
regulatory authorities specifically require a more stringent definition, the local 
regulation takes precedent. 
 
• Results in persistent or significant disability/incapacity or substantial 
disruption of a person’s ability to conduct life’s normal functions. 
 
• Is a congenital anomaly/birth defect 
 
• Is an important medical event. Important medical events that may not result 
death, be life-threatening, or require hospitalization may be considered a 
serious adverse experience when, based upon appropriate medical judgment, 
they may jeopardize the subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. 
 
o Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, blood 
disease or disorders, or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
The development of a new cancer is always considered an important 
medical event. 
 
7.2. 
Adverse Event Evaluation 
The investigator or designee is responsible for ensuring that all adverse events (both 
serious and non-serious) observed by the clinical team or reported by the subject which 
occur after the subject has started immune therapy are fully recorded in the subject’s 
medical records. Source documentation must be available to support all adverse events. 
A laboratory test abnormality considered clinically relevant (e.g., causing the subject to 
withdraw from the study, requiring treatment or causing apparent clinical manifestations, 
result in a delay or dose modification of study treatment, or judged relevant by the 
investigator), should be reported as an adverse event. 
The investigator or sub-investigator (treating physician if applicable) will provide the 
following for all adverse events (both serious and non-serious): 
• Event term (as per CTCAE version 4.0) 
• Description of the event 

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• Date of onset and resolution 
• Expectedness of the toxicity 
• Grade of toxicity 
• Attribution of relatedness to the investigational agent- (this must be assigned 
by an investigator, sub-investigator, or treating physician) 
• Action taken as a result of the event, including but not limited to; no changes, 
dose interrupted, reduced, discontinued, etc. or action taken with regard to the 
event, i.e. no action, received con-med or other intervention, etc. 
• Outcome of event 
 
The most common adverse event from the short courses of focal radiation therapy used in this study will 
be fatigue. This may be accompanied by decreased appetite, changes in taste, or weight loss. Since 
radiation is a focal, localized treatment to a specific targeted tumor, the likelihood of all other side 
effects is dependent on the part of the body that is treated, as described in the table below. Unknown 
side effects may also arise due to the combination of radiation therapy and immunotherapy in this study. 
 
Acute/Short-Term/Temporary 
Chronic/Long-Term/Permanent 
Skin 
redness, dryness, darkening, itching, 
peeling, tenderness, hair loss 
thickening, firmness, 
discoloration, hair loss 
Bone 
decreased blood counts 
fracture, pain 
Nerves 
electrical sensation 
pain, loss of strength, numbness, 
tingling, paralysis 
Lymphatics 
Swelling 
lymphedema 
Brain 
fatigue, brain swelling, headaches, 
nausea, vomiting, dizziness, 
drowsiness, altered taste or smell 
loss of strength, numbness, 
tingling, paralysis 
Lungs 
cough, shortness of breath, bleeding 
cough, shortness of breath, bleeding, 
decreased lung capacity 
Heart 
chest pain, pericarditis, 
abnormal rhythm 
chest pain, heart attack, 
heart failure, pericarditis 
Esophagus 
difficulty swallowing, painful swallowing, 
food sticking, heartburn, nausea, 
vomiting, decreased appetite, 
stricture, obstruction, perforation, 
fistula, bleeding, chest pain 
Stomach/ 
Bowel 
nausea, vomiting, fatigue, diarrhea, 
cramping, decreased appetite 
stricture, obstruction, perforation, 
bleeding, abdominal pain, ulceration 
Liver 
nausea, vomiting, fatigue, diarrhea 
decreased liver function, ascites, 
cirrhosis, encephalopathy, bleeding 
Rectum 
spasm, frequent bowel movements 
ulceration, bleeding 
Bladder 
burning/pain with urination, 
increased frequency, urinary urgency 
decreased bladder capacity, 
bladder spasms, bleeding 
 
 
Immune therapy agents have their own set of expected side effects, as detailed below. 
Nivolumab 
Pembrolizumab 
Atezolizumab 
Common 
Fatigue 
Decreased appetite 
Fatigue 
Decreased appetite 
Fatigue 
Decreased appetite 

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Generalized weakness 
Nausea 
Rash 
Lung inflammation 
Fever 
Occasional 
Nausea 
Diarrhea 
Joint inflammation 
Fever 
Lung inflammation 
Rash 
Diarrhea 
Decreased thyroid hormone levels 
Increased thyroid hormone levels 
Lung inflammation 
Generalized weakness 
Anemia 
Mouth/Lip Sores 
Nausea 
Diarrhea 
Joint inflammation 
Insomnia 
Lung Infection 
Generalized weakness 
Rare 
Mouth/Lip Sores 
Muscle inflammation 
Colon inflammation 
Anemia 
Peripheral Neuropathy 
Decreased white blood cell count 
Hair Loss 
Liver inflammation 
Hair loss 
Decreased white blood cell count 
Colon inflammation 
Severe rash (skin blistering/ulceration) 
Pancreas inflammation 
Decreased adrenal hormone levels 
Muscle inflammation 
Liver inflammation 
Diabetes Mellitus 
Myalgia 
Hair loss 
Pneumonia 
Decreased thyroid hormone levels 
Peripheral neuropathy 
Neutropenia 
Muscle inflammation 
 
7.2.1. 
Adverse Event Grading 
Descriptions and grading scales found in the NCI Common Terminology Criteria for 
Adverse Events (CTCAE) version 4 will be utilized for AE reporting. 
 
Grade 
Description 
 
0 
No AE (or within normal limits). 
 
1 
Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
 
2 
Moderate; minimal, local or noninvasive intervention (e.g., packing 
cautery) indicated; limiting age-appropriate instrumental activities 
of daily living (ADL). 
 
3 
Severe or medically significant but not immediately life- 
threatening; hospitalization or prolongation of hospitalization 
indicated; disabling; limiting self-care ADL. 
 
4 
Life-threatening consequences; urgent intervention indicated. 
 
5 
Death related to AE 
 
7.2.2. 
Adverse Event Attribution 
 
An expected adverse event is an event previously known or anticipated to result from 
participation in the research study or any underlying disease, disorder, or condition of the 
subject. The event is usually listed in the Investigator Brochure, consent form or research 
protocol. 

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An unexpected adverse event is an adverse event not previously known or anticipated to 
result from the research study or any underlying disease, disorder, or condition of the 
subject. 
 
Attribution is the relationship between an adverse event or serious adverse event and the 
study treatment. For the purposes of this study, adverse events may be differentiated as a 
radiation-induced AE or an immune-related AE (irAE). Attribution will be assigned as 
follows: 
 
• Definite – The AE is clearly related to the study drug. 
• Probable – The AE is likely related to the study drug. 
• Possible – The AE may be related to the study drug. 
• Unlikely – The AE is doubtfully related to the study drug. 
• Unrelated – The AE is clearly NOT related to the study drug. 
 
Protocol must specify if attribution is required for individual components of the treatment 
regimen or the treatment regimen as a whole. 
 
7.3. 
Adverse Event Reporting Procedures 
 
All patients will be evaluable for toxicity from the time of their first treatment with 
immune therapy. It is the responsibility of all investigators to assess AEs during the 
subject’s participation in the study. Subjects will be followed for 30 days after treatment 
has stopped or until an alternative systemic therapy has been started or until death, 
whichever comes first. Each AE should be followed until resolution, stabilization, or until 
it has been determined that the study treatment or participation is not the cause. 
 
Adverse events that occur after the subject has started immune therapy must be 
documented in the study database/case report forms (OnCore or other PRMC approved 
database), subject’s medical records, and as required per additional institutional 
standards. Source documentation must be available to support all reported adverse events. 
 
A laboratory test abnormality considered clinically relevant (e.g., causing the subject to 
withdraw from the study), requiring treatment or causing apparent clinical manifestations, 
or judged relevant by the investigator, should be reported as an adverse event. 
 
This protocol will use the NCI Common Terminology Criteria for Adverse Events 
(CTCAE) version 4.0 available at http://ctep.cancer.gov for adverse event reporting. 
 
