Clinical trial NCT03850691
Conditions: Metastatic Melanoma
Keywords: MM
Sponsor: Masonic Cancer Center, University of Minnesota
Start date: 2019-05-28; Completion date: 2022-12-12
Enrollment: 4 participants; Allocation: NON_RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is a Phase 2 study designed to evaluate the combination of checkpoint blockade and aldesleukin (IL-2) therapy after a course of standard of care palliative radiation in the management of unresectable metastatic melanoma. To be eligible, a patient must have a minimum of 3 (preferably \>5) radiographically distinct, measurable (\>1.5 cm) lesions based on RECIST 1.1. Metastatic cutaneous melanoma must be refractory to standard immunotherapy drugs, molecular targeted agents and/or chemotherapy. Patients with ocular melanoma subtypes may enroll in this study without prior therapy, as there is no standard front-line therapy for this subset of patients.

Detailed description:

Arms: arm 1: None arm 2: None
Interventions: intervention 1: Aldesleukin: All Patients intervention 2: Nivolumab: Cohort 1 (Cutaneous) intervention 3: Nivolumab: Cohort 2 (Ocular) intervention 4: Ipilimumab: Cohort 2 (Ocular)
Intervention descriptions: intervention 1: Cycle 1:

(600,000 U/kg/dose) given as a bolus infusion once every 8 to 12 hours over 5 days or until no longer tolerated (to a maximum of 10 doses). Administered as an inpatient.

Days 1-5 and Days 15-19 (all patients) intervention 2: Cycle 1: 6 Week Duration Nivolumab 240 mg IV

Cycle 2: 6 Week Duration Nivolumab 240 mg IV on Day 1, 15 and 29

Cycle 3: 4 Week Duration Nivolumab 240 mg IV on Day 1 and 15

Patients may continue maintenance nivolumab 240 mg IV every 2 weeks OR nivolumab 480 mg IV every 4 weeks per 2018 FDA approval at discretion of the treating physician and independent of this study intervention 3: Cycle 1: 6 Week Duration Nivolumab 3 mg/kg IV on Day 29

OR for a high risk patient with an excellent performance status, the following regimen may be given at the discretion of the treating investigator:

Nivolumab 1 mg/kg IV on Day 29

Cycle 2: 6 Week Duration Nivolumab on Day 8 and on Day 29 using the same dose regimen as used Cycle 1 Day 29

Cycle 3: 4 Week Duration Nivolumab on Day 8 using the same dose regimen as used Cycle 1 Day 29.

Patients may continue maintenance nivolumab 240 mg IV every 2 weeks OR nivolumab 480 mg IV every 4 weeks per 2018 FDA approval at discretion of the treating physician and independent of this study intervention 4: Cycle 1: 6 Week Duration Ipilimumab 1 mg/kg IV on Day 29

OR for a high risk patient with an excellent performance status, the following regimen may be given at the discretion of the treating investigator:

Ipilimumab 3 mg/kg IV on Day 29

Cycle 2: 6 Week Duration Ipilimumab on Day 8 and on Day 29 using the same dose regimen as used Cycle 1 Day 29

Cycle 3: 4 Week Duration Ipilimumab on Day 8 using the same dose regimen as used Cycle 1 Day 29

Protocol documents:
Prot_SAP_000.pdf: 
Masonic Cancer Center 
University of Minnesota 
A Phase 2 Study of Palliative Radiation and Combination Sequential 
Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
CPRC # 2018LS110 
Principal Investigator: 
Evidio Domingo-Musibay, MD 
Department of Medicine 
Division of Hematology, Oncology and Transplantation 
Co-Investigators: 
Division of Hematology, Oncology and Transplantation 
Naomi Fujioka, MD* 
Shernan Holtan, MD 
Martin Felices, PhD* 
Department of Surgery 
Todd Tuttle, MD* 
Jane Hui, MD, MS* 
Department of Interventional Radiology 
Shamar Young, MD* 
Department of Radiation Oncology 
Jianling Yuan, MD PhD* 
Chris Wilke, MD, PhD* 
Department of Radiology 
Daniel J Steinberger, MD* 
Laboratory Medicine and Pathology 
Alessio Giubellino, MD, PhD*  
Bartosz Grzywacz, MD* 
Division of Epidemiology and Community Health 
Heather H Nelson MPH, PhD* 
*will not consent patients
Biostatistician:
Saonli Basu, PhD
Version Date 
February 18, 2020 
Confidential 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
February 18, 2020 
Page 2 of 64 
CPRC # 2018LS110 
Revision History 
 
Revision 
# 
Version 
Date 
Summary Of Changes 
Consent 
Changes 
 
09/12/2018 
Original to CPRC 
n/a 
 
11/12/2018 
Response to CPRC stips including updating the title and 
adding background information on ocular melanoma 
Other minor edits and clarfications including: 
 Synospsis – correct IL-2 dose 
 Schema – clarify treatment days for each cohort, 
change the ocular melanoma cohort treatment Day 7 to 
treatment Day 8 (changed throughout the protocol) 
 Section 9 – Schedule of patient activities – clarify that 
the schedule of visits will be identical for both cohorts 
(although treatment will occur at different visits based 
on cutaneous vs ocular melanoma); in Section 9.2, add 
a Day 8 time point for Cycles 2 and 3 to match clinical 
calendar 
n/a 
 
03/05/2019 
In response to IRB’s initial review: 
 Section 9.1 - Clarify that for study eligibility a patient 
must have either archived tumor tissue or a fresh tumor 
biopsy must be done – SOC – charge to insurance 
 Section 9.2 – Clarify that a patient must have a fresh 
tumor biopsy prior to treatment start – if a fresh tumor 
biopsy is done for eligibility per Section 9.1, the baseline 
biopsy in Section 9.2 is not required; however if a patient 
has archived tissue, a fresh tumor biopsy is required per 
Section 9.2 and charged to research. 
 Synopsis and Section 1.3 - Add a correlative objective 
for the stool samples and add a new section (Section 
9.2.3) regarding sample collection 
Edits and clarifications from the Clinical Care Planning 
Meeting: 
 Minor clarifications to the inclusion and exclusion 
criteria 
 Section 9.2 greatly reduce the number of times the 
FACT QOL survey is completed and stool samples 
collected 
 Other minor edits through-out 
yes 
1 
07/02/2019 
 Synopsis, Schema, Sections 4 and 7.1: For patients 
receiving palliative RT outside of the study shorten the 
window to within 30 days (previously 60) and clarify 30 
days is based on the time between the last dose of RT 
and 1st dose of aldesleukin. 
 Synopsis, Schema, Section 7.4: Update the nivolumab/ 
impilimab dosing for ocular cohort based on new 
information – rationale added to Section 2.4 
 Section 9.2: Remove stool sample collection from x 
chart, delete Section 9.2.3 and correlative objective 
related to stool collection 
 Sections 9.1 and 9.2 – clarify a fresh tumor biopsy is 
required at baseline on all patients, but if patient has 
yes 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
February 18, 2020 
Page 3 of 64 
CPRC # 2018LS110 
Revision 
# 
Version 
Date 
Summary Of Changes 
Consent 
Changes 
archived tissue, biopsy will be charged for research 
Standardize the maintenance therapy language that it 
is independent of the study and at the discretion of the 
treating phyisician 

Section 9.2: reduce the frequency of research related
blood samples
Other edits and minor clarifications: 

Section 5.1.10 and Appendix I: Inclusion criteria add “if
given” for time requirement since previous anti-tumor
therapy and RT start

Section 5.1.11: Inclusion criteria add “if applicable”
regarding recovery from previous cancer treatment side
effects

Synopsis: Correct wording in the inclusion criteria in
regarding prior treatment to match Section 5.1.10 and
appendix I

Section 4: delete treatment details are repeat of
information in schema, synopsis and Section 7

Section 9.1: added pregnancy testing to the x-chart to
match exclusion criteria Section 5.1.2.

Replace IL-2 with aldesleukin at several places in the
protocol for drug name consistency (although also
retain reference to IL-2 when using as a general term
and in the consent form)

Other minor edits and formatting changes as tracked
2 
02/18/2020 

Increase the allowable time between last dose of
radiation therapy to 1st dose of IL-2 from 30 days to 90
days for patients enrolling on the study after palliative
therapy.

Remove all tests and evaluations under the radiation
column

Add windows around individual treatments without
affecting future treatment schedule and allow longer
delays with adjustment to future dosing as appropriate.

Delete Eligibility Checklist as Appendix I and
renumbering remaining appendices (and update
numbering in the protocol text).

Other minor edits including adding > 80 years of age
must be approved by PI to synopsis to match other
protocol sections, adding to missing x’s bloodwork

Add Chris Wilke, MD, PhD as co-I
Yes – Timing 
of previous 
RT, delete 
blood work 
during RT 
Principal Investigator Contact Information: 
Evidio Domingo-Musibay, MD 
University of Minnesota Department of Medicine 
Division of Hematology, Oncology, and Transplantation 
420 Delaware Street SE  MMC 480 
Minneapolis, MN 55455 
Phone: 612-624-5373    Email:  musib024@umn.edu 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
Table of Contents 
Revision History ................................................................................................................... 2 
Key Abbreviations ................................................................................................................ 6 
Protocol Synopsis ................................................................................................................ 7 
Study Schema .....................................................................................................................10 
1. 
Objectives ....................................................................................................................11 
1.1. 
Primary Objective ..................................................................................................11 
1.2. 
Secondary Objectives ...........................................................................................11 
1.3. 
Correlative Objectives ...........................................................................................11 
2. 
Background ..................................................................................................................11 
2.1. 
Metastatic Melanoma and Standard Treatments ...................................................11 
2.2. 
Pre-clinical Results of Radiation and Immunotherapy Combinations .....................13 
2.3. 
Clinical Experience with Radiation and Combination Immunotherapy ...................13 
2.4. 
Clinical Experience with Aldesleukin and Checkpoint Inhibition .............................14 
2.5. 
Summary of Safety and Pharmacologic Considerations ........................................15 
2.6. 
Correlative Studies ................................................................................................16 
3. 
Study Rationale ............................................................................................................19 
4. 
Study Design ................................................................................................................20 
5. 
Patient Selection ..........................................................................................................21 
5.1. 
Inclusion Criteria ...................................................................................................21 
5.2. 
Exclusion Criteria ..................................................................................................23 
6. 
Patient Screening and Study Enrollment ......................................................................23 
6.1. 
Enrollment with the University of Minnesota Clinical Trials Office ..........................23 
6.2. 
Patient Enrollment in OnCore ................................................................................23 
6.3. 
Patients Who Do Not Begin Study Treatment ........................................................24 
7. 
Treatment Plan.............................................................................................................24 
7.1. 
Palliative Radiation Therapy ..................................................................................24 
7.2. 
Aldesleukin (IL-2) – All Participants .......................................................................24 
7.3. 
Nivolumab Monotherapy (Cohort 1 - Cutaneous) ..................................................25 
7.4. 
Nivolumab and Ipilimumab (Cohort 2- Ocular) .......................................................26 
7.5. 
Supportive Care ....................................................................................................27 
7.6. 
Duration of Study Treatment .................................................................................27 
7.7. 
Duration of Study Participation ..............................................................................28 
8. 
Expected Side Effects and Management of Selected Toxicities ...................................28 
8.1. 
Palliative Radiation Therapy ..................................................................................28 


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CPRC # 2018LS110 
8.2. 
Aldesleukin (IL-2) ..................................................................................................30 
8.3. 
Ipilimumab and Nivolumab Related Toxicity Management ....................................31 
9. 
Schedule of Patient Activities .......................................................................................35 
9.1. 
Required Clinical Care ..........................................................................................36 
9.2. 
Research Related Sample Collection ....................................................................37 
9.2.1. Collection of Tumor Biospecimens ........................................................................37 
9.2.2. Collection of Blood Specimens ..............................................................................38 
9.2.3. Quality of Life (QOL) Measurement, FACT-Melanoma ..........................................38 
9.3. 
Imaging Assessments ...........................................................................................38 
10. 
Adverse Event Reporting ..........................................................................................39 
10.1. Definitions .............................................................................................................39 
10.2. Adverse Event Monitoring and Documentation ......................................................40 
10.3. Required Reporting: IRB and Masonic Cancer Center’s SAE Coordinator ............41 
11. 
Study Data Collection and Monitoring .......................................................................41 
11.1. Data Management .................................................................................................41 
11.2. Case Report Forms ...............................................................................................42 
11.3. Data and Safety Monitoring Plan (DSMP) .............................................................42 
11.4. Monitoring .............................................................................................................42 
11.5. Record Retention ..................................................................................................43 
12. 
Statistical Considerations..........................................................................................43 
13. 
Conduct of the Study ................................................................................................44 
13.1. Good Clinical Practice ...........................................................................................44 
13.2. Ethical Considerations ..........................................................................................44 
13.3. Informed Consent..................................................................................................44 
Appendix 1 – Performance Status Criteria ...........................................................................45 
Appendix 2 – Aldesleukin (IL-2) Toxicities and Corrective Measures ...................................46 
Appendix 3 – Management Algorithms for Ipilimumab and Other Immuno-oncology Drugs .48 
Appendix 4 – FACT-M (Version 4) .......................................................................................54 
Appendix 5 – Correlative Objectives and Testing ................................................................58 
Appendix 6 – RECIST 1.1 response definitions ...................................................................60 
References ..........................................................................................................................62 
 
 
 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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KEY ABBREVIATIONS 
 
AE 
Adverse event 
CRF 
Case report form 
DLCO 
 diffusing capacity of lung 
eGFR 
estimated glomerular filtration rate 
EOT 
End of Treatment 
FACT-M 
Functional Assessment of Cancer Therapy – Melanoma  
GKR 
Gamma Knife Radiosurgery 
iDOR 
duration of response based on iRECIST 
IL-2 
Interleukin-2 (Aldesleukin) 
I-O 
immuno-oncology 
irAE 
Immune related adverse event 
iRECIST 
immune response evaluation criteria in solid tumours 
IV 
intravenous 
LVEF 
Left Ventricular Ejection Fraction 
MTD 
maximum tolerated dose 
ORR 
objective response rate 
OS 
overall survival 
PBMC 
Peripheral blood mononuclear cells 
PD 
progressive disease 
PFS 
progression free survival 
QOL 
Quality of life 
RECIST 
response evaluation criteria in solid tumours 
SBRT 
Stereotactic Body Radiation Therapy 
ULN 
Upper limit of normal 
WBRT 
whole brain radiation therapy 
 
 
 
 
 
 
 
 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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PROTOCOL SYNOPSIS 
A Phase 2 Study of Palliative Radiation and Combination Sequential Immunotherapy 
for Metastatic Cutaneous Melanoma and Ocular Melanoma 
Study 
Design: 
This is a Phase 2 study designed to evaluate the combination of checkpoint blockade and 
aldesleukin (IL-2) therapy after a course of standard of care palliative radiation in the 
management of unresectable metastatic melanoma. To be eligible, a patient must have 
a minimum of 3 (preferably >5) radiographically distinct, measurable (>1.5 cm) lesions 
based on RECIST 1.1. Metastatic cutaneous melanoma must be refractory to standard 
immunotherapy drugs, molecular targeted agents and/or chemotherapy. Patients with 
ocular melanoma subtypes may enroll in this study without prior therapy, as there is no 
standard front-line therapy for this subset of patients.  
 
Two treatment cohorts will be used based on disease origin:  
Cohort 1: Cutaneous melanoma  
Cohort 2: Ocular melanoma  
 
Each cohort enrolls 22 patients employing a separate Simon’s two stage design and 
separate monitoring for excessive toxicity.  
 
Standard of care palliative radiation therapy is delivered to a maximum of 3 metastatic 
tumors over no more than 3 weeks. A minimum of 2 lesions must remain non-irradiated 
for disease response assessments. Patients who have received palliative radiation 
therapy prior to study enrollment also may be considered for the study provided the 1st 
dose of aldesleukin is given within 90 days after the last dose of RT.  
 
Direct participation consists of 3 cycles of study treatment over 16 weeks and an End of 
Trial (EOT) visit.  
 
Disease re-assessment includes physical examination and radiographic response 
assessment by irRECIST and RECIST v1.1 of non-irradiated target lesions using CT (or 
PET/CT) and/or at MRI during Week 6 of Cycle 1 and again after Cycle 3 as part of the 
End of Trial (EOT) visit.  
 
Direct study participation ends with the EOT; however, patients may continue receiving 
nivolumab every 2 weeks at 240 mg IV as maintenance therapy independent of this study 
at the discretion of the treating physician OR nivolumab 480 mg IV every 4 weeks per 
2018 FDA approval. 
 
Determinaton of disease progression for the study requires confirmation of progression 
with scans obtained at least 4-6 weeks later that qualify as progressive disease (PD) by 
irRECIST due to pseudoprogression and late responses seen with immunotherapy. 
Therapy after progression remain at the discretion of the treating physician and study 
participant. 
 
All patients are followed for progression-free and overall survival endpoints for two years 
from the start of aldesleukin. 
 