7.4. 
Serious Adverse Event Reporting Procedures 
Serious Adverse Events (SAE) requiring expedited reporting within 24 hours will also be 
reviewed by DSTC at the next scheduled meeting. For immune-related SAE’s attributed 
to FDA approved standard of care immune therapy, FDA MedWatch will be used only 
for unexpected related events (not on package insert). All serious adverse events due to 
radiation therapy will be reported into OnCore and internally reviewed. All subsequent 
SAE documentation will be submitted to the DSTC once available. The DSTC will 
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7.5. 
SAEs and OnCore 
• All SAEs will be entered into OnCore. 
• A copy of the SAE form(s) submitted to the sponsor-investigator is also uploaded 
into Oncore. 
 
7.6. 
Data Safety and Toxicity Committee 
It is the responsibility of each site PI to ensure that ALL SAEs occurring on this trial 
(internal or external) are reported to the MBRCC DSTC, Data and Safety Toxicity 
Committee. This submission is simultaneous with their submission to the sponsor and/or 
other regulatory bodies. 
 
The sponsor-investigator is responsible for submitting an annual report to the DSTC as 
per MBRCC Data and Safety Monitoring Plan. 
 
7.7. 
Data and Safety Monitoring Plan (DSMP) 
This protocol will adhere to the policies of the Mary Babb Randolph Cancer Center Data 
and Safety Monitoring Plan in accordance with NCI guidelines. 
 
 
8. 
PHARMACEUTICAL INFORMATION 
A list of the adverse events and potential risks associated with the investigational or 
commercial agents administered in this study can be found in Section 7. Immune 
checkpoint inhibitors that are FDA approved for use in patients with metastatic NSCLC 
will be acceptable for use concurrently with radiotherapy in this trial. 
 
 
8.1. 
Commercial Agent #1 
 
8.1.1. 
Name of Agent 
Nivolumab 
 
 
Other Names: 
Opdivo 
 
 
Product 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, diethylenetriaminepentacetic acid (pentetic acid) and polysorbate 80 
(Tween® 80), pH 6.0. 
 
Solution preparation: Nivolumab injection can be infused undiluted (10 mg/mL) or 
diluted with 0.9% Sodium Chloride Injection, USP or 5% Dextrose, USP to drug 
concentrations no less than 0.35 mg/mL. Note: Mix gently. Do not shake. 

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Compatibility: no incompatibilities between nivolumab and polyvinyl chlorie (PVC), 
nonPVC/non DEHP (di(2-ethylhexyl)phthalate) IV components, or glass bottles have 
been observed. 
 
Attach a low protein binding filter 0.2-1.2 micron 
 
Storage requirements: Vials of nivolumab injection must be stored at 2°-8°C (36°- 
46°F) and protected from light, freezing and shaking. 
 
Stability: The administration of undiluted and diluted solutions of nivolumab must be 
completed within 24 hours of preparation. If not used immediately, the infusion solution 
may be stored up to 24 hours in a refrigerator at 2°-8°C (36°-46°F) and a maximum of 4 
hours of the total 24 hours can be at room temperature (20°-25°C, 68°-77°F) and room 
light. The maximum 4-hour period under room temperature and room light conditions 
includes the product administration period. 
 
Route of administration: Nivolumab injection is to be administered as a 30 minute IV 
infusion through a 0.2 micron to 1.2 micron pore size, low-protein binding 
polyethersulfone membrane in-line filter. DO NOT administer as IV push or bolus 
injection. 
 
Drug Procurement: Nivolumab is considered standard of care and will be utilized from 
commercially available supply. Nivolumab is available as 40 mg/4 mL single-dose vial 
and 100 mg/10 mL single-dose vial. 
 
The cost of this agent will be the subject’s responsibility. 
 
Drug Accountability: N/A; this is standard of care treatment. 
 
Drug Destruction: Commercially available supply. Institutional standards apply 
 
 
8.2. 
Commercial Agent #2 
 
8.2.1. 
Name of Agent 
 
Pembrolizumab 
 
 
Other Names: 
 
Keytruda 
 
 
Product description: Pembrolizumab Solution for Infusion is a sterile, non-pyrogenic 
aqueous solution supplied in single-use Type I glass vial containing 100 mg/4 mL of 
pembrolizumab (MK-3475). The product is preservative-free solution which is essentially 
free of extraneous particulates. 
 
Solution preparation: Pembrolizumab infusion solutions should be prepared in 0.9% 
Sodium Chloride Injection, USP (normal saline) or regional equivalent or 5% Dextrose 

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Injection, USP (5% dextrose) or regional equivalent and the final concentration of 
pembrolizumab in the infusion solutions should be between 1 mg/mL and 10 mg/mL. 
 
Please note, the preferred diluent is 0.9% Sodium Chloride and 5% dextrose is only 
permissible if normal saline is not available. 
 
Storage requirements: Pembrolizumab Solution for Infusion, 100 mg/ 4 mL vial for 
Infusion should be stored at refrigerated conditions (2 – 8 °C) and protected from light. 
 
Note: vials should be stored in the original box to ensure the drug product is protected 
from light. 
 
Stability: Following reconstitution with sterile water for injection, Pembrolizumab 
infusion solutions should be prepared in 0.9% Sodium Chloride Injection, USP (normal 
saline) and the final concentration of pembrolizumab in the infusion solutions should be 
between 1 mg/mL and 10 mg/mL. 
 
If normal saline is not available, 5% Dextrose Injection, USP or regional equivalent (5% 
dextrose) is permissible. 
Please note, the preferred diluent is 0.9% Sodium Chloride and 5% dextrose is only 
permissible if normal saline is not available. 
 
Pembrolizumab solutions may be stored at room temperature for a cumulative time of up 
to 6 hours. This includes room temperature storage of admixture solutions in the IV bags 
and the duration of infusion 
 
In addition, IV bags may be stored under refrigeration at 2 °C to 8 °C (36 °F to 46 °F) for 
up to 24 hours. If refrigerated, allow the IV bags to come to room temperature prior to 
use. 
 
Parenteral drug products should be inspected visually for particulate matter and 
discoloration prior to administration. Discard the drug product vial if extraneous 
particulate matter other than translucent to white proteinaceous particles is observed. 
 
 
Route of administration: Administer infusion solution intravenously over 30 minutes 
through an intravenous line containing a sterile, non-pyrogenic, low-protein binding 0.2 
micron to 5 micron in-line or add-on filter. 
 
Drug Procurement: Pembrolizumab is considered standard of care in this trial and will 
be utilized from commercially available supply. Pembrolizumab injection (solution): 
carton containing one 100 mg/4 mL (25 mg/mL), single-use vial 
 
The cost of this agent will be the subject’s responsibility. 
 
Drug Accountability: N/A; this is standard of care treatment. 

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Drug Destruction: Commercially available supply. Institutional standards apply 
 
Other Information: 
• DO NOT USE PEMBROLIZUMAB IF DISCOLORATION IS OBSERVED. 
 
• DO NOT SHAKE OR FREEZE THE VIAL(S). 
 
• DO NOT ADMINISTER THE PRODUCT AS AN (INTRAVENOUS (IV) PUSH 
OR BOLUS). 
 
• DO NOT COMBINE, DILUTE OR ADMINISTER IT AS AN INFUSION WITH 
OTHER MEDICINAL PRODUCTS. 
 
• DO NOT CO-ADMINISTER OTHER DRUGS THROUGH THE SAME 
INFUSION LINE. 
 
• Parenteral drug products should be inspected visually for particulate matter and 
discoloration prior to administration. Discard the drug product vial if extraneous 
particulate matter other than translucent to white proteinaceous particles is observed. 
 
 
8.3. 
Commercial Agent #3 
 
8.3.1. 
Name of Agent 
 Atezolizumab 
 
 
Other Names: 
 Tecentriq 
 
 
Product description: Atezolizumab Injection is a colorless to slightly yellow solution. 
The drug product is a sterile, nonpyrogenic, single-use, isotonic aqueous solution 
formulated in glacial acetic acid, L-histidine, sucrose, polysorbate 20. pH 5.8. 
 
Solution preparation: Withdraw 20 mL of atezolizumab from the vial; dilute into a 250 
mL bag containing 0.9% Sodium Chloride Injection, USP. Dilute dose in NS only; gently 
invert to mix without shaking. Discard vial if solution is cloudy, is discolored, or contains 
visible particles. 
 
Compatibility: Use infusion bag made of polyvinyl chloride (PVC), polyethylene (PE), 
or polyolefin (PO). 
 
Storage requirements: Diluted infusion solution may exist at room temperature for no 
more than 6 hours (including infusion time), or under refrigeration (2 to 8°C or 36 to 
46°F) for no more than 24 hours. Protect from light. Do not shake. Do not freeze. 

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Stability: The administration of undiluted and diluted solutions of atezolizumab must 
be completed within 24 hours of preparation. If not used immediately, the infusion 
solution may be stored up to 24 hours in a refrigerator at 2° to 8°C (36° to 46°F) and a 
maximum of 6 hours of the total 24 hours can be at room temperature (20° to 25°C, 68° 
to 77°F) and room light. The maximum 6-hour period under room temperature and room 
light conditions includes the product administration period. 
 
Route of administration: Atezolizumab injection is to be administered as a 60 minute 
infusion for the initial dose. If first dose is well tolerated, may infuse subsequent doses 
over 30 minutes. Infuse with or without a 0.2- to 0.22-micron sterile, non-pyrogenic, low- 
protein binding in-line filter. Do not administer as an IV push or bolus. Do not administer 
other medications at the same time through the same IV line. Monitor for infusion 
reactions. Atezolizumab is compatible in NS. 
 
Drug Procurement:  Atezolizumab will be obtained from commercially available 
supply. Atezolizumab is available as a 60 mg/1 mL (1200 mg/20 mL) PF single dose vial. 
 
The cost of this agent will be the subject’s responsibility. 
 
Drug Accountability: FDA labelled indication non-small cell lung cancer (NSCLC), 
Metastatic, with progression during or after platinum-based chemotherapy; patients with 
ALK or EGFR genomic tumor aberrations should have disease progression on FDA- 
approved therapy for these aberrations prior to receiving atezolizumab. Pre-clinical and 
clinical studies have established a safety and efficacy profile for this drug beyond that of 
its FDA labelled indication. 
 
Drug Destruction: Commercially available supply. Institutional standards apply. 
 
 
 
9. 
CORRELATIVE STUDIES 
9.1. 
Correlative Study #1 
Use flow cytometry to characterize levels of circulating CD4+, CD8+ and Treg T-cell 
subsets, as well as iNOS+/CD80+ macrophages in peripheral blood samples. 
 
9.1.1. 
Background 
Preclinical data suggests that immune checkpoint inhibitors increase the quantity of the 
activated cytotoxic T-cell subpopulation, with a higher CD8/Treg ratio correlating with 
more robust immune activation.28-29 Additionally, M1/TH1 pro-inflammatory 
iNOS+/CD80+ macrophages may also be recruited to a tumor and involved in cell-killing 
in this clinical context.30-31 
 
9.1.2. 
Rationale for Analysis 
Biomarkers predictive of response to immune therapy are currently not well developed. 
Levels of circulating immune cells before and during therapy have the potential to help 

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better determine which patients will benefit from therapy. The data from these correlative 
studies will be used as part of a univariate and multivariate logistic regression model to 
assess the association between response to treatment and several variables related to the 
radiotherapy, tumor, and patient characteristics. 
 
9.1.3. 
Collection of Specimens 
After consenting patients, peripheral blood samples will be collected at baseline before 
initiation of treatment and at the time of any change in response status as assessed on 
follow-up imaging studies. All attempts will be made to draw the blood with currently 
scheduled venipuncture, but it will also be permissible to draw specifically for this study 
if necessary. 
 
9.1.4. 
Handling of Specimens 
Approximately 10-16 mL of blood will be obtained from the patient in two 10 ml EDTA 
(purple top) tube. These tubes of blood will serve as the specimen for both correlative 
study #1 and #2. In order to facilitate the subsequent analyses all research samples will be 
collected on Monday-Thursday from 8:00am-3:00pm. Specimens will be put on ice after 
collection and transported to the Biospecimen Processing Core Laboratory (Room 1826 
MBRCC) within 30 minutes of acquisition. All subsamples will be labeled with only the 
following: patient research ID (obtained from the PI/study coordinator), date/time of 
collection, type of sample. The labeled sample for correlative study #1 and #2 will then 
be transported on ice to the laboratory of Dr. Tim Eubank (HSC 5602) for further 
processing and analysis. 
 
9.1.5. 
Analytical Laboratory 
The specimens will be processed and analyzed in Health Sciences Center (HSC) 
laboratory 5602, under the direction of Dr. Tim Eubank. Dr. Eubank and his personnel 
will provide technical support for the isolation of both the serum and cellular component 
of the samples, and provide overall guidance in experimental design and interpretation of 
results. 
 
 
9.1.6. 
Methods 
Need IB buffer (0.5 g BSA in 100 ml MACS buffer, filter). Keep at 40C. 
 
1. Put pad in hood to work on. Mix the tube with blood. 
2. Pipet x 250 ul blood in 4 yellow cap BD microtainer tubes (SST – serum separator). Centrifuge 
Hermle 15000 rpm/40C/5min. While centrifuging, prepare 4 Eppendorf tubes, with label on top 
– patient ID, initials, and date. 
3. Collect the serum in the 4 Eppendorf tubes and freeze at -800C (left freezer, box “Tim Eubank 
Clinical Trials Plasma Samples”. 
4. The remaining blood, ~ 8 ml – dilute 1:1 with PBS. Prepare 2 Falcon 15 tubes with 4 ml PBS in 
each. Divide the blood between the two tubes and add additional PBS depending on the volume 
of blood. Mix well. 
5. Prepare two Falcon 15 tubes with x 4 ml Ficoll. Layer the diluted blood on top of the Ficoll – 
put the pipettor on “LOW” and “GRAVITY”. 
6. Centrifuge at 2000 rpm/250C/20 min with no brake (brake=0, 0). Program Buffy. Go to next 
step as soon as the centrifuge stops. 
7. Collect the plasma from the 2 Falcons in a new Falcon tube. [When incubating at a later step, 
aliquot the plasma in 10 Eppendorf tubes, labelled with patient ID/initials/date and keep in right 

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-800C freezer, second shelf from bottom, box “Diluted Plasma Eubank Clinical Samples”]. 
Leave ~3-4 mm of plasma on top of the PBMC layer. Next, collect the PBMC layer in a new 
Falcon tube. Volume is ~4-5ml. 
8. Add 5 ml PBS to the PBMCs (10 ml, if some of the Ficoll has been transferred). Mix by 
inverting 3-4 times. Centrifuge 1500 rpm/5min/40C (Program No1 Cell spin). 
9. Label 10 Eppendorf tubes 1-10. Take out supernatant and resuspend in 1 ml IB buffer. 10 min 
ice. 
10. 
Aliquot the cells in the Eppendorf tubes: 
1. Unstained 
2. 70 ul cells + 5ul CD4 Ab 
3. 70 ul cells + 5ul CD25 Ab 
4. 70 ul cells 
+ 5ul FoxP3 Ab 
5. 70 ul cells 
+ 2ul iNOS Ab 
6. 70 ul cells + 5ul CD80 Ab 
7. 190 ul cells + 5ul CD4 Ab + 5ul CD25 Ab 
+ 5 ul FOXP3 Ab 
8. 190 ul cells + 5ul CD8 Ab 
9. 190 ul cells + 5ul CD80 Ab 
+ 2 ul iNOS Ab 
 
11. Incubate for 1h at 40C covered with foil. 
12. Add x 1 ml MACS buffer and centrifuge 1500 rpm 5min/40C. Repeat. 
13. Resuspend in x 100 ul MACS buffer. Add x 900 ul Methanol (keep at -200C). Incubate for 
30 min on ice, covered with foil. 
14. Centrifuge 2000 rpm/5min/40C. Resuspend in 1 ml MACS buffer. Centrifuge again. 
15. Samples 1, 2, 3, 4, 7, and 9 – resuspend in x 300 ul MACS buffer, transfer to FACS tubes 
and keep at 40C covered with foil. Label the FACS tubes with the name of the antibody. 
16. Samples 5, 6, 8, and 10 – add antibodies for intracellular staining. 
17. Incubate on ice for 1h, covered with foil. 
18. Add x 1 ml MACS buffer to the tubes. Centrifuge 2000 rpm/5min/40C. Repeat. 
19. Resuspend samples in x 300 ul MACS buffer. Transfer to FACS tubes, keep at 40C covered 
with foil. 
20. Bring tubes to the Flow facility. 
 