Primary 
Objective: 
Determine the objective response rate (ORR) and confirm safety and tolerability of 
sequential combination immunotherapy 
 
Secondary  
Objectives: 
● Estimate 6-month Progression-Free Survival (PFS)  
● Estimate 12-month Overall Survival (OS) 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
Correlative 
Objectives: 
● Assessment of tumor microenvironment changes and systemic immune parameters, 
identification of biomarkers of response, identification of autoimmune toxicities 
associated with therapy, and characterization of resistance and response mechanisms. 
● Assess the effect of natural genetic variation (SNPs) in selected genes including PD-1, 
PD-L1/L2, CTLA-4, TIM-3, LAG-3, OX40/OX40L as well as HLA, NKG2D and NKG2D 
Ligand genes.  
● Evaluate Health Related Quality of Life as assessed by the FACT-M 
 
Disease 
Status 
Biopsy-proven unresectable, metastatic melanoma refractory to standard front-line 
therapy with a minimum of 3 radiographically distinct metastases (>1.5 cm) 
measurable by RECIST 1.1.  
o 
At least 2 lesions must remain non-irradiated for systemic response assessments 
o 
A maximum of 3 metastases will be treated by palliative radiation (max 2 metastases 
per treated organ may be targeted, but must be separated by more than 5 cm of 
normal tissue) 
Note: Appropriate candidates with lung metastases may be considered for ablative hypofractionation. 
Appropriate liver metastases may be considered for ablative hypofractionation or Y-90 radioembolization. 
Suitable brain metastases will be treated using Gamma Knife Radiosurgery (GKR) or whole brain radiation 
therapy (WBRT) per the treating radiation oncologist. Total radiation dose and number of fractions will be 
determined by the treating radiation oncologist based on anatomic and dosing constraints. 
Archival tissue block and/or newly obtained core, punch, or excisional biopsy of tumor 
tissue. 
Prior recent palliative radiation: enrollment is permissible if the last dose of palliative 
radiation therapy was given within 90 days of the 1st dose of aldesleukin and at least 2 
radiographically distinct non-irradiated metastases (>1.5 cm) remain for systemic 
response assessment 
Ocular melanoma: patients with metastatic ocular melanoma may enroll in this study 
without prior therapy, given no standard front-line therapy available for this subset of 
patients. 
 
Key 
Inclusion:  
● Age 18 through 80 years, >80 years of age must be approved by the PI  
● ECOG performance status 0 or 1 
● Willingness to undergo two (2) separate biopsies (core and/or excisional) during the 
study period; an accessible site is always preferred. 
● Adequate organ function as evidenced by testing within 14 days of study enrollment 
defined as: 
o Hematologic: leukocytes ≥ 2,000/mcL, ANC ≥ 1,000/mcL, hemoglobin ≥ 9.0 g/dL, 
platelets ≥ 100,000/mcL 
o Renal: creatinine ≤ 1.8 mg/dL, if > 1.5 mg/dL must have eGFR of ≥ 35 mL/min 
o Hepatic: AST, ALT, ALP ≤3 x upper limit of normal (≤5 x UNL if know or suspected 
liver mets), total bilirubin ≤ 2.0 mg/dL 
o Pulmonary: oxygen saturation ≥90% on room air; corrected DLCO and FEV1, 
≥60% predicted 
o Cardiac: absence of clinical decompensated congestive heart failure or 
uncontrolled arrhythmia; LVEF ≥ 40%. QTc < 450 ms in males and < 470 ms in 
females. 
● A minimum of 1 week between last anti-tumor treatment if given, and 1st dose of 
radiation therapy (not applicable for patients enrolling after palliative radiation therapy) 
● Recovery from previous cancer treatment if applicable (acute toxicity ≤ Grade 1 by 
CTCAE 5.0 criteria) prior to first radiation treatment  
● Women of childbearing potential and males with partners of childbearing potential 
must agree to the use of barrier methods of contraception, hormonal contraceptives, 
or to abstain from heterosexual activity for the duration of study participation. Women 
of childbearing potential must have a negative pregnancy test within 14 days of study 
enrollment. 
● Ability to understand and provide voluntary written consent 
 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
Key 
Exclusion 
Criteria: 
● Concurrent use of high-dose steroids Note: chronic or maintenance steroids (< 2 mg 
dexamethasone equivalent) permissible 
● Any concurrent malignancy requiring active treatment. 
● Severe and active autoimmune diseases requiring systemic immunosuppression. 
● Prior organ allograft or allogeneic transplantation. 
 
Treatment 
Plan 
After completion of palliative radiation therapy: 
 
Cycle 1 (6 week duration): 
Days 1-5 and Days 15-19 (all patients):  
Aldesleukin (IL-2)  (600,000 U/kg/dose) given as a bolus infusion once every 8 to 12 hours 
over 5 days or until no longer tolerated (to a maximum of 10 doses). Administered as an 
inpatient. 
 
The reminder of treatment is given as an outpatient: 
On Day 29 Cohort 1 (cutaneous): Nivolumab 240 mg IV  
 
On Day 29 Cohort 2 (ocular):  
 Nivolumab 3 mg/kg IV and Ipilimumab 1 mg/kg IV  
OR for a high risk patient with an excellent performance status, the following regimen 
may be given at the discretion of the treating investigator: 
 Nivolumab 1 mg/kg IV and Ipilimumab 3 mg/kg IV  
 
Cycle 2 (6 week duration):  
Cohort 1: Nivolumab 240 mg IV on Day 1, 15 and 29. 
 
Cohort 2: Nivolumab followed by Ipilimumab on Day 8 and on Day 29 using the same 
dose regimen as used Cycle 1 Day 29. 
 
Cycle 3 (4 week duration):  
Cohort 1: Nivolumab 240 mg IV on Day 1 and 15. 
 
Cohort 2: Nivolumab followed by Ipilimumab on Day 8 using the same dose regimen as 
used Cycle 1 Day 29. 
 
After Cycle 3 and the End of Trial (EOT) assessment is completed, direct study 
participation ends. Patients may continue maintenance nivolumab 240 mg IV every 2 
weeks OR nivolumab 480 mg IV every 4 weeks per 2018 FDA approval at discretion of 
the treating physician and independent of this study. 
 
All patients are followed for progression-free and overall survival endpoints for two years 
from the start of aldesleukin by phone/electronic communications. 
 
Enrollment: 
Enrollment for each melanoma cohort will be independent of the other: 
Stage 1: enroll 16 patients – if 4 or more patients have a disease response, activate 
stage 2. If 3 or fewer responses in these 16 patients, the cohort will be stopped for futility.   
Stage 2: enroll 6 additional patients for a total accrual of 22 
Approximately 44 patients will be enrolled over a period of 24 months; based on an 
average of 1-2 patients per month. 
 
 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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STUDY SCHEMA 
 
Palliative Radiation administered per standard of care. Patients who have received recent palliative radiation 
may be considered for the study provided the 1st dose of aldeskeukin can be given within 90 days of the last 
dose of palliative radiation therapy. 
 
Aldesleukin (IL-2) 600,000 U/kg is administered as an intravenous infusion via a central catheter (either 
PICC line or port) over 15 minutes approximately once every 8 hours per institutional guidelines and standard 
clinical practice. Patients may receive a maximum of 10 doses, no longer than 24-hours apart, on Days 1 
through 5 and Days 15 through 19 of Cycle 1. 
 
Cohort 1 only (Cutaneous Melanoma): 
Nivolumab 240 mg IV is administered every 2 weeks after IL-2 treatments for six doses (Cycle 1 Day 29 and 
Cycle 2 Day 1, 15, and 29, and Cycle 3 Day 1 and 15). 
 
Cohort 2 only (Ocular Melanoma): 
 
Nivolumab 3 mg/kg IV and Ipilimumab 1 mg/kg IV  
OR for a high risk patient with an excellent performance status, the following regimen may be given at 
the discretion of the treating investigator: 
 
Nivolumab 1 mg/kg IV and Ipilimumab 3 mg/kg IV  
Dosing occurs every 3 weeks after IL-2 treatments for four doses (Cycle 1 Day 29 and Cycle 2 Day 8 and 
29, and Cycle 3 Day 8). 
 
After Cycle 3 and an End of Trial (EOT) assessment 2-4 weeks after last dose of study drug is completed, 
direct study participation ends.  
 
Patients may continue maintenance nivolumab 240 mg IV every 2 weeks OR nivolumab 480 mg IV every 4 
weeks  per 2018 FDA approval at discretion of the treating physician and independent of this study. 
 
 


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1. OBJECTIVES 
1.1. Primary Objective 
The primary objective of this study is to determine the objective response rate (ORR) 
and confirm safety and tolerability of sequential combination immunotherapy in 
patients with metastatic melanoma after palliative radiation therapy.  
1.2. Secondary Objectives 
● 
Estimate 6-month Progression-Free Survival (PFS) 
● 
Estimate 12-month Overall Survival (OS) 
1.3. Correlative Objectives 
● Assessment of tumor microenvironment changes and systemic immune 
parameters, identification of biomarkers of response, identification of autoimmune 
toxicities associated with therapy, and characterization of resistance and response 
mechanisms. 
● Assess the effect of natural genetic variation (SNPs) in selected genes including 
PD-1, PD-L1/L2, CTLA-4, TIM-3, LAG-3, OX40/OX40L as well as HLA, NKG2D 
and NKG2D Ligand genes. 
● Evaluation of Health Related Quality of Life as assessed by the FACT-M 
2. BACKGROUND 
2.1. Metastatic Melanoma and Standard Treatments 
Melanoma is the deadliest form of skin cancer affecting people of all ages. In the 
United States, melanoma incidence rates have been increasing for the last 40 years 
and it is estimated in 2017 approximately 87,110 patients will be diagnosed with 
malignant melanoma, and 9,730 deaths are expected from the disease(1). 
Melanoma metastasis is associated with a poor prognosis, with historical 5-year 
survival rates of less than 10%(2). While the use molecularly targeted agents and 
routine use of checkpoint inhibition has improved the outlook for many patients, still 6 
in 10 patient with metastatic cutaneous melanoma fail to respond to front-line 
immunotherapy with anti-PD1 antibodies(3).  
Fortunately, for approximately 50% of cutaneous melanoma cases harboring a BRAF 
mutation, targeted BRAF/MEK inhibition demonstrates high initial response rates. 
However, responses are short-lived due to rapidly acquired resistance.  Median 
duration of response to dabrafenib and trametinib is 12 months(4), and nearly 25% of 
patients recur with a metastasis to brain(5).  
Brain metastasis is a common finding in cutaneous melanoma patients, with nearly 
37% of patients eventually developing brain metastasis and autopsies showing 75% 
of melanoma deaths associated with brain metastasis(6). Currently, asymptomatic 
patients may be initially managed with systemic therapy, but symptomatic brain 
metastasis is primarily treated with surgery and radiation as standard brain directed 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
therapy(7). Particularly for patients with heavily pre-treated CNS metastatic disease, 
there is no standard immunotherapy approach for subsequent management. 
The standard of care for refractory metastatic melanoma is clinical trial participation. 
The two most widely used historical chemotherapy agents, temozolomide and 
dacarbazine, are associated with response rates of 13% after 2 cycles of therapy, and 
median overall survival times of 7.7 and 6.4 months, for each respectively(8). The 
primary toxicities associated with dacarbazine and temozolomide are hematologic 
including Grade 3 to 4 neutropenia (16%), lymphopenia (9%), leukopenia (8%), and 
thrombocytopenia (6%). Common non-hematologic toxicity includes Grade 3 to 4 
fatigue (5%), nausea (3%), and vomiting (2%)(9). 
For ocular melanoma subtypes, the malignant cells initiate within the uveal tract of the 
eye. Patients with localized uveal melanoma are typically managed with local therapy 
first, using radiation, laser therapy, or surgery (enucleation), followed by observation 
or clinical trial participation. There are no approved adjuvant therapies, and following 
local therapy greater than 50% of patients develop metastatic disease. Tumor cells 
spread hematogenously to liver and patients typically die from hepatic infiltration and 
liver failure.  
Despite the significant success of immune checkpoint blockade in the management of 
metastatic cutaneous melanoma, similar success has not been seen in treatment of 
ocular melanoma. Ocular melanoma is a unique subset with distinct biology and 
natural history compared with cutaneous melanoma. While characteristic BRAF 
mutation in cutaneous melanoma is targetable, mutations in the G-coupled receptor 
subunits GNA11 and GNAQ seen in >50% of uveal melanoma tumors, are not 
effective drug targets. A randomized phase II study of the MEK inhibitor, selumetinib, 
versus chemotherapy demonstrated no significant improvement in overall survival(10).  
Similarly, less than 10% of uveal melanoma tumors express the biomarker PD-L1(11). 
Ocular melanoma treatment outcome with standard anti-PD1 monotherapy is poor, 
with ORR of 3.6%, median PFS of 2.6 months, and OS of 7.6 months(12).  Standard 
practice is to treat metastatic ocular melanoma patients with approved immunotherapy 
agents for cutaneous melanoma, with ipilimumab and nivolumab being the most 
common front-line regimen for fit patients with this disease. Efficacy is limited in this 
disease, though, and this is a population of patients with high unmet need. New 
immunotherapy approaches are needed and novel immunologic therapeutic strategies 
should be further investigated in this population. 
The sequential administration of immunostimulatory Interleukin-2 (IL-2) following 
radiation therapy for palliation, brain directed therapy, or liver directed therapy (ocular 
melanoma) offers a rational immunologic priming strategy to sustain and expand 
antigen priming of T cells under growth promoting effects.  The sequential addition of 
checkpoint inhibition strategies after IL-2 also offers rational timing of anti-PD1 and 
anti-CTLA-4 blockade to inhibit activity of regulatory and exhausted T cells following 
IL-2 based immunotherapy. 


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2.2. Pre-clinical Results of Radiation and Immunotherapy Combinations 
Radiation therapy is known to be an effective palliative treatment for melanoma(13), 
and it is used routinely and safely in the multidisciplinary management of advanced, 
metastatic disease(14, 15). It has long been observed that radiation can also cause 
tumor regressions outside of the field of radiation; a phenomenon termed the abscopal 
effect(16). Studies have shown that ionizing radiation enhances immunogenicity of 
tumor associated antigens(17) by inducing immunogenic cell death (ICD) and 
activating host innate immune signaling and APC processing and antigen presentation 
to stimulate adaptive T-cell mediated immunity(18, 19) creating strong rationale for 
combination radiation and immunotherapy. 
Pre-clinical models have also demonstrated abscopal effects require an intact immune 
system, and ionizing radiation to melanoma tumors generates large quantities of 
antigen that induce APC maturation and migration into draining lymph nodes where 
they can activate naïve T cells that subsequently traffic to distant sites as TILs(20). 
Further studies have also shown that T-cell priming in draining lymph nodes leads to 
regression of distant non-irradiated metastases in a cytotoxic CD8+ T cell dependent 
fashion(21).  
Advances in the planning and delivery of radiation therapy now allow for highly 
conformal treatment that spares normal adjacent tissues and structures. Technological 
improvements have also made it possible to deliver higher doses of radiation per 
fraction using image-guided radiation therapy (IGRT) and stereotactic body radiation 
therapy (SBRT) techniques. For patients with melanoma brain metastasis, stereotactic 
techniques like Gamma Knife can spare patients the late effects of whole brain 
radiation therapy. 
2.3. Clinical Experience with Radiation and Combination Immunotherapy  
Strategies aimed at potentiating immunologic effects of local therapy in cancer 
management offers patients the potential to maintain quality of life and improve 
immunotherapy outcomes, even in refractory metastatic disease. 
Metastatic melanoma to brain affects 30-50% of metastatic melanoma patients, and 
combinations of radiotherapy and IL-2 in that setting have demonstrated clinical 
efficacy and long-term disease control using both WBRT and stereotactic radiosurgical 
techniques(22). A single-institution retrospective study from the University of 
Minnesota identified 15 patients receiving high-dose IL-2 therapy, two of which had 
brain metastases treated with WBRT followed by IL-2, in both cases resulting in 
durable complete responses(23). Gamma Knife radiosurgery combined with 
Ipilimumab has also been associated with improvement in outcomes and survival rates 
equivalent to melanoma patients without brain metastases(24). 
Most radiotherapy combinations reported in the literature have used Ipilimumab, the 
first checkpoint inhibitor approved for treatment of metastatic melanoma based on 
improvement in overall survival(25, 26). Early evidence for immune enhancement 
came in case report format describing abscopal effects in a patient receiving 