 
9.2. 
Correlative Study #2 
Evaluate levels of circulating cytokines (HGF, TGF-β1, TGF-β2, TGF-β3) and 
chemokines (CCL2 for M1 macrophages, and CXCL9, CXCL10, and CXCL11 for T- 
cells). 
 
9.2.1. 
Background 
Immune cell infiltration into malignant tumors is thought to be an important component 
of a patient having a response immune checkpoint inhibitors and radiation, however, 
mechanisms of T-cell and macrophage trafficking have not been well studied in patients 
receiving immune checkpoint inhibitors or radiation. Changes in cytokine and chemokine 
levels specific for T-cells and macrophages may correlate with levels of circulating 
immune cells and tumor response to therapy. 
 
9.2.2. 
Rationale for Analysis 
As above, biomarkers predictive of response to immune therapy are currently not well 
developed. Levels of circulating cytokines and chemokines for T-cells and macrophages 
before and during therapy have the potential to help better determine which patients will 
benefit from therapy. The data from these correlative studies will be used as part of a 
univariate and multivariate logistic regression model to assess the association between 

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response to treatment and several variables related to the radiotherapy, tumor, and patient 
characteristics 
 
 
9.2.3. 
Collection of Specimens 
After consenting patients, peripheral blood samples will be collected at baseline before 
initiation of treatment and at the time of any change in response status as assessed on 
follow-up imaging studies. All attempts will be made to draw the blood with currently 
scheduled venipuncture, but it will also be permissible to draw specifically for this study 
if necessary. 
 
9.2.4. 
Handling of Specimens 
Approximately 10-16 mL of blood will be obtained from the patient in two 10 ml EDTA 
(purple top) tubes. These tubes of blood will serve as the specimen for both correlative 
study #1 and #2. In order to facilitate the subsequent analyses all research samples will be 
collected on Monday-Thursday from 8:00am-3:00pm. Specimens will be put on ice after 
collection and transported to the Biospecimen Processing Core Laboratory (Room 1826 
MBRCC) within 30 minutes of acquisition. All subsamples will be labeled with only the 
following: patient research ID (obtained from the PI/study coordinator), date/time of 
collection, type of sample. The labeled sample for correlative study #1 and #2 will then 
be transported on ice to the laboratory of Dr. Tim Eubank (HSC 5602) for further 
processing and analysis. 
 
9.2.5. 
Analytical Laboratory 
The specimens will be processed and analyzed in Health Sciences Center (HSC) 
laboratory 5602, under the direction of Dr. Tim Eubank. Dr. Eubank and his personnel 
will provide technical support for the isolation of both the serum and cellular component 
of the samples, and provide overall guidance in experimental design and interpretation of 
results. 
 
9.2.6. 
Methods 
In our sterile biosafety cabinet in lab 5602 HSC, patient whole blood will be diluted 1:2 
with sterile phosphate buffered saline (PBS). The mixture will be layered atop 15 mL 
Ficoll and centrifuged at 1200 rpm for 20 minutes (no break). After, the serum will be 
collected from the top layer and aliquoted into 1.5 mL Eppendorf tubes and frozen at - 
80C until further analysis for cytokines/chemokines by ELISA or Multiplex analysis. 
 
Determination of chemokines in plasma: 
An aliquot (100 L in duplicate) of patient serum will be thawed form -80C storage and 
subjected to ELISA analysis specific for human CCL2, CXCL9, CXCL10, and CXCL11 
(R&D Systems, Duoset Kits) as described by the manufacturer. Validity of the assay: We 
will be using standard “sandwich” ELISA kits sold by R&D Systems, Inc. Each kit is 
built specifically for the detection of human CCL2, CXCL9, CXCL10, and CXCL11 
from cell supernatants, homogenized tissue extract, plasma, and serum. The kit is 
composed of a specific monoclonal “capture” antibodies for the protein of interest. After 
incubation of the sample and binding, a polyclonal “detection” antibody is incubated with 
the sample followed by a signaling molecule that allows for detection. A standard curve 
is generated using recombinant protein for quantitative comparison. These samples will 
be run in duplicate and averaged to minimize error. This is a well-accepted and highly- 
published method in the literature. 

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9.3. 
Correlative Study #3 
Immune-Repertoire next generation sequencing (NGS) analysis. 
 
9.3.1. 
Background 
The clonality and diversity of the T-cell receptor (TCR) CDR3 region may help 
determine the specific lung cancer antigens and host immune response that was triggered 
by immune therapy and radiation. We will use next generation sequencing of the 
circulating T-cells immune-repertoire (i-repertoire) to better understand the evolution of 
tumor response during the course of treatment. 
9.3.2. 
Rationale for Analysis 
Assessing the dynamic changes of the immune-repertoire of a patient under checkpoint 
anti-PD-1 immunotherapy, with the adjunctive addition of local radiotherapy, would 
allow us to gain insight into the determinant of immunotherapy response. Such 
knowledge would have significant diagnostic potential when validated in the future in the 
arena of cancer immunotherapy. 
 
9.3.3. 
Collection of Specimens 
After consenting patients, peripheral blood samples will be collected at baseline before 
initiation of treatment and at the time of any change in response status as assessed on 
follow-up imaging studies. All attempts will be made to draw the blood with currently 
scheduled venipuncture, but it will also be permissible to draw specifically for this study 
if necessary. 
 
9.3.4. 
Handling of Specimens 
Separately from the blood collected for correlative studies #1 and #2, approximately 7-8 
mL of blood will be obtained from the patient in one 10 ml EDTA (purple top) tube for 
correlative study #3. Specimens will be put on ice after collection and transported to the 
Biospecimen Processing Core Laboratory (Room 1826 MBRCC) within 30 minutes of 
acquisition. All subsamples will be labeled with only the following: patient research ID 
(obtained from the PI/study coordinator), date/time of collection, type of sample. The 
labeled sample for correlative study #3 will then be transported on ice to the laboratory of 
Dr. Tim Eubank (HSC 5602) for further processing and analysis. In earlier versions of 
this protocol these samples were processed in the laboratory of Dr. Patrick Ma (HSC 
1815). However, since he has left WVU Dr. Eubank has taken over the role of initial 
processing before sending the samples to Dr. Ma at Penn State University for Next 
Generation Sequencing. 
 
9.3.5. 
Analytical Laboratory 
The specimens will be processed and analyzed in Health Sciences Center (HSC) 
laboratory 5602, under the direction of Dr. Tim Eubank. Dr. Eubank and his personnel 
will provide technical support for the isolation of both the plasma and cellular component 
of the samples, and provide overall guidance in experimental design and interpretation of 
results. 
 