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Ipilimumab during radiotherapy for melanoma(27). The addition of radiation to 
Ipilimumab was followed by distant tumor regressions and changes in peripheral blood 
immune cell subsets and led to antibody production against cancer-testis antigen NY-
ESO-1(27). 
However, newer evidence has shown that anti-PD1 therapy has synergy with 
radiation. In a recent retrospective review of patients treated with concurrent immune 
checkpoint inhibitor therapy and radiotherapy after initial progression on nivolumab, 
further nivolumab treatment was associated with an overall response rate of 30%(28). 
Given the potential for synergy between radiation and immunotherapy there is a need 
for additional prospective clinical trials to optimize in situ vaccination effects, improve 
responses, and reveal mechanistic details concerning the underlying immunobiology 
of radiation induced in situ vaccination. 
Optimal radiation dose and fractionation schemes have not yet been fully defined, but 
fractionated radiation as opposed to single dose radiotherapy appears best able to 
induce abscopal responses(29). A recent retrospective systematic review of 
metastatic melanoma patients treated with Ipilimumab and fractionated palliative 
radiation suggests a threshold effect may be seen at around 2 - 3 Gy per fraction. In 
that study median radiotherapy dose was 26 Gy (range: 8-68 Gy) and median fraction 
size was 4 Gy (range 1.8 – 25 Gy), and though the benefit of combined radiation and 
immunotherapy was highest for fractions < 3 Gy benefits were seen regardless of the 
radiation dose used(30).  
2.4. Clinical Experience with Aldesleukin and Checkpoint Inhibition 
Interleukin-2 (IL-2) is a key human cytokine involved in the activation and proliferation 
of T cells(31). Aldesleukin is a recombinant version of IL-2 approved by the Food and 
Drug Administration (FDA) for treatment of metastatic melanoma. In the first-line 
setting, high-dose Aldesleukin results in durable complete response (CR) in 6% and 
partial response (PR) in 10% of patients, and durable responses seen out past 40 
months(32). 
Importantly, radiation induced abscopal effects appear critically dependent on 
cytotoxic T lymphocytes(21), and IL-2 is known to potently stimulate the expansion 
and activation of CD8+ cytotoxic T cells as well as NK cells. Exogenous IL-2 reduces 
minimal TCR signaling requirements on CD8+ T cells thereby allowing for proliferation 
under conditions of suboptimal TCR stimulation(33) and increase bystander killing 
activity via the release of granzyme-B and perforins. Therapeutic approaches using 
autologous tumor infiltrating lymphocytes (TILs) and high-dose intravenous 
interleukin-2 (IL-2) are also associated with response rates in excess of 50% and 
durable complete responses in 20% of patients(34). 
Current strategies using checkpoint inhibition depend on a pre-existing anti-tumor 
immune response that subsequently becomes tolerogenic. Chronic antigenic 
exposure generates antigen-specific signal 1 and 2 required for activation of T cells, 
and the eventual loss of co-stimulation and induction of CTLA-4, PD-1 and other 


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checkpoints lead to the state of immune suppression that characterizes the 
immunologic state of exhaustion. Use of checkpoint inhibitors reverses T cell 
exhaustion in patients responding to these approaches. 
In MDX010-20, the phase 3 study of Ipilimumab with or without glycoprotein 100 
(gp100) peptide vaccine, the Ipilimumab monotherapy arm received 3 mg/kg 
Ipilimumab every 3 weeks for four doses(35). In that trial median overall survival was 
10.0 months among patients receiving Ipilimumab plus the gp100 vaccine. Similarly, 
in a randomized phase 2 clinical trial of Ipilimumab (10 mg/kg) with or without 
Sargramostim (GM-CSF) improvements in overall survival were seen, with 1year OS 
of 68.9% (95% CI, 60.6-85.5%) vs. 52.9% (95% CI, 43.6-62.2%), respectively(36). 
In CheckMate-069, a randomized phase 2 study with n=142 patients with advanced 
melanoma and previously untreated BRAF-WT tumors, ORR was 61% Nivolumab (1 
mg/kg) and Ipilimumab (3 mg/kg) versus 11% for Ipilimumab (3 mg/kg) and 
placebo(37). A recent phase IIIb/IV study evaluating nivolumab 3 mg/kg plus 
ipilimumab 1 mg/kg in previously untreated stage III or IV melanoma (CheckMate- 511) 
demonstrated significantly lower incidence of treatment-related Grade 3-5 adverse 
events with no differences in efficacy(38). For this reason, either dosing scheme may 
be used in this study based on treating physician judgement. Similarly, safety of  
Ipilimumab and high-dose IL-2 has also been demonstrated in a phase I/II trial 
conducted at the NIH Surgery Branch, National Cancer Institute(39). In that study, 
Ipilimumab was given every 3 weeks for 3 doses, with the 2nd and 3rd doses followed 
within 24 hours by high-dose IL-2 administration(39). No radiation therapy was used 
in the trial and expected toxicity events were encountered with the combination. 
2.5. Summary of Safety and Pharmacologic Considerations 
The sequencing strategy employed in this trial using high dose IL-2 and anti-PD1 and 
anti-CTLA-4 checkpoint blockade aims to promote activation of anti-melanoma T cells 
after radiation therapy induced tumor antigen release. Inhibition of CTLA-4 mediated 
signaling can reduce regulatory T cell function, which may contribute to increased 
potency of IL-2 mediated T cell dependent anti-tumor immune responses. Anti-PD1 
checkpoint inhibition similarly works on effector T cells to decrease physiologic 
inhibition of the exhausted T cell. 
In the phase I/II trial conducted at the NIH Surgery Branch, in which Ipilimumab every 
3 weeks was followed by high-dose IL-2, 14% of patients developed grade III/IV 
toxicities including 4 cases of enterocolitis and 1 case or arthritis and of uveitis. In the 
3 mg/kg dose group, one of five (20%) responders experienced grade III/IV 
autoimmunity attributable to anti-CTLA-4 therapy(39). Anti-CTLA-4 checkpoint 
blockade and its effects on regulatory T cell activation suggests toxicity was most likely 
due to the de-inhibition of T reg activity by repetitive anti-CTLA-4 blockade and 
breaking of peripheral tolerance mechanisms. 
In the larger phase 3 study of Ipilimumab with or without gp100 vaccine (MDX010-20) 
drug related adverse events were seen in 79% of patients receiving Ipilimumab. In the 


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monotherapy arm there were Grade 3/4 events in 21% and Grade 5 events in 3/131 
(2%) of patients(35). The most frequent AEs for all arms of the trial were rash (30%), 
pruritis (33%), diarrhea (33%), colitis (8%), endocrine disorders (9%), AST/ALT 
elevation (2%), and hepatitis (1%). Any grade immune related adverse event rate was 
60%, and the Grade 3/4 immune related adverse event rate was 13% with the most 
frequent adverse events being diarrhea (5%), colitis (5%), rash (2%), and endocrine 
disorders (3%)(35). 
The pharmacokinetics of Ipilimumab was studied in 785 patients with unresectable or 
metastatic melanoma who received doses of 0.3, 3, or 10 mg/kg once every 3 weeks 
for 4 doses(40). Peak concentration (Cmax), trough concentration (Cmin), and area 
under the plasma concentration versus time curve (AUC) of Ipilimumab increased 
dose proportionally within the dose range examined. Upon repeated dosing every 3 
weeks, the clearance (CL) of Ipilimumab was found to be time-invariant, and systemic 
accumulation was 1.5-fold or less. Steady-state concentrations of Ipilimumab were 
reached by the third dose; the mean Cmin at steady-state was 19.4 mcg/mL following 
repeated doses of 3 mg/kg. The mean value (% coefficient of variation) generated 
through population PK analysis for the terminal half-life (t1/2) was 15.4 days (34%) 
and for CL was 16.8 mL/h (38%). Notably, no clinically important effect on the CL of 
Ipilimumab was seen based on: age (range: 23–88 years), gender, performance 
status, renal impairment, mild hepatic impairment, previous cancer therapy, and 
baseline lactate dehydrogenase (LDH) levels(40).  
In this study, steady-state concentrations of Ipilimumab will be reached in cohort 2, 
and the terminal half-life (t1/2) of the drug is anticipated to be approximately 15 days. 
The expected in vivo degradation pattern of the anti-CTLA-4 and anti-PD1 monoclonal 
antibodies is to small peptides and amino acids via biochemical pathways independent 
of cytochrome P450 enzymes.  
Due to the potential for clinically meaningful AEs requiring early recognition and 
prompt intervention, management algorithms have been developed for suspected 
pulmonary toxicity, GI and hepatotoxicity, endocrinopathy, skin toxicity, neurological 
toxicity and nephrotoxicity related to the incorporation of Ipilimumab (see Appendix 3). 
Additional guidelines are available and published separately by the National 
Comprehensive Cancer Network (NCCN) and Society for Immunotherapy of Cancer 
(SITC). 
2.6. Correlative Studies 
The sequence of IL-2 administration and anti-PD1 and anti-CTLA-4 checkpoint 
blockade aims to promote sequential activation of anti-melanoma T cells after radiation 
therapy induced antigenic stimulation. Correlative studies associated with this trial aim 
to characterize the cooperative interactions between radiation therapy and 
combination immunotherapy. 
Central to the goal of the study is assessment of the temporal sequence of 
immunologic activation and the counter-regulatory mechanisms elicited by this 


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approach. Correlative laboratory studies have been designed to help elucidate 
mechanisms of resistance to checkpoint inhibitor strategies. We hypothesize that 
hypofractionated radiation induces immunogenic cell death and that sequential 
Interleukin-2 allows for priming of anti-melanoma tumor immunity in the refractory 
disease setting. We also hypothesize that checkpoint inhibition in sequence with IL-2 
will decrease suppressor T cell activity and exhaustion and increase T effector cell 
subsets. We will also assess the degree to which Nivolumab monotherapy and dual 
checkpoint inhibition with Nivolumab and Ipilimumab affects clinical outcome and 
therapy associated toxicities. 
Several planned studies will also attempt to answer the following questions: 
1. What immunologic checkpoints (i.e. PD1/Tim-3/Lag-3) are induced in the primary T 
cell response to radiation and IL-2 based therapy? Can the approach sensitize 
patients to anti-PD1 blockade, or other agents directed against T and NK cell 
targets? 
2. Is baseline or early intratumoral T-cell infiltrate a marker of response to therapy? 
Can radiation therapy and IL-2 induce TIL mediated anti-tumor rejection? What is 
clonality of TILs in responder patients versus nonresponders? 
3. Does anti-PD1 and anti-CTLA4 checkpoint blockade impact generation and 
functional activity of regulatory T cells? What immune evasion mechanisms are 
active in tumors failing to respond combination therapy approaches? Can gene 
expression profiling of tumors differentiate immunogenic versus non-immunogenic 
tumors? 
4. Does radiation therapy lead to formation of neoantigens, and can whole-
exome/transcriptome sequencing analysis and MHC binding prediction techniques 
predict tumor regression or subsequent response to checkpoint inhibition? 
5. Do cytokine profiles and/or plasma soluble analytes (ctDNA, miRNA) predict 
primary or secondary responses to combination sequential radioimmunotherapy? 
Can ctDNA profiling identify tumor neoantigens recognized by T cells? 
6. Does radiation and IL-2 therapy induce a meaningful anti-melanoma CTL response 
in peripheral blood and/or in TIL subsets? Can anti-tumor humoral immunity be 
induced against tumor-associated antigens? 
7. Does combination sequential radioimmunotherapy lead to CMV reactivation and 
generation of adaptive NK cells (CD57+NKG2C+)? Can anti-CMV T and NK cells 
or other anti-viral T cells in peripheral blood and the tumor microenviroment predict 
treatment response or identify biomarkers of response to T and NK cell therapeutics 
in refractory melanoma patients? 


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2.6.1. Evaluation of Tumor Biopsies 
Tumor infiltrating lymphocytes (TILs) and other immune cells are associated with 
clinical outcome, and this study will collect tumor biopsy specimens to quantify TILs in 
all formalin-fixed paraffin-embedded tumor specimens. 
We will use immunohistochemistry (IHC) and proteomics techniques to determine the 
extent and nature of immune infiltrates at baseline and after treatment. Only non-
irradiated lesions will be biopsied to allow for characterization of therapy-induced 
systemic immunologic responses. We are particularly interested in the relationship of 
treatment with Nivolumab monotherapy versus dual checkpoint inhibition and function 
of T regs, and other T cell subsets.  
Additional immune cells of interest include natural killer (NK) cells, monocytes, 
dendritic cells, myeloid derived suppressor cells (MDSCs), vascular and 
lymphovascular endothelial cells, and stromal cells. The following cellular markers will 
be analyzed using IHC and/or similar technique: CD3, CD8, PD-1, CTLA-4, MHC-I, 
CD4 (T cells), CD56 and CD16 (NK and NK T cells) CD45 (leukocytes), CD19 (B cells), 
CD68, glucocorticoid-induced tumor necrosis factor receptor family related gene 
(GITR), TIM-3, forkhead box P3 (FOXP3), and lymphocyte-activation gene 3 (LAG3).  
We hypothesize that combination sequential radioimmunotherapy increases the pool 
of effector and memory T cells against melanoma tumor-antigens and induces 
molecules such as CTLA-4, PD-1, LAG-3, and TIM-3 on the surface of tumor infiltrating 
lymphocytes. 
Tumor tissue will be processed for DNA/RNA analysis and RNA-seq will be used for 
deep characterization of treatment related responses and identification of signatures 
predicting primary and secondary immunologic responses (UMN Genomics Center). 
2.6.2. Melanoma Specific Cellular Immune Responses 
Correlative studies will help answer several immunologic questions regarding the 
ability of radiation and IL-2 based therapy to prime anti-tumor immunity in refractory 
populations. Studies will assess induction of regulatory T cells and other suppressor 
cells, and the ability of checkpoint inhibition to inhibit these processes.  
Peripheral blood mononuclear cells (PBMC) will be collected and processed for flow 
cytometric analyses and cryostorage for later batch studies. The effect of radiation 
therapy and IL-2 on lymphocyte repertoire, numbers and phenotype will be assessed 
at baseline and at defined time points during the trial. The frequency and percentage 
of PBMC and T-cell subsets (CD4 and CD8 effector memory, central memory and 
Treg subsets), NK cells and myeloid-derived suppressor cells will be determined. 
We 
hypothesize 
that 
T 
cells 
primed 
by 
the 
combination 
sequential 
radioimmunotherapy approach undergo induction of normal homeostatic regulatory 
checkpoints that sensitize a subset of patients to later checkpoint inhibitor based 
therapy with currently approved standard agents.  


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Peripheral blood tumor-specific T cell subsets will be evaluated by flow cytometry in 
cooperation with the Translational Therapy Laboratory, Masonic Cancer Center. 
Cytotoxic T lymphocytes (CD8+ T cells) and CD4+ helper T cells will be isolated using 
fluorescence-activated cell sorting (FACS) from cryopreserved cells followed by 
mRNA expression analysis to assess gene expression changes resulting from 
therapy. Testing will be performed in collaboration with the University of Minnesota 
Flow Cytometry and Genomics Core Laboratories. 
Peripheral blood mononuclear cells (PBMC) may also be tested in functional assays 
(i.e. IFN-γ ELISpot) for responses to known melanoma antigens, viral antigens, and 
predicted neoantigens from whole-exome/transcriptome sequencing of melanoma 
tumors. All patients will also undergo HLA testing to enable epitope discovery using 
available MHC binding prediction algorithms. 
3. STUDY RATIONALE 
There is a growing body of pre-clinical and clinical evidence that points to a synergistic 
relationship between radiation therapy and immunotherapy. Preclinical studies have 
shown that irradiation of tumor cells leads to immunogenic cell death via upregulation of 
major histocompatibility (MHC) molecules, DC cross-presentation of tumor antigens, and 
T-cell priming in draining lymph nodes(20, 21). 
Preclinical studies combining Ipilimumab with radiation demonstrate enhanced abscopal 
responses in several cancer types(29). Similar abscopal effects have been reported in 
multiple instances of patients receiving radiation during concurrent checkpoint inhibition 
with anti-PD1 and anti-CTLA4 antibodies for metastatic disease(17, 30, 41, 42).  
It is known that T cells require distinct sets of signals to proliferate and differentiate into 
effector T cells capable of mounting effective adaptive immune responses(43). The 
classical two-signal model of T cell activation first involves stimulation of a rearranged T 
cell receptor (TCR) with specificity for antigenic peptide within the groove of the MHC 
molecule. This is followed by signal 2, the co-stimulatory interactions of CD28 on the 
surface of naïve T cells with CD80 and CD86 ligands on the surface of antigen presenting 
cells.  
Following the activation of T cells, expression of cytotoxic T-lymphocyte associated protein 
4 (CTLA-4) is induced on the surface of activated T cells to restrain the CD28 activation 
pathway. The CTLA-4 checkpoint molecule is largely restricted to CD4 and CD8 T 
cells(44). However, CTLA-4 is also constitutively expressed in Foxp3+ regulatory (Treg) 
subsets(45), where CTLA-4 competes for CD80 and CD86 ligand interactions to blunt T-
cell activation. It follows that administration of anti-CTLA-4 therapy leads to an increased 
risk of immune related adverse events and autoimmune toxicity. To minimize toxicity from 
anti-CTLA-4 therapy there is interest in reducing Ipilimumab dosing and dosage of 
Ipilimumab. The overarching goal of these strategies is to maintain clinical activity while 
reducing immune related adverse events. 


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This clinical study aims to sequence immunotherapy treatments after radiation therapy to 
coincide with antigen release and uptake and processing by APCs. After completion of 
radiation therapy patients receive high dose Aldesleukin (IL-2) to support in vivo priming 
and expansion of endogenous T cell populations against melanoma antigens. Importantly, 
primary T cell activation is tightly regulated and the sequential signals required to direct 
and amplify T cells must be delivered in-sequence to avoid paralyzing effects on T cell 
dependent immunity seen with out-of sequence delivery(46). 
This combination sequential radioimmunotherapy approach builds on phase 1 study data 
demonstrating safety and preliminary efficacy signals of combination stereotactic ablative 
radiotherapy (SABR) and IL-2 as first-line treatment for metastatic melanoma and renal 
cell carcinoma(47). The current trial adds checkpoint inhibition following aldesleukin to 
maximize induced anti-tumor responses in an immunotherapy refractory patient 
population.  
4. STUDY DESIGN 
This is a Phase 2 study designed to evaluate the combination of checkpoint blockade and 
aldesleukin (IL-2) therapy after a course of standard of care palliative radiation in the 
management of unresectable metastatic melanoma refractory to standard immunotherapy 
drugs, molecular targeted agents and/or chemotherapy. To be eligible, a patient must 
have a minimum of 3 (preferably >5) radiographically distinct, measurable (>1.5 cm) 
lesions based on RECIST 1.1. Ocular melanomas may enroll in this study without prior 
therapy as there is no standard front-line therapy for this subset of patients.  
 
Standard of care palliative radiation therapy is delivered to a maximum of 3 metastatic 
tumors over no more than 3 weeks. A minimum of 2 lesions must remain non-irradiated 
for disease response assessments. Patients who have completed palliative radiation 
therapy within 90 days prior to the 1st dose of aldesleukin also may be considered for the 
study.  
 
Two treatment cohorts (treatment arms in OnCore) will be used based on disease origin:  
Cohort 1: cutaneous melanoma – aldesleukin followed by nivolumab every 2 weeks for 6 
doses. 
Cohort 2: ocular melanoma – aldesleukin followed by nivolumab/ipilimumab given 3 weeks 
for 4 doses. 
 
Each cohort enrolls 22 patients employing a separate Simon’s two stage design and 
separate monitoring for excessive toxicity.  
 
Disease re-assessment includes physical examination, as well as radiographic response 
assessment (RECIST v1.1) of non-irradiated target lesions using CT (or PET/CT) and/or 
MRI at the 6 week (end of Cycle 1) and the end of trial (EOT) visit.  
A final determination of disease progression for the study requires confirmation of 
progression with scans obtained at least 4-6 weeks after the EOT visit, in order to qualify 


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as progressive disease (PD) by RECIST 1.1 due to observed pseudoprogression and late 
responses seen with immunotherapy treatments. Therapy after progression is at the 
discretion of the patient and primary physician. 
Direct study participation ends after the End of Trial (EOT) visit approximately 4 weeks 
after the last dose of study drug; however, nivolumab maintenance therapy may continue 
at the treating physician’s discretion independent of this study. 
 
After the EOT visit, patients are monitored for progression and survival endpoints via 
medical record review or phone/electronic communications every 3 months for two years 
from the start of aldesleukin. 
5. PATIENT SELECTION 
The study is open to persons 18 years through and including 80 years of age regardless 
of gender, race or ethnic background. While there will be every effort to seek out and 
include women and minority patients, the patient population is expected to be no different 
than that of other advanced melanoma studies at the University of Minnesota.  
5.1. Inclusion Criteria 
5.1.1 Biopsy-proven unresectable, metastatic melanoma refractory to standard 
immunotherapy drugs or regimens, including prior treatment with Aldesleukin 
(IL-2), GM-CSF, Ipilimumab, Nivolumab, Pembrolizumab, and/or Imlygic (T-
VEC). 
Prior clinical trial participation or treatment with molecularly targeted agents 
(i.e. Vemurafenib/Cobimetinib, Dabrafenib/Trametinib) or chemotherapy (i.e. 
Temozolomide, Dacarbazine, Platinum, or Taxanes) is permitted. 
Patients with ocular melanoma may enroll (Cohort 2) without prior therapy as 
there is no standard 1st line therapy for this subset of melanoma. 
5.1.2 Must have a minimum of 3 radiographically distinct (>1.5 cm) lesions 
measurable by RECIST 1.1 at time of study enrollment (>5 preferred). 
 A maximum of 2 metastases per treated organ may be targeted for palliative 
radiation, but must be separated by more than 5 cm of normal tissue 
 At least 2 non-irradiated lesions are required for systemic response 
assessments 
5.1.3 Pulmonary metastases: Pulmonary metastasis permissible. Appropriate 
candidates with lung lesions may be considered for ablative hypofractionation 
using stereotactic body radiation therapy (SBRT). 
5.1.4 Hepatic metastases: Hepatic metastasis permissible. Appropriate candidates 
with metastasis to liver may be considered for ablative hypofractionation using 
stereotactic body radiation therapy (SBRT).  


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5.1.5 Brain metastases: Brain metastases may be treated using Gamma Knife 
Radiosurgery (GKR) or whole brain radiation therapy (WBRT) per the treating 
radiation oncologist. Total radiation dose and number of fractions will be 
determined by the treating radiation oncologist based on anatomic and dosing 
constraints. MRI of the vertebral column is required for all patients with 
suspected epidural tumor extension. 
5.1.6 Must have sufficient archival tissue block material (1.5 x 1.5 x 1.5 cm) and/or 
newly obtained core or excisional biopsy of tumor tissue; minimum of 2 cores. 
5.1.7 ECOG performance status 0 or 1 (Appendix 1) 
5.1.8 Age 18 through 80 years of age; > 80 years of age must be approved by the 
Principal Investigator. 
5.1.9 Adequate organ function within 14 days of enrollment (30 days for pulmonary 
and cardiac assessments) defined as: 
Hematologic: leukocytes ≥ 2,000/mcL, ANC ≥ 1,000/mcL, hemoglobin ≥ 9.0 
g/dL, platelets ≥ 100,000/mcL unsupported by transfusions 
Renal: Serum creatinine ≤ 1.8 mg/dL; for patients with a creatinine > 1.5 mg/dL 
or a history of renal dysfunction, an estimated glomerular filtration rate ≥ 35 
mL/min/1.73 m2 is required  
Hepatic: AST, ALT, and alkaline phosphatase ≤ 3 x upper limit of normal (≤ 5 
x ULN if known or suspected liver mets) and total bilirubin ≤ 2.0 mg/dL  
Pulmonary: oxygen saturation ≥90% on room air; corrected DLCO and FEV1, 
≥ 60% predicted 
Cardiac: Absence of clinical decompensated congestive heart failure or 
uncontrolled arrhythmia; left ventricular ejection fraction (echocardiogram 
within 6 months permitted) ≥ 40%. QTc must be < 450 ms in males and < 470 
ms in females. 
5.1.10 A minimum of 1 week between last anti-tumor treatment if given, and 1st dose 
of radiation therapy (not applicable for patients enrolling after palliative 
radiation therapy). 
5.1.11 Recovery from previous cancer treatment if applicable defined as ≤ Grade 1 
(by CTCAE 5.0 criteria) at enrollment 
5.1.12 Women of childbearing potential and males with partners of childbearing 
potential must agree to the use of barrier methods of contraception, hormonal 
contraceptives, or abstain from heterosexual activity for the duration of study 
treatment and for 3 months after the last dose of study drug. 
5.1.13 Ability to understand and provide voluntary written consent 


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5.2. Exclusion Criteria 
5.2.1 Pregnant or breast feeding. The agents used in this study have the potential to 
harm a fetus. Radiation is a known teratogen. There is insufficient information 
regarding potential for fetal harm during immunotherapy at this time. Biological 
females of childbearing potential must have a negative pregnancy test within 
14 days of enrollment. 
5.2.2 Concurrent use of high dose steroids; chronic steroid use of < 2 mg 
dexamethasone or equivalent per day is permissible 
5.2.3 Concurrent malignancy requiring active treatment, except basal cell carcinoma 
of the skin, squamous cell carcinoma of the skin or carcinoma in situ 
5.2.4 Severe 
and 
active 
autoimmune 
diseases 
requiring 
systemic 
immunosuppression  
5.2.5 Prior organ allograft or allogeneic transplantation 
5.2.6 Other contraindication to IL-2, nivolumab, ipilimumab, or combination 
immunotherapy per treating medical oncologist 
5.2.7 Live vaccines within 30 days prior to the first dose of IL-2 and while participating 
in the trial. Examples of live vaccines include, but are not limited to, measles, 
mumps, rubella, chicken pox, yellow fever, rabies, BCG, and typhoid (oral) 
vaccine. Seasonal influenza vaccines for injection are generally inactivated 
virus vaccines and are allowed. Intranasal influenza vaccine (eg, Flu - Mist®) 
is a live attenuated vaccine, and is not allowed. 
6. PATIENT SCREENING AND STUDY ENROLLMENT 
Written consent must be obtained prior to the performance of any research related tests 
or procedures. Consent is obtained before eligibility is confirmed. 
6.1. Enrollment with the University of Minnesota Clinical Trials Office 
Any patient who has been consented is to be entered in OnCore by the site Study 
Coordinator or designee. If a patient is consented but is not enrolled, the patient’s 
record is updated in OnCore as a screen failure and reason for exclusion recorded. 
6.2. Patient Enrollment in OnCore 
To be eligible for study enrollment, the patient must sign the treatment consent and 
meet each inclusion criteria and none of the exclusion criteria on the eligibility checklist 
based on an eligibility assessment documented in the patient’s medical record. 
The Study Coordinator or designee assigns the study treatment arm (Cohort 1 – 
cutaneous melanoma or Cohort 2 – ocular melanoma). 
 
 


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6.3. Patients Who Do Not Begin Study Treatment 
If a patient is registered to the study and is later found unable to begin study treatment 
(1st dose of IL-2) the patient will be removed from study and treated at the physician’s 
discretion. The study staff will update OnCore of the patient’s non-treatment status (off 
study). The reason for removal from study prior to starting study treatment will be 
clearly indicated in OnCore. The patient will be replaced to complete enrollment. 
7. TREATMENT PLAN 
7.1. Palliative Radiation Therapy 
When palliative radiation has been received off-study or delivered outside of the 
University of Minnesota, patients may go on to receive IL-2 and checkpoint inhibitor 
on study as described in Section 7.2 and Section 7.3 provided the 1st dose of 
aldesleukin is given within 90 days of the last dose of RT. If additional palliative 
radiation is clinically warranted, the patient would be treated as described below. 
A maximum of 3 metastatic tumors will be targeted for palliative radiation; up to 2 
metastases per treated organ may be targeted for hypofractionated palliative radiation 
but must be separated by more than 5 cm of normal tissue. Appropriate candidates 
with lung and liver metastases may be considered for ablative hypofractionation. For 
liver directed therapy, patients will have an MRI of the liver for radiation treatment 
planning. Patient must have at least one non-irradiated hepatic metastasis amenable 
to percutaneous biopsy. Treatment for hepatic metastasis must also spare a critical 
hepatic volume (volume receiving <21 Gy) of 700 ml. Appropriate candidates with liver 
metastases may be considered for Y-90 radioembolization. 
Brain metastases may be treated with surgery followed by Gamma Knife (GK) to the 
resection cavity or alternatively as part of definitive brain directed therapy.  Whole brain 
radiation therapy (WBRT) may also be used at the discretion of the treating radiation-
oncologist.  
For sites not amenable to ablative radiotherapy, fractions will be delivered at a 
minimum of 3 Gy per fraction.  
 
At least 2 non-irradiated lesions >1.5 cm are required for systemic response 
assessments. The total radiation dose and number of fractions will be determined by 
the treating radiation oncologist based on anatomic and dosing constraints; however 
when palliative radiation therapy is received on study it must not exceed 3 weeks and 
treatment must be administered in such a way that that patient can be admitted to the 
hospital within 5 days of the last radiation fraction to start high-dose IL-2.  
7.2. Aldesleukin (IL-2) – All Participants 
After palliative radiation is complete, patients are admitted to the hospital to begin 
Aldesleukin (IL-2) therapy. Treatment is administered as an inpatient according to the 
University of Minnesota guidelines for Aldesleukin administration.  


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Aldesleukin (IL-2) at 600,000 U/kg will be administered as an intravenous infusion via 
a central catheter (either PICC line or port) over 15 minutes approximately once every 
8 to 12 hours, per institutional guidelines and standard clinical practice. Patients may 
receive a maximum of 10 doses, no longer than 24-hours apart, on Days 1 through 5 
and Days 15 through 19.  
The dosing calculations should be based on the body weight. If the subject’s weight 
on the day of dosing differs by > 10% from the weight used to calculate the dose, the 
dose must be recalculated. All doses should be rounded to the nearest milligram. 
As it recognized that most patients experience severe toxicity with IL-2 and often are 
not able to complete all planned doses, the number of doses an individual patient 
receives will be based on personal experience and the treating physician’s clinical 
judgement. Even if a patient is unable to receive IL-2 as planned, the study calendar 
for disease reassessment and research sample collections should be followed.  
Patients will have routine vital signs and laboratory tests measured daily during 
aldesleukin therapy. IL-2 is associated with a decrease in systemic vascular resistance 
and low blood pressure from development of capillary leak syndrome (CLS). Increased 
permeability of blood vessels results in extravasation of plasma proteins and fluid into 
extravascular compartments and spaces, necessitating maintenance IV fluid hydration 
and aggressive fluid boluses to support blood pressure and maintain normal organ 
perfusion. 
Standard institutional practices govern IL-2 administration. Briefly, bolus infusions 
continue until the development of CTCAE v5 Grade 3 or 4 expected toxicities based 
on patient tolerance. The most common Grade 4 events are pulmonary and renal 
impairment, and mental status changes. The anticipated toxicities require supportive 
measures during treatment, but toxicities are generally acute and reversible and the 
majority of patients have no long-term sequelae from intensive IL-2 treatment. 
Development of side effects from IL-2 is anticipated and therefore will not be 
considered serious adverse event for safety analyses. However, abnormal lab values 
must plateau and begin trending toward baseline prior to hospital discharge following 
IL-2 treatments.  
Since IL-2 treatment can cause a transient decrease in neutrophil chemotaxis 
antibiotic prophylaxis is given (i.e. penicillin or cephalosporin) to minimize the 
incidence and risk of serious bacterial infections. 
7.3. Nivolumab Monotherapy (Cohort 1 - Cutaneous) 
Nivolumab 240 mg IV is administered over 30 minutes every 2 weeks as maintenance 
therapy.  
For any individual dose a ±3 day window is permitted without affecting (no adjustment 
to) future doses. This window is primarily for scheduling issues (i.e. holidays, inclement 
weather, etc).  


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Longer delays are permitted, if in the opinion of the treating investigator, a delay in 
therapy is in the best interest for the patient and their ability to complete the planned 
treatment. In the instance of longer delays (i.e. 1 week or longer), the reminder of the 
treatment schedule will be shifted to keep proper spacing between the remaining 
doses. Section 8.3 provides guidance on delays for significant immune related toxicity; 
however, delays may be for other reasons. 
The 1st dose is given Day 29 of Cycle 1 and continues in Cycle 2 on Days 1, 15, and 
29 of a 6 week cycle. 
Cycle 3 nivolumab is given on Day 1 and Day 15 of a standard 4 week cycle.  
Cycle 3 is the end of the planned study treatment; however patients may continue 
maintenance nivolumab 240 mg IV every 2 weeks OR nivolumab 480 mg IV every 4 
weeks per 2018 FDA approval at discretion of the treating physician and independent 
of this study. 
Nivolumab is administered in the outpatient setting; however, inpatient administration 
is permitted as medically appropriate if a patient is hospitalized. No premedication is 
required. Monitoring will be according to institutional guidelines with interruption or 
slowing of rate of infusion with Grade 1 to 2 infusional toxicities and discontinuation of 
nivolumab with Grade 3 to 4 infusional toxicities.  
 
The dose is calculated on a pre-treatment (baseline) weight within 7 days of treatment 
start. The dose must be re-calculated in a new treatment cycle if a greater than 10% 
weight change occurs from baseline. 
 
No dose modifications are permitted for nivolumab but dose may be withheld based 
on occurrence of significant immune-related AE Grade 2 or higher based on NCI 
Common Terminology Criteria for Adverse Events (CTCAE) v5.0, as described in 
Section 8.3. 
7.4. Nivolumab and Ipilimumab (Cohort 2- Ocular) 
Nivolumab and Ipilimumab is administered sequentially as an intravenous infusion of 
nivolumab (3 mg/kg) over 30 minutes followed by an intravenous infusion of ipilimumab 
(1 mg/kg) over 90 minutes.  
Alternatively, at the discretion of the treating investigator, a high risk patient with an 
excellent performance status may receive nivolumab (1 mg/kg) over 30 minutes 
followed by an intravenous infusion of ipilimumab (3 mg/kg) over 90 minutes.   
Nivolumab and ipilimumab is given for 4 doses every 3 weeks (on Day 29 of Cycle 1, 
Day 8 and 29 of Cycle 2, and Day 8 of Cycle 3).  
For any individual dose a ±3 day window is permitted without affecting (no adjustment 
to) future doses. This window is primarily for scheduling issues (i.e. holidays, inclement 
weather, etc).  