9.3.6. 
Methods 

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Step one: Obtain Buffy Coat 
• Receive EDTA purple top 7-8ml (usually 10ml) patient blood sample on ice 
• Centrifuge with 4 C 3000g/10mins, with acceleration 9 and brake 9 
• Storage plasma in 1.5 EP tube -80C 
• Qiagen EL Lysis Buffer cat# 79217 10ml to lysis on ice, vortex well, ice 5 mins 
• Centrifuge with 4C 3000g/5mins, with acceleration 9 and brake 9 
• Remove supernatant (make sure to get rid of reddish portion) 
• Qiagen EL Lysis Buffer cat# 79217 5ml to lysis on ice, vortex well, ice 3 mins 
• Centrifuge with 4C 3000g/5mins, with acceleration 9 and brake 9 
• Remove supernatant (make sure to get rid of reddish portion) 
• Use Autoclaved 1ml ice cold PBS wash the pellet 1-2 times. Count cells. 
• Cell counting:  
cell/ml, volume  
ml, total cell # 
 
 
 
Step two: Extraction of RNA 
• With each 3-5x10^7 cells, use Qiazol 1ml mix with buffy coat, vortexing 1 min until no visible 
lump 
• Ice waiting 5 mins 
• Add chloroform 200ul, vortexing 3 sec 
• Ice waiting 2 mins 
• Centrifuge 4C 13000rmp/5mins 
• Take 350ul supernatant clear portion, mix with isopranolol 350ul in a 1.5 EP tube, mixing well 
• Ice waiting 5mins 
• Centrifuge 4C 13000rmp/5 mins 
• Remove supernatant, be careful do not remove the RNA pellet 
• Use 500ul 75% ethanol to wash, vortex each time 3-5 sec, 
• Centrifuge 4C 13000rpm/3mins 
• Repeat red steps for 3 times 
• Remove as much as possible the remaining ethanol, open lid, dry up RNA EP tube in the fume 
hood for 5 mins til all portion of the inner tube is dried 
• Add appropriate amount of Rnase-free H2O, starting from low volume, you can always add 
more later, the key is to have good concentration level. 
• Nanodrop measurement 
• Concertation  
ng/ul, 260/280 
;260/230 
;total vol 
ul; yield  
ug 
 
 
Step 3: DNA Extraction—using Qiagen Blood DNA kit CAT# 51104 
• The spin column’s’ capacity is 5x10^6 cells for buffy coat ONLY, use Qiagen protocol 
 
Step 4: buffy coat in the LN (consider start adding this step as this new 
step would be helpful in future if we want to perform live immune cell 
assays) 
• Store buffy coat with 90%FBS+10% DMSO in LN If have more cells 
Next Generation Sequencing 
Processed samples will be sent to Dr. Patrick Ma at Penn State University for this analysis. 

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RNA extraction and purification would be performed as outlined above. Purified RNA is 
then amplified using iRepertoire’s HTBI-M Reagent System (barcodes 01-10) per the 
manufacturer’s instructions using Qiagen’s One-step RT-PCR and Multiplex Master kit. 
The amplified band of interest (~500 bp) is extracted and gel purified using Qiagen’s 
Qiaquick Gel Extraction kit. Ten libraries will be pooled for each Illumina MiSeq Flow 
Cell using equimolar quantities of each amplified library. The pooled libraries will be 
subjected to a QC and quantification process including Qubit quantification, bioanalysis, 
and quantification with Kappa qPCR. The libraries will then be sequenced on an Illumina 
MiSeq capable of 250 paired-end reads. Bioinformatics analysis is performed in 
conjunction with MBRCC Bioinformatics and Biostatistics Core (Dr. Sijin Wen). When 
samples are sent out for NGS and bioinformatics analysis in vendors or collaborators 
outside of WVU Cancer Institute, MBRCC, samples or data would be fully deidentified 
and strict HIPAA regulation compliance will be followed. 
 
 
10. STUDY PARAMETERS AND CALENDAR 
10.1. Study Parameters 
 
10.1.1. Screening Evaluation 
All evaluations must be completed ≤ 28 days prior to administration of protocol therapy 
with documentation of the following elements: 
• Informed Consent 
• Demographics: 
- 
Patient age & gender 
- 
Full oncologic history including all prior cancer-directed therapies and 
their dates of administration. 
- 
Smoking history (active, past, or nonsmoker; number of pack-years) 
- 
History of weight loss or oral corticosteroid use in the past 3 months, 
autoimmune conditions, dialysis, cirrhosis, splenectomy, mental illness, 
diabetes mellitus, statin use, metformin use, and recurrent infections in the 
past 6 months (including location, frequency, severity, duration, 
complications, and infections with unusual organisms). 
- 
For females, assessment of childbearing potential 
- 
Baseline Symptoms Assessment and Review of Systems 
• History & physical exam 
• Height, weight, ECOG performance status, and vital signs (including blood 
pressure, pulse, respiratory rate, and temperature) 
• Concomitant medications assessment 
• PD-L1 status of any pre-treatment biopsy specimen 
• Laboratory Studies: 
- 
Non-fasting: 
▪ Complete Blood Count (CBC) with differential and smear 
▪ Serum Chemistries: sodium, potassium, chloride, bicarbonate, 
BUN, creatinine, glucose, calcium, magnesium, phosphorous, 
albumin 
▪ Liver Function Tests: alkaline phosphatase, total bilirubin, total 
protein, SGOT [AST], SGPT [ALT] 
▪ Thyroid Function Tests (TSH) 

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▪ Urinalysis (macroscopic and microscopic) with culture reflex 
- 
Special circumstances: 
▪ Serum ß-HCG for women of childbearing potential 
▪ Hemoglobin A1c for diabetic patients 
• Imaging: 
- 
Full body PET/CT scan (preferred) or CT chest, abdomen, and pelvis with 
IV contrast. 
- 
CT brain or MRI brain (preferred) with IV contrast 
• Quality of Life Questionnaires (Appendix C): 
- 
The validated Functional Assessment of Cancer Therapy (FACT) 
instrument will be used to assess physical, social/family, emotional and 
functional well-being, and additional questions specific for lung cancer 
patients (FACT-L) and fatigue (FACIT Fatigue Scale). These validated 
instrument is user friendly (can be completed in less than 10 minutes) and 
has been used extensively to measure QOL in lung cancer patients.41-42 
 
10.1.2. Treatment Period & Follow-up 
All medical care provided on the days of immune checkpoint therapy administration will 
be at the discretion of the treating medical oncologist according to standard of care. No 
specific data will be recorded from these visits, but at the subsequent study follow-up 
visit all prior administrations of immune therapy (date and dose) will be recorded. All 
treatment data related to the radiotherapy will be recorded on the first and last day of each 
course, and will include the start and end date of the radiotherapy course, total dose, dose 
per fraction and number of fractions of radiation received during the course. Data from 
follow-up studies will be recorded as per the study calendar in section 10.2. 

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10.2. Study Calendar 
Parameters 
≤28 days 
prior to 
registration 
Day 1 of 
immune 
therapy 
Last day of 
first course 
of RT 
Follow-up 
before 
documented 
progressive 
disease, at 3, 6, 
9, and 
12 months 
after initial 
cycle of 
immune 
therapy1 
Follow-up 
before 
documented 
progressive 
disease, 
beyond 12 
months after 
initial cycle of 
immune 
therapy is 
timed per 
standard of 
care at treating 
physicians’ 
discretion 
Follow-up 
after 
progressive 
disease or 
switch to 
alternative 
systemic 
therapy2 
Informed Consent 
X 
Demographics 
X 
History and Physical Exam X3 
X15 
X 
Wt/Vitals/ ECOG PS 
X 
X15 
X 
Concomitant Med 
Assessment 
X 
X15 
FACT/FACIT 
Questionnaire4 
X 
X15 
Serum CBC/diff/platelets5 
X 
X2 
Serum chemistries6 
X 
X2 
Serum liver function tests7 X 
X2 
Serum TSH 
X 
X2 
Urinalysis with reflex 
culture 
X 
Serum -hCG8 
X 
Hemoglobin A1c9 
X 
MRI (preferred) or CT 
brain with IV contrast 
X 
FDG-PET/CT (preferred) 
or CT 
chest/abdomen/pelvis 
with IV contrast10 
X 
X16 
X 
Research blood sample11 
X 
X17 
X17 
Immunotherapy 
Administration 
Assessment12 
X 
X 
X 
X 
Radiation Therapy 
Administration 
Assessment13 
X 
X 
X 
Survival assessment14 
X 
AE/SAE Assessment19 
X 
X 
X 
X 
X 
PD-L1 status20 
X 
Rebiopsy (optional) 
X18 
X18 
X18 

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1The final formal assessment will be at time of documented disease progression. 
2 To be performed according to standard of care. 
3To be documented by treating radiation oncologist. Vital signs to include blood pressure, pulse, 
respiratory rate, and temperature 
4 See Appendix C for questionnaires, which will be administered electronically using REDCap. A 
research assistant will open the questionnaire weblink (http://j.mp/2eLzfjE) on a password 
protected tablet computer, enter the patient’s study ID into the survey instrument, and then the 
patient will complete the rest of the electronic form and submit it. The research assistant will be 
available to answer any questions that the patients have, if necessary. Details on REDCap can be 
found in Section 12.1 below. The initial questionnaire may be done anytime between signing the 
consent and the first immune therapy treatment. The questionnaires may be completed using 
paper forms if REDCap is unable to be accessed or based on patient preference. 
5CBC with differential includes hemoglobin, hematocrit, white blood cell count, absolute 
neutrophil count, and platelets 
6Serum chemistries include sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose, 
calcium, magnesium, phosphorous, albumin 
7Serum liver function tests include alkaline phosphatase, total bilirubin, total protein, SGOT 
[AST], SGPT [ALT] 
8Only for women of childbearing potential (within 14 days of registration) 
9Only for patients with diabetes mellitus 
10In patients with contrast allergy a short course of steroids may be given as needed. In patients 
with poor kidney function in whom contrast is contraindicated a non-contrast imaging study is 
permissible. 
11Please refer to protocol section 9 for details. The initial research blood sample may be drawn 
anytime between signing the consent and the first immune therapy treatment. 
12Record all past and current administrations of immune therapy (sections 5.2 and 6.2), including 
date and dose of each administration. 
13Record all past and current administrations of radiation therapy (sections 5.1, 5.3, and 6.1), 
including for each course: the start and end date, total dose, dose per fraction, number of 
fractions, and location of treated lesion. 
14Survival assessment may be carried out via chart review or phone call only. 
15A window of ± 14 days around the standard time point every 3 months is allowed as necessary 
16A minimum of one scan every 4 months is required, however, scans may be completed at more 
frequent intervals as clinically indicated. 
17Performed in coordination with imaging studies, at baseline prior to treatment, and thereafter 
only for a change in extracranial response on follow-up imaging. The blood will be drawn within 
30 days of any imaging study showing a change in extracranial response status. 
18Optional rebiopsy of an accessible non-irradiated tumor may be obtained at the treating 
physicians’ discretion if it is deemed clinically warranted and safe to perform, for diagnostic 
purpose in order to confirm progression of disease and underlying histopathology. If indicated, it 
should be carried out within 30 days of the confirmatory imaging study showing disease 
progression, and prior to initiating any further systemic therapy. 
19AEs and SAEs will be collected on a continuous basis starting with the first cycle of immune 
therapy. Both AEs and SAEs will be collected up until 30 days after the last dose of immune 
therapy or until the patient begins a new cancer-directed therapy, or death, whichever comes first. 
20 PD-L1 status (percentage staining by immunohistochemistry) of any pre-treatment biopsy 
specimen is not required for eligibility, but if information is available at any time point prior to 
or after enrolling in the trial, this data will be collected in the EDC. 

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11. MEASUREMENT OF EFFECT 
11.1. Antitumor Effect 
 
11.1.1. Imaging Modalities 
At baseline and follow-up, systemic response (for unirradiated lesions) and local 
response (for irradiated lesions) will be assessed using FDG-PET/CT (preferred) or CT 
scan of the chest/abdomen/pelvis. Ideally IV contrast and CT slice thickness < 5mm 
will be used for either type of study. Images will be acquired according to the standard 
of care schedule used for patients receiving immune checkpoint therapy, at intervals of 
4 months or less after initiation of immune therapy. In the event of an imaging study 
showing disease progression, a confirmatory scan is recommended at least 4 weeks 
later to confirm progression. The same method of assessment and technique should be 
used to characterize each index lesion at baseline and during follow-up. All 
measurements should be recorded in metric notation and specified to the nearest 
millimeter. All baseline evaluations should be performed as closely as possible to the 
beginning of treatment and never more than 4 weeks before the beginning of the 
treatment. Imaging-based evaluation is preferred to evaluation by clinical examination 
unless the lesion(s) being followed cannot be imaged but are assessable by clinical 
exam. 
11.1.2. 
Definitions 
Evaluable for objective response: Only those patients who have received at least one 
course of radiation therapy, and have had their disease re-evaluated by imaging at least 
4 weeks after initiation of therapy will be considered evaluable for response. These 
patients will have their response classified according to the definitions stated below. 
 
Immune-Related Response Criteria (irRC)43-44: Novel criteria for the evaluation of 
antitumor responses with immunotherapeutic agents, as described in Wolchok et al. 
The patterns of response to immune therapy agents differ from those of cytotoxic 
therapy in several ways: There may be a transient worsening of disease before 
stabilization or regression, responses can take months to become apparent and may 
continue long after completion of the initial therapy, and prolonged periods of stable 
disease are common. For the purposes of this study, irRC will be used for evaluation of 
all non-irradiated index lesions and the unit of measure will be the sum of the 
products of the two largest perpendicular diameters (SPD) for all index lesions. 
 
Response Evaluation Criteria in Solid Tumors (RECIST) Version 1.145: Method for the 
evaluation of antitumor responses to cytotoxic agents, as described by Eisenhauer et al. 
For the purposes of this study, RECIST 1.1 criteria will be used only for the evaluation 
of irradiated lesions and the unit of measure will be the single largest diameter. 
 
Measurable lesions on initial imaging: Measurable malignant lesions on initial imaging 
are defined as those that can be accurately measured in at least one dimension as ≥10 
mm (≥1.0 cm) with CT or PET/CT scan. Lymph nodes will be considered malignant 
(and thus measurable lesions) if their short axis is ≥15 mm (≥1.5 cm) by CT scan. All 
other lesions will be considered non-measureable disease. Bone lesions without a soft 

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tissue component, leptomeningeal disease, ascites, pleural/pericardial effusions, 
lymphangitis cutis/pneumonitis, inflammatory breast disease, and abdominal masses 
(not followed by CT or MRI), are considered non-measurable. Simple cysts are by 
definition non-malignant and non-measureable, but cystic metastases can be considered 
as measurable lesions, if they meet the size cutoff of measurability described above. 
Tumor lesions that are situated in a previously irradiated areas are not considered 
measurable. 
 
Measureable lesions on follow-up imaging: Per irRC specifications, new measureable 
lesions on follow-up imaging will be defined as being > 5 x 5 mm in size 
 
Index lesions: All measurable lesions up to a maximum of 10 visceral lesions (< 5 per 
organ) and 5 cutaneous lesions, should be identified as index lesions and recorded and 
measured at baseline. Target lesions should be selected on the basis of their size 
(lesions with the longest diameter), be representative of all involved organs, and lend 
themselves to reproducible repeated measurements. It may be the case that, on 
occasion, the largest lesion does not lend itself to reproducible measurement in which 
circumstance the next largest lesion which can be measured reproducibly should be 
selected. It is preferable to exclude cystic metastases as index lesions if other non- 
cystic lesions are available. Prior to selecting index lesions a decision should be made 
on which lesion will receive an initial course of radiation therapy, as this lesion is not 
eligible to be considered as an index lesion to assess response to immune therapy. If 
any subsequent course(s) of radiation therapy are given to what was previously 
considered an index lesion, this lesion will no longer be considered an index lesion for 
subsequent systemic response assessment. The rationale for this is that including 
irradiated lesions in response assessment would bias the assessment of a systemic 
effect. 
Tumor Burden: At the baseline tumor assessment, the sum of the products of the two 
largest perpendicular diameters (SPD) of all index lesions is calculated. At each 
subsequent tumor assessment, the SPD of the index lesions and of new, measurable 
lesions are added together to provide the total tumor burden: Tumor Burden = SPDindex 
lesions + SPDnew, measurable lesions. 
 