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Longer delays are permitted, if in the opinion of the treating investigator, a delay in 
therapy is in the best interest for the patient and their ability to complete the planned 
treatment. In the instance of longer delays (i.e. 1 week or longer), the reminder of the 
treatment schedule will be shifted to keep proper spacing between the remaining 
doses. Section 8.3 provides guidance on delays for significant immune related toxicity; 
however, delays may be for other reasons. 
On Day 1 of Cycle 4 the patient may begin nivolumab maintenance as a single agent 
per Section 7.3. 
Diphenhydramine and/or acetaminophen may be administered as prophylactic pre-
medications. 
Nivolumab and Ipilimumab is administered in the outpatient setting; however, inpatient 
administration is permitted as medically appropriate if a patient is hospitalized. No 
premedication is required. Monitoring will be according to institutional guidelines with 
interruption or slowing of rate of infusion with grade 1 to 2 infusional toxicities and 
discontinuation of nivolumab and ipilimumab with grade 3 to 4 infusional toxicities.  
 
The dose is calculated on a pre-treatment (baseline) weight within 7 days of treatment 
start. The dose must be re-calculated in a new treatment cycle if a greater than 10% 
weight change occurs from baseline. 
 
No dose modifications are permitted for nivolumab and ipilimumab but doses may be 
withheld based on occurrence of significant immune-related AE Grade 2 or higher 
based on NCI Common Terminology Criteria for Adverse Events (CTCAE) v5.0, as 
described in Section 8.3. 
7.5. Supportive Care 
In order to provide optimal patient care and to account for individual medical 
conditions, investigator discretion may be used in the prescribing of all supportive care 
drug therapy (i.e. acetaminophen, diphenhydramine, etc.), and will not be considered 
a protocol deviation. 
7.6. Duration of Study Treatment 
Treatment is given over approximately 16 weeks. Treatment continues in the absence 
of 
documented 
progression, 
unacceptable 
side 
effects 
or 
patient 
refusal/noncompliance. A final determination of disease progression for the study 
requires confirmation of progression with radiographic scans obtained at least 4-6 
weeks after the EOT visit, in order to qualify as progressive disease (PD) by RECIST 
1.1 due to observed pseudoprogression and late responses seen with immunotherapy 
treatments. 
Palliative radiation is administered to most patients over a 3 week period just prior to 
starting aldesleukin infusions, although patients may be considered for the study if 
they have completed palliative radiation within 90 days of the 1st dose of aldesleukin. 


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Patients may continue maintenance nivolumab 240 mg IV every 2 weeks OR 
nivolumab 480 mg IV every 4 weeks per 2018 FDA approval at discretion of the 
treating physician and independent of this study. 
7.7. Duration of Study Participation 
Direct study participation ends after the End of Trial (EOT) visit approximately 4 weeks 
after last dose of study directed treatment. If in the opinion of the investigator there is 
ongoing toxicity at least possibly related to the study treatment, the patient will be 
followed as medically appropriate until resolution or stabilization of the toxicity. 
Follow-up for disease status and survival will continue for up to 2 years from study 
enrollment by electronic/phone contact every 3 months (± 2 weeks) unless the patient 
withdraws consent. 
8. EXPECTED SIDE EFFECTS AND MANAGEMENT OF SELECTED 
TOXICITIES 
8.1. Palliative Radiation Therapy 
Adverse events related to radiation therapy for the treatment of metastases are 
dependent on the location of the metastases treated as well as from exposure of 
surrounding normal tissues. For all treated metastases, fatigue is likely to occur and 
should be transient lasting < 8 weeks. Other adverse events are likely to be related to 
the specific metastatic location receiving radiation therapy. All radiation therapy 
associated adverse events should be graded according to the Common Terminology 
Criteria for Adverse Events (CTCAE), v. 5.  
8.1.1. Lung (Central and Peripheral), Mediastinal/Cervical Lymph Node 
Metastases  
 Cardiac and Pericardial Injury: uncommon in conventionally fractionated 
course of radiation therapy, but with large doses per fraction of SBRT 
myocarditis, pericarditis and other side-effects can be seen. 
 Gastrointestinal/Esophageal Injury: The radiation effects on the esophagus 
can be acute: esophagitis (i.e. dysphagia) typically improves soon after RT 
course is completed, or chronic: esophageal stenosis, ulceration, or 
perforation (rarely in extreme cases). 
 Central Airway/Bronchial Injury: Bronchial injury may cause subsequent 
focal 
collapse 
of 
lung 
impairing 
overall 
pulmonary 
status. 
Collapsed/atelectatic lung may make further assessment of tumor 
response more difficult. Bronchial toxicity may lead to cough, dyspnea, 
hypoxia, impairment in pulmonary function test parameters, pleural 
effusion, or pleuritic pain.   
 Lung Injury: Radiation pneumonitis is a subacute (weeks to months from 
treatment) inflammation of the end bronchioles and alveoli. Radiation 
fibrosis is a late manifestation of radiation injury to the irradiated lung. 
Infiltrates on chest x-ray characteristically include the area treated to high 


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dose, but may extend outside of the region and appear “geometric” in 
appearance, corresponding to the radiation portal. 
o Mild radiation pneumonitis may be treated with nonsteroidal anti-
inflammatory agents or steroid inhalers. 
o Moderate to severe radiation pneumonitis will be treated with 
systemic steroids, bronchodilators, and pulmonary hygiene. 
8.1.2. Liver and Abdominal-Pelvic Metastases  
 
Radiation-induced liver disease (RILD): Not likely (<5%), but serious. 
Classic RILD is a clinical diagnosis of anicteric ascites, hepatomegaly and 
elevation of alkaline phosphatase relative to other transaminases that may 
occur 2 weeks to 3 months following radiation to the Liver; non-classic RILD 
includes elevation of liver enzymes and/or any decline in liver function 
within 12 weeks from start of therapy. There is increased risk of liver toxicity 
in patients with large tumors and in patients with pre-existing liver disease. 
 
Permanent thrombocytopenia (<1%), which may lead to bleeding 
 
Kidney injury (<1%), which may lead to changes on imaging studies. 
8.1.3. Spinal Metastases  
 
Radiation myelitis: Given proximity and position of spinal cord in relation to 
the radiosurgery target, every effort should be made to minimize radiation 
dose to the spinal cord. Radiation myelitis is a subacute or chronic clinical 
syndrome after radiation. Symptoms may include paresthesia, sensory 
changes, and motor weakness including paralysis. There is no active 
treatment for radiation myelitis, therefore it is important to prevent any injury 
to the spinal cord. 
 
Radiation esophagitis: Thoracic spine treatment will likely lead to 
esophageal mucositis within the first 2 weeks. Symptoms generally subside 
with time. Hydration is important given that dehydration may result due to 
consequences of esophageal toxicity i.e. dysphagia, cough, swallowing 
difficulty. Dysphonia and fistula are rare. 
 
Radiation Laryngitis or pharyngitis: Cervical spine treatment will likely lead 
to laryngopharyngeal mucositis within the first 2 weeks. Symptoms 
generally subside with time. Hydration is important given that dehydration 
may result due to consequences of radiation toxicity i.e. dysphagia, cough, 
swallowing difficulty. Dysphonia and fistula are rare. 
 
Compression Fracture of treated Vertebra: Radiation doses in excess of 19 
Gy for a single fraction have been associated with higher rates of vertebral 
body compression (Saghal 2013) and will be avoided. 
8.1.4. Osseous metastases  
 
Erythema, desquamation and alopecia are common side effects from 
radiation therapy for osseous metastases; other effects based on location 
of metastasis and may include pain, edema, and neuralgia. 


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8.2. Aldesleukin (IL-2) 
The development of anticipated side effects from IL-2 is physiologic and therefore side 
effects are not considered serious adverse events for safety analyses. However, 
abnormal lab values must plateau and begin trending toward baseline prior to Hospital 
discharge following IL-2 treatments.  
Aldesleukin (IL-2) Expected Risks 
Most common 
Common 
Less Common 
● diarrhea 
● fever and chills 
● flu-like symptoms 
● capillary leak syndrome 
(hypotension and 
tachycardia from 
decreased intravascular 
volume) 
● heartburn 
● indigestion 
● itching skin 
● nausea 
● rash 
● severe stomach pain, 
cramping, or burning 
● unusual tiredness or 
weakness 
● vomiting 
● dizziness 
● double vision 
● drooping eyelids 
● drowsiness 
● swelling of the face, feet, or 
lower leg 
● unusual weight gain 
● abdominal or stomach tenderness 
● anxiety 
● blistering, crusting, irritation, 
itching, or reddening of the skin 
● blurred vision  
● burning or itching eyes 
● burning, tingling, numbness or 
pain in the hands, arms, feet, or 
legs 
● chest pain 
● clay-colored stools 
● cough 
● cracked or scaly skin 
● dark urine 
● decreased appetite 
● decreased frequency or amount of 
urine 
● eye discharge or excessive 
tearing 
● eye pain or sensitivity to light 
● fainting 
● headache 
● hives or welts 
● loss of appetite 
● mental depression 
● muscle pain or stiffness 
● muscle weakness 
● painful or difficult urination 
● redness, pain, or swelling of the 
eye, eyelid, or inner lining of the 
eyelid 
● sensation of pins and needles 
● severe tiredness 
● shortness of breath 
● sore throat 
● sores, ulcers, or white spots on 
the lips or in the mouth 
● stabbing pain 
● swollen glands 
● trouble breathing 
●  bloody or cloudy urine 
● bloody, black or tarry stools 
● bloating 
● blue or pale skin 
● chest pain, possibly moving to the 
left arm, neck, or shoulder 
● confusion 
● constipation 
● difficulty with moving 
● fast heartbeat 
● general feeling of discomfort or 
illness 
● increased blood pressure 
● increased thirst 
● lower back or side pain 
● pain or burning in the throat 
● pain, swelling, or redness in the 
joints 
● pains in the stomach or side, 
possibly radiating to the back 
● sores, welting, or blisters on the 
skin 
● stiff neck or back 
● unusual bleeding or bruising 
● yellow eyes or skin 
● vomiting of material that looks like 
coffee grounds, severe and 
continuing 
● difficulty breathing, chewing, 
swallowing, or talking 
 
Treatment Guidelines for High-Dose Aldesleukin (IL-2) Toxicity Management 
● Acetaminophen, naproxen (as needed), and H2 blocker therapy will be used to manage 
anticipated side effects of high-dose IL-2 therapy, and will generally be continued for 8-
12 hours after last dose of IL-2 to avoid development of high fever. 
● Meperidine (25-50 mg) may be given intravenously if severe chills develop. 


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● Additional antiemetic therapy will be administered for breakthrough nausea and/or 
vomiting. 
● Supportive care measures are outlined in Appendix 2, as indicated for expected 
toxicities from high-dose IL-2. 
8.3. Ipilimumab and Nivolumab Related Toxicity Management 
Immune-related adverse events (irAEs) from ipilimumab and nivolumab will be managed 
depending on severity (NCI CTCAE V5.0 grading) as outlined below.  
 
Immune-Related (ir) Adverse Events Management – General Guidelines  
 
Grade 1 to 2: Treat symptomatically or hold checkpoint inhibitors. Consideration of 
moderate dose steroids (0.5 mg/kg), and more frequent monitoring. 
 
Grade 1 to 2 (persistent):  Manage similar to Grade 3 to 4 irAE 
 
Grade 3 to 4: Treat with high dose corticosteroids, typically 1-2 mg/kg of prednisone or IV 
steroid equivalent and 
 
Grade 4 irAEs permanently discontinue treatment with nivolumab or nivolumab and 
ipilimumab 
 
Grade 3 irAEs requires withholding nivolumab or nivolumab and ipilimumab except 
for any of the following: Transient (≤ 6 hours) Grade 3 flu-like symptoms or fever, which 
is controlled with medical management, transient (≤ 24 hours) Grade 3 fatigue, local 
reactions, headache, nausea, emesis that resolves to Grade ≤ 1 and single laboratory 
values out of normal range (excluding Grade ≥ 3 liver function test increase) that are 
unlikely related to study treatment according to the Investigator, do not have any clinical 
correlate, and resolve to Grade ≤ 1 within 7 days with adequate medical management 
 
Any Grade 2 irAEs should be managed as follows: 
If a Grade 2 irAE resolves to Grade ≤ 1 by the next planned cycle, treatment may continue. 
 
If a Grade 2 irAE does not resolve to Grade ≤ 1 by the next planned cycle, treatment 
should be withheld at next cycle. If at the end of the following cycle the event has not 
resolved to ≤ Grade 1, the subject should be treated with high-dose steroids or discontinue 
treatment with nivolumab or nivolumab and ipilimumab (except for hormone 
insufficiencies, which can be managed by replacement therapy).  
 
Upon the recurrence of the same Grade 2 irAE (except for hormone insufficiencies that 
can be managed by replacement therapy) in the same subject, treatment with nivolumab 
or nivolumab and ipilimumab should be permanently discontinued.  
 
Treatment of gastrointestinal, dermatological, pulmonary, hepatic and endocrine irAEs 
should follow guidelines in the following table. 


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GI irAEs 
Severity of Diarrhea/Colitis 
Management 
Follow-up 
Grade 1 
Diarrhea: < 4 stools/day 
over baseline 
Colitis: asymptomatic  
Continue checkpoint inhibitor therapy. 
Symptomatic treatment (for example, 
loperamide) 
Close monitoring for worsening symptoms 
Educate subject to report worsening 
immediately 
If worsens: 
Treat as Grade 2 or 3 to 4  
Grade 2 
Diarrhea:  4 to 6 stools per 
day over baseline; IV fluids 
indicated < 24 hours; not 
interfering with ADL 
Colitis:  abdominal pain; 
blood in stool  
Withhold checkpoint inhibitor therapy 
for the current cycle  
Symptomatic treatment 
If improves to Grade ≤1:  
Resume checkpoint inhibitor  
 
If worsens: treat as Grade 3 to 4 
Grade 3 to 4 
Diarrhea (Grade 3): ≥ 7 
stools per day over 
Baseline; incontinence; IV 
fluids ≥ 24 hrs.; interfering 
with ADL 
Colitis (Grade 3):  severe 
abdominal pain, medical 
intervention indicated, 
peritoneal signs 
Grade 4:  life-threatening, 
perforation 
Grade 3: Withhold checkpoint inhibitor 
for the current cycle 
Grade 4 or recurrent Grade 3: 
permanently discontinue checkpoint 
inhibitor  
 
Begin methylprednisolone 1.0 to 2.0 
mg/kg/day IV or equivalent 
 
Add prophylactic antibiotics for 
opportunistic infections  
 
Consider colonoscopy if needed  
If improves, continue steroids until Grade < 
1, then taper over at least 1 month,  
Resume checkpoint inhibitor on Day 1 of the 
next cycle  
 
If worsens, persists > 3 to 5 days, or recurs 
after improvement, add infliximab 5 mg/kg (if 
no contraindication), Note: Infliximab should 
not be used in cases of perforation or sepsis  
Dermatological irAEs 
Grade of Rash 
Management 
Follow-up 
Grade 1 to 2 
Covering  for Grade 3 30% 
body surface area 
Symptomatic therapy (for example, 
antihistamines, topical steroids) 
Continue checkpoint inhibitor 
If persists > 1 to 2 weeks or recurs: 
Consider skin biopsy 
 
Consider methylprednisolone 0.5 to 1.0 
mg/kg/day IV or oral equivalent. Once 
improving, taper steroids over at least 1 
month, consider prophylactic antibiotics for 
opportunistic infections. If worsens. treat as 
Grade 3 or 4 
Grade 3 to 4 
Covering > 30%  
Grade 4: body surface area; 
life threatening 
consequences  
Grade 3: Skip checkpoint inhibitor for 
the current cycle 
Grade 4 or recurrent Grade 3: 
Permanently discontinue checkpoint 
inhibitor 
Consider skin biopsy  
Dermatology consult  
methylprednisolone 1.0 to 2.0 
mg/kg/day IV or IV equivalent  
If improves to ≤ Grade 1, taper steroids over 
at least 1 month and add prophylactic 
antibiotics for opportunistic infections 
Resume checkpoint inhibitor therapy Day 1 
of next cycle for Grade 3 


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Pulmonary irAEs 
Grade of Pneumonitis 
Management 
Follow-up 
Grade 1 
Radiographic changes only  
Permanently discontinue checkpoint 
inhibitor 
Monitor for symptoms every 2 to 3 days  
Consider pulmonary and Infectious 
disease consults 
If worsens, treat as Grade 2 or 3 to 4  
Grade 2 
Mild to moderate new 
symptoms  
Permanently discontinue checkpoint 
inhibitor 
Pulmonary and Infectious Disease 
consults 
Monitor symptoms daily, consider 
hospitalization  
methyl-prednisolone 1.0 mg/kg/day IV 
or oral equivalent  
Consider bronchoscopy, lung biopsy  
When symptoms improve to Grade ≤1, taper 
steroids over at least 1 month   
 
If not improving after 2 weeks or worsening, 
treat as Grade 3 to 4  
Grade 3 to 4 
Severe new symptoms; New 
/ worsening hypoxia; life-
threatening  
Permanently discontinue checkpoint 
inhibitor  
Hospitalize  
Pulmonary and Infectious Disease 
consults 
methyl-prednisolone 2 to 4 mg/kg/day 
IV or IV equivalent  
Add prophylactic antibiotics for 
opportunistic infections  
Consider bronchoscopy, lung biopsy  
When symptoms improve to Grade ≤ 1, taper 
steroids over at least 1 month  
 
If not improving after 48 hours or worsening:, 
add additional immunosuppression (for 
example, infliximab, cyclophosphamide, IV 
immunoglobulin, or mycophenolate mofetil)  
Hepatic irAEs 
Grade of Liver Test 
Elevation 
Management 
Follow-up 
Grade 1 
Grade 1 AST or ALT > ULN 
to 3.0 x ULN and/or total 
bilirubin > ULN to 1.5 x ULN  
Continue checkpoint inhibitor 
Continue liver function monitoring  
If worsens, treat as Grade 2 or 3 to 4  
Grade 2 
AST or ALT > 3.0 to ≤ 5 x 
ULN and / or total bilirubin > 
1.5 to ≤ 3 x ULN  
Skip checkpoint inhibitor for the current 
cycle 
Increase frequency of monitoring to 
every 3 days  
If returns Grade ≤ 1, resume routine 
monitoring, resume checkpoint inhibitor on 
Day 1 of the next cycle 
If elevations persist > 7 days or worsens, 
methylprednisolone 0.5 to 1 mg/kg/day or oral 
equivalent and when LFT returns to Grade ≤ 1
taper steroids over at least 1 month, resume  
checkpoint inhibitor on Day 1 of next cycle 
Grade 3 to 4  
AST or ALT > 5 x ULN and / 
or total bilirubin > 3 x ULN  
Permanently discontinue checkpoint 
inhibitor 
Increase frequency of monitoring to 
every 1 to 2 days  
methylprednisolone 1.0 to 2.0 
mg/kg/day IV or IV equivalent 
Consult gastroenterologist 
Consider obtaining MRI/CT scan of 
liver and liver biopsy if clinically 
warranted  
If returns to Grade ≤1, taper steroids over at 
least 1 month  
If does not improve in > 5 days, worsens or 
rebounds, add mycophenolate mofetil 1 
gram (g) twice daily  
If no response within an additional 3 to 5 
days, consider other immunosuppressants 
per local guidelines  


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Cardiac irAEs 
Myocarditis 
Management 
Follow-up 
New onset cardiac 
signs/symptoms and/or new 
laboratory cardiac biomarker 
elevations (e.g. troponin, 
CK-MB, BNP) or cardiac 
imaging suggestive of 
myocarditis  
Skip checkpoint inhibitor for the current 
cycle 
Hospitalize. 
Cardiology consult to establish etiology 
and rule-out immune-mediated 
myocarditis, consider myocardial 
biopsy 
 
If symptoms improve and immune-mediated 
etiology is ruled out, resume checkpoint 
inhibitor Day 1 of next cycle.  
 
If symptoms do not improve or worsen, and 
immune-mediated etiology is suspected or 
confirmed manage as immune-mediated 
myocarditis. 
Immune-mediated 
myocarditis 
Permanently discontinue checkpoint 
inhibitor 
Methylprednisolone 1 to 2 mg/kg/day. 
 
Once improving, taper steroids over at least 
1 month  
If no improvement or worsening, consider 
additional immunosuppressants (e.g. 
azathioprine, cyclosporine A) 
Endocrine irAEs 
Endocrine Disorder 
Management 
Follow-up 
Asymptomatic TSH 
abnormality  
Continue checkpoint inhibitor 
If TSH < 0.5 x LLN, or TSH > 2 x ULN, or consistently out of range in 2 subsequent 
measurements: include T4 at subsequent cycles as clinically indicated; consider 
endocrinology consult  
Hypophysitis 
Grade 2 or 3 
Evaluate endocrine function  
Consider pituitary scan  
Withhold checkpoint inhibitor 
1 mg/day prednisone  equivalents  
Initiate appropriate hormone therapy as 
indicated 
Consider Endocrinology consult   
If improves (with or without hormone 
replacement):  
Taper steroids over at least 1 month  
Resume checkpoint inhibitor on Day 1 of 
next cycle 
 
Grade 4 
Permanently discontinue checkpoint 
inhibitor 
 
Adrenal Insufficiency 
Grade 2 
 
Withhold checkpoint inhibitor 
Evaluate endocrine function 
Consider Endocrinology consult 
If improves to Grade ≤1, 
Resume checkpoint inhibitor Day 1 of next 
cycle 
 
Grade 3 or 4  
Permanently discontinue checkpoint 
inhibitor 
Consider Endocrinology consult 
prednisone 1 to 2 mg/kg/day or 
equivalents    
 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
9. SCHEDULE OF PATIENT ACTIVITIES 
Scheduled evaluations/drug dosing during treatment may be performed ±3 days from the 
targeted date. In addition, targeted days may be altered as clinically appropriate. Follow-up is 
by record review, phone/electronic communication every 3 months (±2 weeks). 
For any individual dose a ±3 day window is permitted without affecting (no adjustment to) 
future doses. This window is primarily for scheduling issues (i.e. holidays, inclement weather, 
etc).  
Longer delays are permitted, if in the opinion of the treating investigator, a delay in therapy is 
in the best interest for the patient and their ability to complete the planned treatment. In the 
instance of longer delays (i.e. 1 week or longer), the reminder of the treatment schedule be 
shifted to keep proper spacing between the remaining doses. 
Section 8.3 provides guidance on delays for significant immune related toxicity; however, 
delays may be for other reasons. 
 
Note:  Although the treatment days for Cohort 1 and 2 differ, the clinic visit schedule is the 
same.


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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9.1. Required Clinical Care 
 
Baseline 
RT (if 
given) 
Cycle 1 (6 week duration) 
Cycle 2 (6 week duration) 
Cycle  3  
(4 week duration) 
End of 
Trial (EOT) 
visit2 
Optional 
nivolumab 
maintenance3 
Every 3 months until 2 
years from 1st dose of 
IL-2 
Day 1 
Day 
8 
Day 15 
Day 
22 
Day 
29 
Day 
36 
Day 
1 
Day 
8  
Day 
15 
Day 
29 
Day 
1 
Day 
8  
Day 
15 
 
 
 
Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening Assessment 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History including other 
malignancies, concomitant medications 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RAD-ONC/IR Consult 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam 
X 
 
Daily 
during IL-2 
X 
Daily 
during IL-2 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Vital Signs, O2 sats 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Fluid I/O (inpt only) 
 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight 
X 
 
X 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
 
 
Height 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Documentation of lesions and ID of non-
irradiated lesions for disease response 
X 
 
X 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
Archived Tumor Tissue  
X2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Performance Status 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Toxicity Assessment/Stopping Rule Event
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
CBC with Diff, Plt 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Basic metabolic panel (BMP) – unless 
CMP done 
 
 
Daily 
during IL-2 
 
Daily 
during IL-2 
 
 
 
 
 
 
 
 
 
 
 
 
 
Comprehensive metabolic panel (CMP) 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
ACTH and TSH w/ reflex free T4 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
eGFR 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LDH 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
Pregancy test (serum or urine) per 
Section 5.2.1  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease Staging/Status 
X 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
X 
Tumor Biopsy 
X2 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
PFTs 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EKG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Echocardiogram  
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disease and Survival Status 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
Study Treatment  
Aldesleukin (IL-2) - both Cohorts 
 
 
Day 1-5 
 
Day 15-19 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nivolumab (Cohort 1) 
 
 
 
 
 
 
X 
 
X 
 
X 
X 
X 
 
X 
 
 
 
Nivolumab/Ipilimumab (Cohort 2 only) 
 
 
 
 
 
 
X 
 
 
X 
 
X 
 
X 
 
 
 
 
Nivolumab maintenance – both Cohorts 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
1. Within 30 days of study enrollment except for labs required for eligibility must be within 14 days of study enrollment 
2. As part of this protocol’s eligibility, a patient must have sufficient archival tissue block material (1.5 x 1.5 x 1.5 cm) If archived tissue not available, a fresh tumor biopsy is required (core or excisional 
biopsy of tumor tissue; minimum of 2 cores) for study eligibility; however, if archived tissue is available, the fresh tumor biopsy will be charged to research – refer to Section 9.2 
3. End of trial clinical visit and disease reassessment 2-4 weeks after Cycle 3 Day 15 (cohort 1) or 2-4 weeks after Cycle 3 Day 8 (cohort 2) 


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9.2. Research Related Sample Collection 
If a patient discontinues aldesleukin early, the research calendar and disease 
reassessment should continue to follow the schedule below using the 1st dose of 
aldesleukin as the calendar anchor. 
1 – On RT treatment Day 7 (±3 days),  
2 – before the 1st dose of aldesleukin and 8 to 12 hours after the last dose of aldesleukin 
administered 
3- a fresh tumor biopsy is requried at baseline; however, it is done only once. If the patient 
has archived tissue and does not require a biopsy for study eligibility per footnote #2 in 
Section 9.1, a tumor biopsy will be done and charged to research per Section 9.2. 
 
All research samples go to the Masonic Cancer Center’s Translational Therapy Lab 
(TTL) unless otherwise specified on the lab slip. 
Research sample collection and questionnaire completion are tied to the clinical care 
schedule of events and their associated window for performance. Therefore, if a 
clinical time point does not occur or is altered, the research related time point will be 
adjusted (or eliminated) as appropriate.  
It is recognized that with novel therapies as used in this study, the timing of protocol 
directed research samples may miss important patient specific events. For this reason, 
up to 3 extra samples for a total of 180 ml of blood may be drawn at additional time 
points that are not specified above.  
9.2.1. Collection of Tumor Biospecimens 
As part of this protocol’s eligibility, a patient must have sufficient archival tissue 
block material (1.5 x 1.5 x 1.5 cm) and/or newly obtained core or excisional biopsy 
of tumor tissue; minimum of 2 cores. A biopsy is performed around Day 36 of cycle 
1 and again at the EOT visit soley for research purposes. In patients with confirmed 
radiologic progression, a biopsy sample of a tumor would ideally be obtained near 
the time of progression if feasible and safe (core, punch or excisional biopsy). 
Biopsy confirmation at time of progression is a standard of care practice. 
Pre- and post-treatment levels of CD8+ T-cell tumor infiltrates will be assessed by 
IHC, in the Department of Laboratory Medicine and Pathology and with the 
assistance of BIONET. PD-1 and PD-L1, LAG-3, and TIM-3 expression will be 
  
Baseline 
Day 7 of 
RT 
(if given) 
Day 1 
and 5 
Day 
15 
and 
19 
Cycle 1  
Day 36 
Cycle 2 
Day 29 
End of 
Trial (EOT) 
visit 
At disease 
progression if 
feasible 
Toxicity Notation 
X 
X 
X 
X 
X 
X 
X 
  
FACT-M questionnaire 
X 
X 
Day 1 
Day 
15 
X 
X 
X 
  
Whole blood for Plasma (CMV DNA and 
cytokine testing) and PBMC 
(Immunophenotyping and functional 
studies) (10 mL x 5, green top, 
heparinized) Collect prior to Day’s dosing 
(except 8 hour post IL-2 sample) 
X 
X1 
X2 
X2 
X 
X 
X 
  
Tumor biopsy (4 cores); FFPE (x2) and 
Frozen (x2) -80 C 
X3 
  
  
  
X  
  
X 
X 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
tested using Immunohistochemical reagents and techniques. RNA sequencing 
(RNA-Seq) analysis will be performed from unstained tissue slide material. Gene 
expression analysis will be performed by the University of Minnesota Genomics 
Core (UMGC). 
9.2.2. Collection of Blood Specimens 
Research sample processing and specialized testing will be provided by the 
Translational Therapy Shared Resource, at the Masonic Cancer Center, University 
of Minnesota. When appropriate, samples from normal donors will be used in 
comparative analyses. 
We will collect whole blood for cytokine studies, DNA/RNA and Immune cell gene 
expression, and for PBMC isolation at various time points. For immune cell 
phenotype and functional studies we will collect 5 x 10 mL Green top (Heparinized) 
tubes for detailed NK cell and T-cell subset analysis and for plasma isolation and 
PBMC storage at -80°C. 
To determine if tetramer reagents would be applicable for a given patient, a low-
resolution human leukocyte antigen (HLA) Class I typing assay will also be 
performed at study enrollment. 
For a complete listing of correlative objectives and tissue and assays planned, see 
Appendix 5.  
9.2.3. Quality of Life (QOL) Measurement, FACT-Melanoma  
The Functional Assessment of Cancer Therapy (FACT) subscale specific for 
melanoma, FACT-M, is a melanoma-specific quality of life (QOL) assessment 
instrument. The FACT–Melanoma subscale was developed to assess and identify 
the unique concerns of patients with melanoma. 
The FACT-Melanoma questionnaire is a reliable and valid instrument for patients 
with melanoma that can be used for the assessment of QOL in clinical trials(48). 
During the course of the study patients will fill out the FACT-Melanoma QOL 
assessment instrument to monitor patient wellbeing in multiple domains (Appendix 
4). 
9.3. Imaging Assessments 
Tumor response will be defined by the Response Evaluation Criteria in Solid Tumors 
(RECIST 1.1) according to the schedule outlined in Section 9.1.  
Based on immune related RECIST (irRECIST 1.1), a modification of RECIST, the 
study requires confirmation of progressive disease (PD) with an additional scan 4 to 6 
weeks later that also meets criteria for progression per RECIST 1.1. (see Appendix 6) 
 
 


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10. ADVERSE EVENT REPORTING 
Toxicity and adverse events will be classified according to NCI's Common Terminology 
Criteria for Adverse Events V 5.0 (CTCAE). A copy of the CTCAE can be downloaded 
from 
the 
CTEP 
home 
page 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Q
uick_Reference_5x7.pdf 
10.1. Definitions 
The following definitions are based on the Code of Federal Regulations Title 21 Part 
312.32 (21CFR312.32(a)). 
Adverse Event:  Any untoward medical occurrence associated with the use of a drug 
in humans, whether or not considered drug related.  
Suspected Adverse Reaction:  Any adverse event for which there is a reasonable 
possibility that the drug caused the adverse event.  For the purposes of IND safety 
reporting, "reasonable possibility" means there is evidence to suggest a causal 
relationship between the drug and the adverse event. Suspected adverse reaction 
implies a lesser degree of certainty about causality than adverse reaction, which 
means any adverse event caused by a drug. 
Life-Threatening Adverse Event Or Life-Threatening Suspected Adverse 
Reaction: An adverse event or suspected adverse reaction is considered “life-
threatening” if, in the view of either the investigator or sponsor, its occurrence places 
the patient or subject at immediate risk of death. It does not include an adverse event 
or suspected adverse reaction that, had it occurred in a more severe form, might have 
caused death. 
Serious Adverse Event Or Serious Suspected Adverse Reaction:  An adverse 
event or suspected adverse reaction is considered “serious” if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes:  
● Death 
● A life-threatening adverse event 
● Inpatient hospitalization or prolongation of existing hospitalization 
● A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions 
● A congenital anomaly/birth defect 
● Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered serious when, based upon appropriate 
medical judgment, they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this 
definition 
 
Unexpected adverse event or unexpected suspected adverse reaction: An 
adverse event or suspected adverse reaction is considered “unexpected” if it is not 
listed in the investigator brochure or is not listed at the specificity or severity that has 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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Page 40 of 64 
CPRC # 2018LS110 
been observed; or, if an investigator brochure is not required or available, is not 
consistent with the risk information described in the general investigational plan or 
elsewhere in the current application, as amended. "Unexpected," as used in this 
definition, also refers to adverse events or suspected adverse reactions that are 
mentioned in the investigator brochure as occurring with a class of drugs or as 
anticipated from the pharmacological properties of the drug, but are not specifically 
mentioned as occurring with the particular drug under investigation.  
 
Attribution of the AE: 
- Definite – The AE is clearly related to the study treatment. 
- Probable – The AE is likely related to the study treatment. 
- Possible – The AE may be related to the study treatment. 
- Unlikely – The AE is doubtfully related to the study treatment. 
- Unrelated – The AE is clearly NOT related to the study treatment. 
 
The following definitions are from the Masonic Cancer Center’s Standard Operating 
Procedure (SOP) Deviation Reporting: 
 
Major Deviation: A deviation or violation that impacts the risks and benefits of the 
research; may impact subject safety, affect the integrity of research data and/or affect 
a subject’s willingness to participate in the research. Deviations that place a subject at 
risk, but do not result in harm are considered to be major deviations. 
 