11.2. Response Criteria 
The irRC criteria for assessing systemic disease response (including only non-irradiated 
lesions) can be seen in the following table: 
New, measurable lesions 
(ie, > 5 x 5 mm) 
Incorporated into tumor burden 
New, non-measurable lesions 
(ie, < 5 x 5 mm) 
Do not define progression (but preclude irCR) 
Non-index lesions 
Contribute to defining irCR (complete disappearance 
required) 
irCR 
Disappearance of all lesions in two consecutive observations 
at least 4 weeks apart 
irPR 
> 50% decrease in tumor burden compared with baseline in 
two observations at least 4 weeks apart 
irSD 
Neither sufficient decrease in tumor burden to qualify as irPR 

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nor sufficient increase in tumor burden to qualify as irPD. 
irPD 
> 25% increase in tumor burden compared with nadir (at any 
single time point) in two consecutive observations at least 4 
weeks apart. 
 
Examples of irRC overall response37: 
 
RECIST version 1.1 will be used to assess the local response of irradiated lesions only, 
taking as reference the baseline largest diameter: 
Complete Response 
(CR) 
Disappearance of the irradiated lesion 
Partial Response 
(PR) 
> 30% decrease in the single largest diameter of the irradiated lesion 
Stable Disease 
(SD) 
Neither sufficient decrease in diameter to qualify as PR nor 
sufficient increase in diameter to qualify as PD 
Progressive Disease 
(PD) 
> 20% increase in the single largest diameter of the irradiated 
lesion. In addition to the relative increase of 20%, the sum must also 
demonstrate an absolute increase of at least 5 mm (0.5 cm). 
 
 
11.2.1. Best Overall Response 
The best response recorded from the start of the treatment until disease 
progression/recurrence (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started). The patient's best response 
assignment will depend on the achievement of both measurement and confirmation 
criteria. 
 
11.2.2. Progression-Free Survival 
The duration of time from start of treatment to time of progression or death, 
whichever occurs first. For those patients with a CR or PR, the reference for 
progressive disease the smallest measurements recorded since the treatment started). 
 
11.2.3. Response Review 
All responses will be reviewed by an expert radiologist and/or radiation oncologist at 
the study’s completion, with simultaneous review of the patients’ files and 
radiological images. 

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12. DATA REPORTING / REGULATORY CONSIDERATIONS 
Adverse event lists, guidelines, and instructions for AE reporting can be found in Section 
7.0 (Adverse Events: List and Reporting Requirements). 
 
12.1. Data Reporting 
The OnCore Database will be utilized, as required by the WVU MBRCC, to provide data 
collection for both accrual entry and trial data management. OnCore is a Clinical Trials 
Management System housed on secure servers maintained at West Virginia University. 
OnCore properly used is compliant with Title 21 CFR Part 11. Access to data through 
OnCore is restricted by user accounts and assigned roles. Once logged into the OnCore 
system with a user ID and password, OnCore defines roles for each user which limits 
access to appropriate data. User information and password can be obtained by contacting 
the OnCore Administrator at lwallace@hsc.wvu.edu. 
 
OnCore is designed with the capability for study setup, activation, tracking, reporting, 
data monitoring and review, and eligibility verification. This study will utilize 
electronic Case Report Form completion in the OnCore database. A calendar of 
events and required forms are available in OnCore. 
 
REDCap will be utilized to collect quality of life data directly from the patients, using 
the following weblink: http://j.mp/2eLzfjE. This link will be accessed on a password 
protected tablet computer by the clinical trials nurse on the day when quality of life 
data is to be collected. The clinical trials nurse will enter the patient’s study ID into 
the survey instrument and then the patient will complete the rest of the electronic 
form and submit it. REDCap is a secure, web-based application for building and 
managing online surveys and databases. REDCap is an NIH-sponsored application 
and follows HIPAA guidelines. The WVCTSI instance of REDCap is housed at the 
Ruby Office Complex (ROC) which was built in 2008 and designed by IBM. It a 
fully redundant building with generator backup that is manned and monitored 24/7 
with onsite staff, closed-circuit camera, automated reporting systems. It’s secure by 
magnetic locks and only accessible via card access. Systems are secured through 
multiple layers of security including encryption, firewalls, reverse proxy and tested 
regularly for vulnerabilities. The OnCore Administrator lwallace@hsc.wvu.edu will 
be able to access the data reported from all patients at the time of analysis. 
 
12.1.1. Method 
Data will submitted on a real-time basis, within 2 weeks of the protocol-related visit via 
OnCore electronic case report forms. 
 
12.1.2. Responsibility for Data Submission 
It is the responsibility of the PI(s) at the site to ensure that all investigators understand 
the procedures for data submission and that protocol specified data are submitted 
accurately and in a timely manner via the electronic data capture system, OnCore. 

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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. 
 
 
12.2. Regulatory Considerations 
The study will be conducted in compliance with ICH guidelines and with all applicable 
federal (including 21 CFR parts 56 & 50), state or local laws. 
 
12.2.1. Written Informed Consent 
Provision of written informed consent must be obtained prior to any study-related 
procedures. The Principal Investigator will ensure that the subject is given full and 
adequate oral and written information about the nature, purpose, possible risks and 
benefits of the study as well as the subject’s financial responsibility. Subjects must also 
be notified that they are free to discontinue from the study at any time. The subject 
should be given the opportunity to ask questions and be allowed time to consider the 
information provided. 
The original, signed written Informed Consent Form must be kept with the Research 
Chart in conformance with the institution’s standard operating procedures. A copy of the 
signed written Informed Consent Form must be given to the subject. Additionally, 
documentation of the consenting process should be noted in the medical record. 
 
12.2.2. Subject Data Protection 
In accordance with the Health Information Portability and Accountability Act (HIPAA), a 
subject must sign an authorization to release medical information to the sponsor and/or 
allow the sponsor, a regulatory authority, or Institutional Review Board access to 
subject’s medical information that includes all hospital records relevant to the study, 
including subjects’ medical history. 
 
12.2.3. Retention of records 
The Principal Investigator supervises the retention of all documentation of adverse 
events, records of study drug receipt and dispensation, and all IRB correspondence for as 
long as needed to comply with national and international regulations. No records will be 
destroyed until the Principal Investigator confirms destruction is permitted. 
 
12.2.4. Audits and inspections 
Authorized representatives of the sponsor, a regulatory authority, an Independent Ethics 
Committee (IEC) or an Institutional Review Board (IRB) may visit the site to perform 
audits or inspections, including source data verification. The purpose of an audit or 
inspection is to systematically and independently examine all study-related activities and 
documents to determine whether these activities were conducted, and data were recorded, 
analysed, and accurately reported according to the protocol, Good Clinical Practice 
(GCP), guidelines of the International Conference on Harmonization (ICH), and any 
applicable regulatory requirements. 

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12.2.5. Data Safety and Monitoring Plan 
This protocol will adhere to the policies of the WVU Mary Babb Randolph Cancer 
Center Data and Safety Monitoring Plan. 
 
13. STATISTICAL CONSIDERATIONS 
13.1. Study Design/Endpoints 
The primary endpoint is the best overall response rate (complete and partial) after the 
initial course of radiation therapy with concurrent immune therapy. The secondary 
objectives include determination of the progression-free and overall survival at 1 year, 
toxicity, and quality of life. Correlative objectives include an assessment of levels of 
circulating CD4+, CD8+ and Treg T-cell subsets, iNOS+ macrophages, and the 
chemokines CCL2, CXCL9, CXCL10, and CXCL11 in relation to clinical response. 
 
13.2. Sample Size/Accrual Rate 
The primary analysis will be for patients enrolled at time-points (A) and (B) above, 
whereas patients enrolled at time-point (C) will be included in observational analysis only 
(see section 3.1). The primary endpoint of this study is the overall response rate 
(complete + partial response) and the efficacy will be assessed using the Simon’s two- 
stage Minmax design. A sample size of 33 patients is chosen to differentiate between the 
response rate of 20% and 40% with 80% power at a significance level of 0.05. In 
particular, 18 patients will be enrolled at the first stage. If 15 or more of the first 18 
patients have disease progression prior to any response, the trial will be terminated; 
otherwise an additional 15 patients will be treated for a total of 33 patients. In the final 
data analysis, if 10 or fewer patients respond among 33 patients, the treatment will be 
concluded ineffective. The probability of early termination due to futility is 0.72. 
 