Minor Deviation: A deviation or violation that does not impact subject safety, 
compromise the integrity of research data and/or affect a subject’s willingness to 
participate in the research. 
10.2. Adverse Event Monitoring and Documentation 
The monitoring period for adverse events begins with the administration of the 1st dose 
of aldesleukin (IL-2) through the End of Trial visit.  
Patients who are withdrawn due to an AE should have an AE assessment completed 
28 days or more after their last trial treatment. All AEs will be captured on the AE CRF. 
For the purposes of this study, adverse event documentation requirements will be 
determined based on grade, expectedness and relationship to the study treatment: 
 
 
Grade 1 
Grade 2 
Grade 3 
Grade 4 and 5 
Expected or 
Unexpected 
Expected 
Unexpected 
Expected 
Unexpected 
Expected 
or 
Unexpected 
Unrelated 
Unlikely 
Not required 
Not 
required 
Not required 
Not 
required 
Required 
Required 
Possible 
Probable 
Definite 
Not required 
Not 
required 
Required 
Required 
Required 
Required 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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The following events count toward an early stopping rule event per Section 12: 
 
Any Grade 2 or greater drug-related uveitis, eye pain, or blurred vision that 
does not respond to topical therapy and does not improve to Grade 1 severity 
within 7 days of checkpoint inhibitor OR requires systemic treatment with 
corticosteroids 
 
Any Grade 3 or greater non-skin, drug-related adverse event lasting > 7 days, 
including uveitis, pneumonitis, bronchospasm, diarrhea, colitis, neurologic 
toxicity, hypersensitivity reactions, and infusion reactions with the following 
exceptions: 
o Grade 3 or greater drug-related laboratory abnormalities are not considered 
a stopping rule event if they constitute an expected side effect that is 
reversible and corrects with usual supportive measures. 
In addition, the trial would be stopped and re-evaluated if there is ≥ 1 treatment-related 
mortality event. 
10.3. 
Required Reporting: IRB and Masonic Cancer Center’s SAE 
Coordinator 
Agency 
Criteria for reporting 
Timeframe 
Form to Use 
Submission address/ 
form 
U of MN IRB 
Unexpected Death, Information that 
indicates a new or increased risk, or a 
safety issue. 
Within 5 
business 
days of 
event 
discovery 
RNI 
ethos 
Masonic 
Cancer 
Center SAE 
Coordinator 
Events that count an early study stopping 
rule. 
At time of 
reporting 
Stopping Rule 
Form 
SAE Coordinator 
mcc-saes@umn.edu 
The SAE Coordinator will provide the Masonic Cancer Center’s Data and Safety 
Monitoring Council (DSMC) with the SAE in an appropriate format depending on the 
individual SAE (as reported or in a summary format). 
11. STUDY DATA COLLECTION AND MONITORING 
11.1. Data Management 
This study will collect regulatory and clinical data using University of Minnesota CTSI’s 
instance of OnCore® (Online Enterprise Research Management Environment). The 
Oncore database resides on dedicated secure and PHI compliant hardware. All 
relevant Academic Health Center – Information Systems (AHC-IS) procedures related 
for PHI compliant servers (as required by the Center of Excellence for HIPAA Data) 
apply to Oncore databases. 
 
Additional immune monitoring data about correlative laboratory samples generated by 
the Masonic Cancer Center Translational Therapy Laboratory (TTL) from the protocol-


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directed correlative research samples is stored in their Laboratory Information 
Management System (LIMS). The LIMS database application is also stored on a 
production server located in the UMN datacenter (WBOB) and is managed by the 
Academic Health Center. 
 
Key study personnel are trained on the use of OnCore and will comply with protocol 
specific instructions embedded within the OnCore. 
11.2. Case Report Forms 
Participant data will be collected using protocol specific electronic case report forms 
(e-CRF) developed within OnCore based on its library of standardized forms. The e-
CRF will be approved by the study’s Principal Investigator and the Biostatistician prior 
to release for use. The Study Coordinator or designee will be responsible for 
registering the patient into OnCore at time of study entry, completing e-CRF based on 
the patient specific calendar, and updating the patient record until patient death or end 
of required study participation.  
11.3. Data and Safety Monitoring Plan (DSMP) 
The study’s Data and Safety Monitoring Plan will be in compliance with the University 
of Minnesota Masonic Cancer Center's Data & Safety Monitoring Plan (DSMP), which 
can be accessed at http://z.umn.edu/dmsp. 
For the purposes of data and safety monitoring, this study is classified as moderate 
risk. 
Therefore the following requirements will be fulfilled: 
▪ The Masonic Cancer Center Data and Safety Monitoring Council (DSMC) will 
review the study’s progress at least twice yearly with the understanding the Cancer 
Protocol Review Committee (CPRC) may require more frequent reporting. 
▪ The PI will comply with at least twice yearly monitoring of the project by the Masonic 
Cancer Center monitoring services. 
▪ The PI will oversee the submission of all reportable adverse events per the definition 
of reportable in Section 10.3 to the Masonic Cancer Center’s SAE Coordinator, the 
University of Minnesota IRB, and the FDA.  
11.4. Monitoring 
The investigator will permit study-related monitoring, audits, and inspections by the 
investigator and/or investigator designee, IRB, government regulatory bodies, and 
University of Minnesota compliance groups. The investigator will make available all 
study related documents (e.g. source documents, regulatory documents, data 
collection instruments, study data, etc.). The investigator will ensure the capability for 
inspections of applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.) will be available for trial related monitoring, audits, or regulatory inspections. 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
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CPRC # 2018LS110 
11.5. Record Retention 
The investigator will retain study records including source data, copies of case report 
forms, consent forms, HIPAA authorizations, and all study correspondence in a 
secured facility for at 6 years after the study file is closed with the IRB.  
In addition, the Clinical Trials Office (CTO) will keep a master log of all patients 
participating in the study with sufficient information to allow retrieval of the medical 
records for that patient.  
Please contact the CTO before destroying any study related records. 
12. 
STATISTICAL CONSIDERATIONS 
All analyses of demographics, safety, biological activity, and biomarkers will be 
descriptive. AEs, SAEs, deaths, and abnormal laboratory values will be summarized by 
the proportion of patients who experience them.  Descriptive statistics of safety will be 
presented using National Cancer Institute (NCI) Common Terminology Criteria for 
Adverse Events (CTCAE) version 5.0. All on-study AEs, Grade 3-4 AEs, treatment-related 
AEs, Grade 3-4 treatment-related AEs, SAEs, treatment-related SAEs, and AEs leading 
to discontinuation will be tabulated using the worst grade per NCI CTCAE v 5.0 criteria by 
system organ class. On-study lab parameters including hematology, chemistry panel, liver 
and renal function tests, and thyroid function, and all Grade 3-4 Lab abnormalities will be 
summarized using worst grade NCI CTCAE v 5.0 criteria. 
Each cohort in this phase 2 trial uses a Simon’s two-stage design (39). The null hypothesis 
that the true response rate is 13% will be tested against a one-sided alternative. In the first 
stage, 16 patients will be accrued. If there are 3 or fewer responses in these 16 patients, 
the study will be stopped for futility. If there are 4 or more responses in 16 patients, the 
null hypothesis will be rejected and 6 additional patients will be accrued for a total of 22. 
The null hypothesis will be rejected if 6 or more responses are observed in 22 patients. 
This design yields a type I error rate of 0.05 and power of 0.8 when the true response rate 
is 35%. 
The ORR will be presented as the proportion of patients who achieved complete response 
(CR) or partial response (PR). The disease control rate (DCR) will be presented as the 
proportion of patients with CR, PR, or stable disease. The best overall response (BOR) 
will be measured as the maximum change from baseline in the sum of the longest diameter 
for each of the target lesions over the full 2 year follow-up period. The percentage of 
responders still in response at different time points (6 and 12 months) will be presented 
based on the Kaplan-Meier (KM) method. 
In general, categorical data measurements will be summarized as counts and percentages 
(or proportions) and continuous data will be summarized with descriptive statistics such 
as mean, standard deviation, median, minimum and maximum. Summary statistics will be 
provided for changes in number of tumor infiltrating lymphocytes and in PD-L1/Tim-3/Lag-
3 and other expressed proteins in tumors from baseline to protocol-specified time points 
during treatment. 


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Sequential boundaries will be used to monitor excessive toxicity rate as defined in Section 
10.3 by treatment cohort (arm). The accrual will be halted and the study re-evaluated if 
excessive toxicity is seen, that is, if the number of excessive toxicity is equal to or exceeds 
8 out of 22 patients in phase 2 with full follow-up (i.e. stop if 2/2, 3/3, 3/4, 4/5, 4/6, 4/7, 4/8, 
5/9, 5/10, 5/11, 5/12, 6/13, 6/14, 6/15, 6/16, 6/17, 7/18, 7/19, 7/20, 7/21, or 8/22). This is 
a Pocock-type (40) stopping boundary that yields the probability of crossing the boundary 
at most [0.05] when the rate of excessive toxicity is equal to the acceptable rate [0.13]. 
In addition, the trial would be stopped and re-evaluated if there is ≥ 1 treatment-related 
mortality event. 
13. 
CONDUCT OF THE STUDY 
13.1. Good Clinical Practice 
The study will be conducted in accordance with the appropriate regulatory 
requirement(s). Essential clinical documents will be maintained to demonstrate 
the validity of the study and the integrity of the data collected. Master files 
should be established at the beginning of the study, maintained for the duration 
of the study and retained according to the appropriate regulations.  
13.2. Ethical Considerations 
The study will be conducted in accordance with ethical principles founded in 
the Declaration of Helsinki. The IRB will review all appropriate study 
documentation in order to safeguard the rights, safety and well-being of the 
patients. The study will only be conducted at sites where IRB approval has 
been obtained. The protocol, consent, written information given to the patients, 
safety updates, annual progress reports, and any revisions to these documents 
will be provided to the IRB by the investigator.  
13.3. Informed Consent 
All potential study participants will be given a copy of the IRB-approved consent 
to review. The investigator or designee will explain all aspects of the study in 
lay language and answer all questions regarding the study. If the participant 
decides to participate in the study, he/she will be asked to sign and date the 
consent document. Patients who refuse to participate or who withdraw from the 
study will be treated without prejudice. 


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CPRC # 2018LS110 
APPENDIX 1 – PERFORMANCE STATUS CRITERIA 
 


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APPENDIX 2 – ALDESLEUKIN (IL-2) TOXICITIES AND 
CORRECTIVE MEASURES 
 
EXPECTED IL-2 
TOXICITIES 
CORRECTIVE MEASURES / MANAGEMENT 
Arrhythmia 
Stop IL-2 (most arrhythmias). Correct electrolytes, minerals, anemia, hypoxia. Use 
medications as indicated 
Anemia 
Transfuse PRBC's to achieve Hct>28% during IL-2 dosing 
Acidosis 
Total CO2 (bicarbonate)<20 mmol/l, give 50meq bicarb 
<18 mmol/l, give 100 meq bicarb IV 
Chills 
Warm blankets as first measure 
IV meperidine if persists 
CK elevation 
Measure isoenzymes, EKG. If have evidence of myocarditis, must stop IL-2. Will 
need ECHO before next cycle of IL-2 to rule out myocardial dysfunction. Future IL-
2 may be considered if the ECHO is normal. 
Dermatitis 
Oatmeal baths, lotions (NO steroid or alcohol containing lotions) 
Diarrhea 
Antidiarrheals. Avoid overuse because of complicating ileus and distention. 
Edema 
Elevate symptomatic extremity. Use fluids judiciously. AVOID DIURETICS. Notify 
MD to evaluate if signs of pulmonary edema. 
Epigastric pain 
Evaluate cause, consider antacids. 
Fever breakthrough 
Scheduled acetaminophen. Naproxen prn. Consider septic work-up if happens 
after first 24 hours of therapy. 
Hypoalbuminemia 
Observe 
Hypocalcemia 
Maintain above lowest normal at institution (compensate for low albumin). 
Hypokalemia 
Maintain potassium above 3.6 
Hypomagnesemia 
Maintain above lowest normal at institution (compensate for low albumin). 
Hypotension 
Use crystalloids to maintain BPsys>80-90 (1000-1500 cc/day max boluses to 
avoid pulmonary edema). Auscultate lungs before and after each bolus to identify 
development of crackles or wheezing. 


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EXPECTED IL-2 
TOXICITIES 
CORRECTIVE MEASURES / MANAGEMENT 
Infection 
Stop IL-2 and treat infection as indicated. 
Mucositis/stomatitis 
Frequent oral care, mouthwashes, topical anesthetics, nystatin 
Oliguria 
Fluid boluses to maintain UO 30cc/h based on last 8 hours (240 cc/8h). Limit to 
1000-1500 cc/day max boluses to avoid pulmonary edema. Auscultate lungs 
before and after each bolus to identify development of crackles or wheezing. Stop 
IL-2 if unable to meet UO criteria for 24 hours since last dose. Consider foley 
catheter. AVOID DIURETICS! 
Nausea/vomiting 
Antiemetics (alternate medications and routes if any one not effective) 
Nasal congestion 
Room humidifier, decongestant (NO topical steroids). 
Pruritus 
Oatmeal baths, lotions, antipruritics. NO steroids (topical or systemic). 
Shortness of breath 
Check transcutaneous O2 sat. If <95%, use O2. Use fluids judiciously. Do not use 
inhalational steroids. Stop IL-2 for airway tightness/reactive airway. 
Tachycardia 
Correct fever, hypotension, hypoxia, anemia. 
Thrombocytopenia 
Consider platelet transfusion at appropriate parameters. 
 
 
 
 
 
 


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APPENDIX 3 – MANAGEMENT ALGORITHMS FOR IPILIMUMAB 
AND OTHER IMMUNO-ONCOLOGY DRUGS 
 
These general guidelines constitute guidance to the Investigator and may be supplemented 
by discussions with the principal investigator and Inpatient Attending. The guidance applies 
to all immuno-oncology (I-O) agents and regimens. 
A general principle is that differential diagnoses should be diligently evaluated according to 
standard medical practice. Non-inflammatory etiologies should be considered and 
appropriately treated. 
Corticosteroids are a primary therapy for immuno-oncology drug-related adverse events. The 
oral equivalent of the recommended IV doses may be considered for ambulatory patients with 
low-grade toxicity. The lower bioavailability of oral corticosteroids should be taken into account 
when switching to the equivalent dose of oral corticosteroids. 
Consultation with a medical or surgical specialist, especially prior to an invasive diagnostic or 
therapeutic procedure, is recommended. The frequency and severity of the related adverse 
events covered by these algorithms will depend on the immuno-oncology agent or regimen 
being used. 
 
 
 
 
 
 
 


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APPENDIX 4 – FACT-M (VERSION 4) 
 http://www.facit.org/LiteratureRetrieve.aspx?ID=42277 
 


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APPENDIX 5 – CORRELATIVE OBJECTIVES AND TESTING 
 
CORRELATIVE OBJECTIVE 
LABORATORY 
ASSAYS 
TISSUE/BODY FLUID TESTED AND 
TIMING 
mRNA expression profiling 
(immune signature genes) 
 
UMN Genomics Core 
Q-RT-PCR 
NanoString 
Illumina Arrays 
Tumor: Prior to treatment (baseline), 
prior to Ipilimumab, at EOT, and at 
time of confirmed progression (if 
feasible) 
PBMC: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT  
Tumor Gene expression 
profiling 
 
UMN Genomics Core 
NGS Illumina HiSeq 
Tumor: Prior to treatment (baseline), 
prior to Ipilimumab, at EOT, and at 
time of confirmed progression (if 
feasible) 
 
Tumor PD-1 and PD-L1 
Expression 
 
BioNet/LaMP 
IHC 
 
Tumor: Prior to treatment (baseline), 
prior to Ipilimumab, at EOT, and at 
time of confirmed progression (if 
feasible) 
 
Immune cell infiltrate markers: 
CD3, CD8, MHC Class I. CD4, 
CD56, CD16, CD45, CD19, CD68, 
GITR, TIM-3, FOXP3 and LAG3 
BioNet/LaMP 
IHC 
Tumor: Prior to treatment (baseline), 
prior to Ipilimumab, at EOT, and at 
time of confirmed progression (if 
feasible) 
 
Melanoma specific T cell 
Immunophenotyping 
 
Flow Cytometry, Mass 
Cytometry Core  
Melanoma peptide specific 
tetramer isolation, CyTOF  
PBMC: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT 
Anti-melanoma T cell gene 
expression analysis 
Flow Cytometry and 
UMN Genomics Core 
mRNA expression (e.g. 
Nanostring) 
PBMC: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT  
Melanoma specific T cell 
Functional studies 
 
Translational 
Immunology Laboratory 
Pooled CMV and 
melanoma peptide Antigen 
profliferation assays 
IFN-γ ELISpot 
PBMC: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT  
PBMC and T cell subset 
quantification (frequency and 
Flow Cytometry, 
Translational 
Immunology Laboratory 
Multiparameter flow 
cytometric analysis, CyTOF 
(Fluidigm) 
PBMC: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 


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percent), Tregs, NK cells and 
MDSC. 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT  
Systemic cytokine levels 
Cytokine Reference 
Laboratory 
Luminex 
Serum: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT  
Cytomegalovirus (CMV) DNA 
quantitation and reactivation 
testing 
Nelson Laboratory, 
Masonic Cancer Center 
PCR based assay 
Serum: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT 
ctDNA and Neoantigen 
characterization 
UMN Genomics Core 
NGS 
Serum: Prior to treatment start, HD-
XRT mid-cycle on day 7 (+/-3 days), 
cycle1 day 1 and day 15 (before 1st 
dose and 8 hours after last dose), 
prior to Ipilimumab (same day), cycle 
2 day 1 and day 15 (before 1st dose 
and 8 hours after last dose), and EOT 
 


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APPENDIX 6 – RECIST 1.1 RESPONSE DEFINITIONS 
 
Baseline selection of lesions 
All lesions are measured by long and short axis (perpendicular to long axis). At baseline, all tumor lesions are identified as 
either target lesions or non-target lesions and will be evaluated at baseline and every post baseline imaging timepoint. 
 
Target lesions: This trial distinguishes between (A) XRT target lesions and (B) non-irradiated target lesions. The minimum 
size of target lesions is 1.5 cm by long axis. Lymph nodes must measure at least 1.5 cm in short axis. The maximum number 
of lesions targeted for XRT will be 3, with a maximum of 2 lesions allowed per targeted organ. For response assessment, the 
maximum number of non-irradiated target lesions followed will be 5. 
 
Non-target lesions: These are radiographically detectable lesions in excess of the number of target lesions already being 
followed ( >8 total or >2 per organ) or that do not meet size criteria for target lesion status. In the event of innumerable 
metastases, non-target lesions are limited to an additional 8 lesions. Lymph nodes must measure at least 1.0 cm in short 
axis to qualify as non-target lesions (<1cm considered non-pathologic).  
 
Baseline measurements 
The sum of the long diameters (SOD) of A) XRT targeted lesions and B) non-irradiated target lesions is calculated and 
referred to as SOD-A and SOD-B for the baseline timepoint. All other lesions are considered non-target lesions and also 
recorded at baseline. 
 
Radiographic response assessments 
At each imaging timepoint, the SOD of target lesions is measured and recorded. Response is determined by calculating the 
SOD-A and SOD-B at each imaging timepoint. Any new lesions (C) are measured and recorded, and the SOD-C calculated 
for that imaging timepoint. A previously involved lymph node must also measure > 1.0 cm by short axis diameter to continue 
to qualify as pathologic. 
 
Target lesion response 
Complete response (CR): disappearance of all target lesions. Any pathological lymph nodes (whether target or non-target) 
must have reduction in short axis to < 1 cm. 
 
Partial response (PR): Decrease of at least 30% in the sum of diameters (SOD) of target lesions, taking as reference the 
baseline SOD. 
 
Progressive disease (PD): Increase of at least 20% in the sum of diameters (SOD) of target lesions, taking as reference the 
smallest prior SOD in the trial (including the baseline sum if it is the smallest).  
 
Stable disease (SD): Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for PD, taking as 
reference the smallest SOD achieved in the trial. 
 
Non-target lesion response  
Complete response (CR): disappearance of all non-target lesions. All lymph nodes must be non-pathological in size (<10 
mm short axis). 
 
Non-CR/Non-PD: Persistence of 1 or more non–target lesion(s). 
 
Progressive disease (PD): Unequivocal progression of existing non-target lesions. (Note: appearance of 1 or more new 
lesions is considered progression). 
 
New lesion assessment 
At each imaging timepoint, presence of new lesions is determined, and each new lesion is recorded as a new lesion (i.e. C1, 
C2, etc.) and they are not considered target or non-target lesions. 
 
Lymph nodes must be a new lesion and measure at least 10 cm by short diameter to qualify as a new lesion overall 
response assessment. 
 
A lesion identified on a follow-up study in an anatomical location that was not scanned at baseline is considered a new 
lesion. 
  
 


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Objective Response assessment 
 
An overall response is based on both target and non-target lesion responses, as well as the appearance of any new lesions 
as listed in the Objective Response table below: 
 
Target Lesions 
Non-target Lesions 
New Lesions 
Objective Response 
CR 
CR 
No 
CR 
CR 
Non-CR/non-PD 
No 
PR 
CR 
Not evaluated  
No 
PR 
PR 
Non-PD or not all evaluated 
No 
PR 
SD 
Non-PD or not all evaluated 
No 
SD 
Not all evaluated Non-PD 
No 
NE 
PD 
Any 
Yes or No 
PD 
Any 
PD 
Yes or No 
PD 
Any 
Any 
Yes 
PD 
 
  
  
 
 
 


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REFERENCES 
1. 
Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin. 
2017;67(1):7-30. 
2. 
Barth A, Wanek LA, Morton DL. Prognostic factors in 1,521 melanoma patients with 
distant metastases. J Am Coll Surg. 1995;181(3):193-201. 
3. 
Ribas A, Hamid O, Daud A, Hodi FS, Wolchok JD, Kefford R, et al. Association of 
Pembrolizumab With Tumor Response and Survival Among Patients With Advanced 
Melanoma. JAMA. 2016;315(15):1600-9. 
4. 
Long GV, Flaherty KT, Stroyakovskiy D, Gogas H, Levchenko E, de Braud F, et al. 
Dabrafenib plus trametinib versus dabrafenib monotherapy in patients with metastatic BRAF 
V600E/K-mutant melanoma: long-term survival and safety analysis of a phase 3 study. Ann 
Oncol. 2017;28(7):1631-9. 
5. 
Maxwell R, Garzon-Muvdi T, Lipson EJ, Sharfman WH, Bettegowda C, Redmond KJ, 
et al. BRAF-V600 mutational status affects recurrence patterns of melanoma brain metastasis. 
Int J Cancer. 2017;140(12):2716-27. 
6. 
Sloan AE, Nock CJ, Einstein DB. Diagnosis and treatment of melanoma brain 
metastasis: a literature review. Cancer Control. 2009;16(3):248-55. 
7. 
Nicholas S, Mathios D, Jackson C, Lim M. Metastatic melanoma to the brain: surgery 
and radiation is still the standard of care. Curr Treat Options Oncol. 2013;14(2):264-79. 
8. 
Middleton MR, Grob JJ, Aaronson N, Fierlbeck G, Tilgen W, Seiter S, et al. 
Randomized phase III study of temozolomide versus dacarbazine in the treatment of patients 
with advanced metastatic malignant melanoma. J Clin Oncol. 2000;18(1):158-66. 
9. 
Patel PM, Suciu S, Mortier L, Kruit WH, Robert C, Schadendorf D, et al. Extended 
schedule, escalated dose temozolomide versus dacarbazine in stage IV melanoma: final results 
of a randomised phase III study (EORTC 18032). Eur J Cancer. 2011;47(10):1476-83. 
10. 
Carvajal RD, Sosman JA, Quevedo JF, Milhem MM, Joshua AM, Kudchadkar RR, et 
al. Effect of selumetinib vs chemotherapy on progression-free survival in uveal melanoma: a 
randomized clinical trial. JAMA. 2014;311(23):2397-405. 
11. 
Kaunitz GJ, Cottrell TR, Lilo M, Muthappan V, Esandrio J, Berry S, et al. Melanoma 
subtypes demonstrate distinct PD-L1 expression profiles. Lab Invest. 2017;97(9):1063-71. 
12. 
Algazi AP, Tsai KK, Shoushtari AN, Munhoz RR, Eroglu Z, Piulats JM, et al. Clinical 
outcomes in metastatic uveal melanoma treated with PD-1 and PD-L1 antibodies. Cancer. 
2016. 
13. 
Seegenschmiedt MH, Keilholz L, Altendorf-Hofmann A, Urban A, Schell H, 
Hohenberger W, et al. Palliative radiotherapy for recurrent and metastatic malignant 
melanoma: prognostic factors for tumor response and long-term outcome: a 20-year 
experience. Int J Radiat Oncol Biol Phys. 1999;44(3):607-18. 
14. 
Konefal JB, Emami B, Pilepich MV. Analysis of dose fractionation in the palliation of 
metastases from malignant melanoma. Cancer. 1988;61(2):243-6. 
15. 
Olivier KR, Schild SE, Morris CG, Brown PD, Markovic SN. A higher radiotherapy 
dose is associated with more durable palliation and longer survival in patients with metastatic 
melanoma. Cancer. 2007;110(8):1791-5. 
16. 
Demaria S, Ng B, Devitt ML, Babb JS, Kawashima N, Liebes L, et al. Ionizing 
radiation inhibition of distant untreated tumors (abscopal effect) is immune mediated. Int J 
Radiat Oncol Biol Phys. 2004;58(3):862-70. 
17. 
Stamell EF, Wolchok JD, Gnjatic S, Lee NY, Brownell I. The abscopal effect 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
February 18, 2020 
Page 63 of 64 
CPRC # 2018LS110 
associated with a systemic anti-melanoma immune response. Int J Radiat Oncol Biol Phys. 
2013;85(2):293-5. 
18. 
Apetoh L, Ghiringhelli F, Tesniere A, Obeid M, Ortiz C, Criollo A, et al. Toll-like 
receptor 4-dependent contribution of the immune system to anticancer chemotherapy and 
radiotherapy. Nat Med. 2007;13(9):1050-9. 
19. 
Gameiro SR, Jammeh ML, Wattenberg MM, Tsang KY, Ferrone S, Hodge JW. 
Radiation-induced immunogenic modulation of tumor enhances antigen processing and 
calreticulin exposure, resulting in enhanced T-cell killing. Oncotarget. 2014;5(2):403-16. 
20. 
Lugade AA, Moran JP, Gerber SA, Rose RC, Frelinger JG, Lord EM. Local radiation 
therapy of B16 melanoma tumors increases the generation of tumor antigen-specific effector 
cells that traffic to the tumor. J Immunol. 2005;174(12):7516-23. 
21. 
Lee Y, Auh SL, Wang Y, Burnette B, Wang Y, Meng Y, et al. Therapeutic effects of 
ablative radiation on local tumor require CD8+ T cells: changing strategies for cancer 
treatment. Blood. 2009;114(3):589-95. 
22. 
Schmittel A, Proebstle T, Engenhart-Cabillic R, Scheibenbogen C, Geueke AM, Thiel 
E, et al. Brain metastases following interleukin-2 plus interferon-alpha-2a therapy: a follow-
up study in 94 stage IV melanoma patients. Eur J Cancer. 2003;39(4):476-80. 
23. 
Powell S, Dudek AZ. Single-institution outcome of high-dose interleukin-2 (HD IL-2) 
therapy for metastatic melanoma and analysis of favorable response in brain metastases. 
Anticancer Res. 2009;29(10):4189-93. 
24. 
Tazi K, Hathaway A, Chiuzan C, Shirai K. Survival of melanoma patients with brain 
metastases treated with ipilimumab and stereotactic radiosurgery. Cancer Med. 2015;4(1):1-6. 
25. 
Wolchok JD, Neyns B, Linette G, Negrier S, Lutzky J, Thomas L, et al. Ipilimumab 
monotherapy in patients with pretreated advanced melanoma: a randomised, double-blind, 
multicentre, phase 2, dose-ranging study. Lancet Oncol. 2010;11(2):155-64. 
26. 
Hodi FS, O'Day SJ, McDermott DF, Weber RW, Sosman JA, Haanen JB, et al. 
Improved survival with ipilimumab in patients with metastatic melanoma. N Engl J Med. 
2010;363(8):711-23. 
27. 
Postow MA, Callahan MK, Barker CA, Yamada Y, Yuan J, Kitano S, et al. 
Immunologic correlates of the abscopal effect in a patient with melanoma. N Engl J Med. 
2012;366(10):925-31. 
28. 
Nomura M, Otsuka A, Yoshimura M, Nonomura Y, Kaku Y, Matsumoto S, et al. 
Efficacy and safety of concurrent immunoradiotherapy in patients with metastatic melanoma 
after progression on nivolumab. Cancer Chemother Pharmacol. 2018;81(5):823-7. 
29. 
Dewan MZ, Galloway AE, Kawashima N, Dewyngaert JK, Babb JS, Formenti SC, et 
al. Fractionated but not single-dose radiotherapy induces an immune-mediated abscopal effect 
when combined with anti-CTLA-4 antibody. Clin Cancer Res. 2009;15(17):5379-88. 
30. 
Chandra RA, Wilhite TJ, Balboni TA, Alexander BM, Spektor A, Ott PA, et al. A 
systematic evaluation of abscopal responses following radiotherapy in patients with metastatic 
melanoma treated with ipilimumab. Oncoimmunology. 2015;4(11):e1046028. 
31. 
Whittington R, Faulds D. Interleukin-2. A review of its pharmacological properties and 
therapeutic use in patients with cancer. Drugs. 1993;46(3):446-514. 
32. 
Atkins MB, Kunkel L, Sznol M, Rosenberg SA. High-dose recombinant interleukin-2 
therapy in patients with metastatic melanoma: long-term survival update. Cancer J Sci Am. 
2000;6 Suppl 1:S11-4. 
33. 
Au-Yeung BB, Smith GA, Mueller JL, Heyn CS, Jaszczak RG, Weiss A, et al. IL-2 


Radiation and Sequential Immunotherapy for Metastatic Cutaneous Melanoma and Ocular Melanoma 
 
 
 
February 18, 2020 
Page 64 of 64 
CPRC # 2018LS110 
Modulates the TCR Signaling Threshold for CD8 but Not CD4 T Cell Proliferation on a Single-
Cell Level. J Immunol. 2017. 
34. 
Rosenberg SA, Yang JC, Sherry RM, Kammula US, Hughes MS, Phan GQ, et al. 
Durable complete responses in heavily pretreated patients with metastatic melanoma using T-
cell transfer immunotherapy. Clin Cancer Res. 2011;17(13):4550-7. 
35. 
Hodi FS, O'Day SJ, McDermott DF, Weber RW, Sosman JA, Haanen JB, et al. 
Improved Survival with Ipilimumab in Patients with Metastatic Melanoma. New England 
Journal of Medicine. 2010;363(8):711-23. 
36. 
Hodi FS, Lee S, McDermott DF, Rao UN, Butterfield LH, Tarhini AA, et al. 
Ipilimumab plus sargramostim vs ipilimumab alone for treatment of metastatic melanoma: a 
randomized clinical trial. JAMA. 2014;312(17):1744-53. 
37. 
Postow MA, Chesney J, Pavlick AC, Robert C, Grossmann K, McDermott D, et al. 
Nivolumab and ipilimumab versus ipilimumab in untreated melanoma. N Engl J Med. 
2015;372(21):2006-17. 
38. 
Lebbe C, Meyer N, Mortier L, Marquez-Rodas I, Robert C, Rutkowski P, et al. 
Evaluation of Two Dosing Regimens for Nivolumab in Combination With Ipilimumab in 
Patients With Advanced Melanoma: Results From the Phase IIIb/IV CheckMate 511 Trial. J 
Clin Oncol. 2019;37(11):867-75. 
39. 
Maker AV, Phan GQ, Attia P, Yang JC, Sherry RM, Topalian SL, et al. Tumor 
regression and autoimmunity in patients treated with cytotoxic T lymphocyte-associated 
antigen 4 blockade and interleukin 2: a phase I/II study. Ann Surg Oncol. 2005;12(12):1005-
16. 
40. 
Bristol-Myers Squibb. Yervoy(R) [package insert]. Bristol-Myers Squibb Company, 
Princeton, NJ 2017 [Available from: https://packageinserts.bms.com/pi/pi_yervoy.pdf. 
41. 
Postow MA, Callahan MK, Barker CA, Yamada Y, Yuan J, Kitano S, et al. 
Immunologic correlates of the abscopal effect in a patient with melanoma. N Engl J Med. 
2012;366(10):925-31. 
42. 
Reynders K, Illidge T, Siva S, Chang JY, De Ruysscher D. The abscopal effect of local 
radiotherapy: using immunotherapy to make a rare event clinically relevant. Cancer Treat Rev. 
2015;41(6):503-10. 
43. 
Bretscher P. The two-signal model of lymphocyte activation twenty-one years later. 
Immunol Today. 1992;13(2):74-6. 
44. 
McCoy KD, Le Gros G. The role of CTLA-4 in the regulation of T cell immune 
responses. Immunol Cell Biol. 1999;77(1):1-10. 
45. 
Walker LS. Treg and CTLA-4: two intertwining pathways to immune tolerance. J 
Autoimmun. 2013;45:49-57. 
46. 
Sckisel GD, Bouchlaka MN, Monjazeb AM, Crittenden M, Curti BD, Wilkins DE, et 
al. Out-of-Sequence Signal 3 Paralyzes Primary CD4(+) T-Cell-Dependent Immunity. 
Immunity. 2015;43(2):240-50. 
47. 
Seung SK, Curti BD, Crittenden M, Walker E, Coffey T, Siebert JC, et al. Phase 1 
study of stereotactic body radiotherapy and interleukin-2--tumor and immunological 
responses. Sci Transl Med. 2012;4(137):137ra74. 
48. 
Cormier JN, Ross MI, Gershenwald JE, Lee JE, Mansfield PF, Camacho LH, et al. 
Prospective assessment of the reliability, validity, and sensitivity to change of the Functional 
Assessment of Cancer Therapy-Melanoma questionnaire. Cancer. 2008;112(10):2249-57.