For correlative study between biomarkers and response, this sample size will have at least 
80% power to detect a 50% change/difference on biomarker data between response and 
non-response groups using a two-sided two-sample t-test at 0.05 significance 
level, assuming that the response rate is 35% or higher and the coefficient of variation 
(CV) of biomarkers is 0.45. 
 
Approximately 100 patients with metastatic NSCLC are diagnosed and treated each year 
at our institution, many of whom will be candidates for immune checkpoint therapy. As 
such, we expect to accrue 3 patients per month to this trial for an estimated accrual period 
of one year. The full estimated duration of the study is two years. 
 
13.3. Methods for Analysis 
Data will be summarized with respect to baseline characteristics and safety measurements 
using descriptive statistics (quantitative data) and contingency tables (qualitative data). 
The safety analysis will consist of AE summaries (frequency tables based on CTCAE 
grades) and laboratory abnormalities summary. For the primary endpoint, the response 
rate and its 95% confidence interval will be estimated with a binomial distribution. 
Univariate and multivariate logistic regression model will be used to assess the 
association between response and several radiotherapy variables (biologic effective dose, 

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number of lesions treated, sequence of radiation and immune therapy), tumor variables 
(irradiated tumor site, size, growth rate, histology, PD-L1 status, local response, extent of 
prior chemotherapy use, and biologic correlates), and patient variables (age, smoking 
status, and other factors associated with secondary immunodeficiency). A predictive 
nomogram for response will be developed based on the outcome of the multivariate 
analysis. In the data analysis on the secondary endpoints, the Kaplan-Meier method will 
be used to estimate overall survival and progression-free survival. Wilcoxon signed-rank 
test for paired data will be used to assess the change of quality of life scores between two 
visits. Since the lung cancer score (LCS) of the FACT-L focuses on lung cancer 
symptoms, this will be used for the primary QOL endpoint; however, the more general 
subscales of physical and functional well-being on the Trial Outcome Index (FACT-TOI) 
will also be collected. A difference of 3 LCS points will be considered clinically 
significant.12-13 Where applicable, comparison will be made to previous randomized trials 
assessing immune checkpoint inhibitors alone in a comparable patient population. 
 
 
 
13.4. 
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Ma Y, Kepp O, Ghiringhelli F, et al. Chemotherapy and radiotherapy: cryptic 
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Postow MA, Callahan MK, Barker CA, et al. Immunologic correlates of the 
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Sharabi AB, Lim M, DeWeese TL, et al. Radiation and checkpoint blockade 
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Demaria S, Golden EB, Formenti SC. Role of Local Radiation Therapy in Cancer 
Immunotherapy. JAMA Oncol 2015;1:1325-32. 
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Regulator of Radiation Therapy-Induced Antitumor Immunity. Cancer Res 
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22. 
Dewan MZ, Galloway AE, Kawashima N, et al. Fractionated but not single-dose 
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Golden EB, Demaria S, Schiff PB, et al. An abscopal response to radiation and 
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Iyengar P, Kavanagh BD, Wardak Z, et al. Phase II trial of stereotactic body 
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Parker C, Nilsson S, Heinrich D, et al. Alpha emitter radium-223 and survival in 
metastatic prostate cancer. N Engl J Med 2013;369:213-23. 
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29. 
Poleszczuk JT, Luddy KA, Prokopiou S, et al. Abscopal Benefits of Localized 
Radiotherapy Depend on Activated T-cell Trafficking and Distribution between 
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Klug F, Prakash H, Huber PE, et al. Low-dose irradiation programs macrophage 
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De Palma M, Coukos G, Hanahan D. A new twist on radiation oncology: low- 
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Slovin SF, Hamid O, Tejwani S, et al. Ipilimumab (IPI) in metastatic castrate- 
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Kwon ED, Drake CG, Scher HI, et al. Ipilimumab versus placebo after 
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Ahmed K.A., Creelan B.C., Kim S., Dilling T.J., Perez B.A. Safety and 
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Combining Radiation Therapy With Systemic Immunotherapy in Metastatic 
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Cella D, Eton DT, Fairclough DL, et al. What is a clinically meaningful change in 
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43. 
Wolchok JD, Hoos A, O'Day S, et al. Guidelines for the evaluation of immune 
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Hoos A, Eggermont AM, Janetzki S, et al. Improved endpoints for cancer 
immunotherapy trials. J Natl Cancer Inst 2010;102:1388-97. 
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Eisenhauer EA, Therasse P, Bogaerts J, et al. New response evaluation criteria in 
solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009 
Jan;45(2):228-47. 

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14. APPENDICES 
 
Appendix A 
 
Eastern Oncology Cooperative Group (ECOG) Performance Status 
 

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Appendix B 
 
Dose-Volume Guidelines for Critical Structures 
for Hypofractionated Radiation Therapy 
 
Structure 
3 Fractions 
5 Fractions 
Cauda Equina 
D0.03cc < 25.5Gy, D5cc < 
21.9Gy 
D0.03cc < 32Gy, D5cc < 30Gy 
Spinal Cord 
D0.03cc <22.5 Gy, D1.2cc < 
13Gy 
Max <28 Gy, D0.35cc < 22.Gy, 
D1.2cc < 15.6Gy 
Total Lung (-CTV) 
V20<15% , V11<37% , D1500cc 
< 10.5Gy, D1000cc < 11.4Gy 
V13.5Gy<37%, D1500cc < 12.5Gy, 
D1000cc < 13.5 Gy 
Heart 
D0.03cc < 30Gy, D15cc < 24Gy 
D0.03cc < 38 Gy, D15cc < 32 Gy 
Esophagus 
D0.03cc < 27Gy, D5cc < 17.7Gy 
D0.03cc < 35Gy, D5cc < 27.5 Gy 
Brachial Plexus 
D0.03cc < 26 Gy, D3cc < 22 Gy 
D0.03cc < 32 Gy, D3cc < 30 Gy 
Trachea & Ipslat 
Bronchus 
D0.03cc < 30Gy, D5cc < 25.8Gy 
D0.3cc< 40 Gy, D5cc < 32 Gy 
Sacral Plexus 
D0.03cc < 24Gy, D5cc < 22.5Gy 
D0.03cc < 32Gy, D5cc < 30 Gy 
 
 
Great Vessels 
D0.03cc < 45Gy, D10cc < 39Gy 
D0.03cc < 53 Gy, D10cc < 47Gy 
Skin 
D0.3cc < 33Gy; D10cc<31Gy 
D0.03cc < 38.5 Gy, D10cc < 36.5 Gy 
Stomach 
D0.03cc < 30Gy, D10cc < 
22.5Gy 
D0.5cc < 35 Gy, D5cc < 26.5 Gy 
Duodenum 
D0.03cc < 24Gy, D10cc < 15Gy 
D0.5cc < 30Gy, D5cc < 18.3Gy 
Bowel 
D0.03cc < 34.5Gy, D20cc < 
24Gy 
D0.03cc < 40 Gy, D20cc < 28.5Gy 
Rectum 
D0.03cc < 49.5Gy, D3.5cc < 
45Gy, D20cc < 27.5Gy 
D0.03cc < 55Gy, D3.5cc < 50Gy, 
D20cc < 32.5Gy 
Bladder 
D0.03cc < 33Gy, D15cc < 
16.8Gy 
D0.03cc < 38 Gy, D15cc < 20 Gy 
Ureter 
D0.03cc < 40Gy 
D0.03cc < 45Gy 
Penile Bulb 
D3cc < 25Gy 
D3cc < 30 Gy 
Femoral Heads 
D10cc < 24Gy 
D10cc < 30 Gy 
Bile Duct 
D0.03cc < 36Gy 
D0.03cc < 41Gy 
Renal hilum 
D15cc < 19.5Gy 
D15cc < 23Gy 
Rib 
D0.03cc < 50Gy, D5cc < 40Gy 
D0.03cc < 57 Gy, D5cc < 45Gy 
Ipsilateral Kidney 
D130cc < 12.3Gy 
D130cc < 14.5Gy 
Total Kidney 
D200cc < 15Gy 
D200cc < 18Gy 
Liver 
D700cc < 17.1Gy 
D700cc < 21Gy 

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Appendix C 
 

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