Clinical trial NCT02221739
Conditions: Non-small Cell Lung Cancer (NSCLC)
Keywords: lung cancer NSCLC lung cancer radiation immunotherapy metastatic
Sponsor: NYU Langone Health
Start date: 2014-07-01; Completion date: 2015-10-27
Enrollment: 39 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this study is to investigate how effective and how safe the combination of radiation therapy and an investigational medication targeting the immune system known as Ipilimumab in the treatment of metastatic non-small cell lung cancer (NSCLC).

The investigators would like to see if this combination of radiation and Ipilimumab can stimulate the body's immune system to stop the growth of tumors that are outside the field of radiation. The investigators would like see if using this combination of radiation therapy with Ipilimumab could help the body reject the patient's own tumor or at least help their immune system to maintain the disease stable and/or slow its growth.

Radiation therapy (RT) is currently a standard procedure for treatment of NSCLC. Ipilimumab is considered an investigational medication because it is not approved by the Food and Drug Administration (FDA) for the treatment of NSCLC. Ipilimumab has been approved by the FDA for the treatment of metastatic melanoma.

Detailed description:
Research Hypothesis:

1. Through a combination of local RT and ipilimumab an anti-tumor immune response is elicited at the irradiated site, as an in vivo, individualized immunization that is systemically effective, as reflected by objective responses outside the RT field (abscopal effect).
2. The immune response can be prospectively monitored among the treated patients.

Objective 1: Evaluate the safety and therapeutic efficacy of anti-cytotoxic T-lymphocyte-associated protein -4 mono clonal Antibody (anti-CTLA-4 mAb) and concurrent local RT in NSCLC patients with metastatic disease.

An open label phase II trial will evaluate the preliminary efficacy of the combination of Ipi and RT, applied to a single metastatic site. Efficacy is measured with respect to systemic tumor responses (abscopal response, outside the field of therapy) defined by immune-related Response Criteria (irRC) in all non-irradiated measurable lesions, as a demonstration of an effective anti-tumor immune response. Secondary endpoints include local response in the RT treated tumor, progression free survival, and overall survival.

Objective 2: Determine the effects of RT and anti-CTLA-4 mAb on development of anti-tumor immunity.

The investigators hypothesize that RT will convert the irradiated tumor into an in situ vaccine and elicit an endogenous tumor-specific cellular and humoral immune response, which in the presence of cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) blockade will promote immune-mediated destruction of the irradiated and abscopal metastases. Pre- and post-treatment tumor biopsies will be examined for changes in immune contexture, and blood for evidence of emerging anti-tumor immune responses. Associations with clinical response will be explored.

Arms: arm 1: Patients receive ipilimumab (Ipi) 3mg/kg i.v. over 90 minutes, within 24 hours of starting radiotherapy (RT) to the biopsied lesion, 6 Gy x5, later changed to 9.5 Gy x3 (conformally or by intensity modulated RT (IMRT) with image guidance to maximally spare normal tissue). Ipilimumab is repeated on days 22, 43 (for patients who consent to the first biopsy), and 64. Repeat biopsy is performed between day 22-29, and patients are re-imaged between day 81-88 and evaluated for response (defined as an objective response by irRC of the measurable metastatic sites outside the radiation field).
Interventions: intervention 1: Ipilimumab intervention 2: Radiotherapy (IMRT or 3-D CRT)
Intervention descriptions: intervention 1: None intervention 2: None

Protocol documents:
Prot_SAP_000.pdf: 
 
1
NYU S14-00208 / CA184-392 
 
 
PHASE II STUDY OF COMBINED IONIZING RADIATION AND IPILIMUMAB IN METASTATIC NON-
SMALL CELL LUNG CANCER (NSCLC) 
 
 
 
Principal Investigator:  
Abraham Chachoua, M.D. 
 
Abraham.Chachoua@nyumc.org 
      212-731-5388 
Co-P.I. 
 
 
Silvia Formenti, M.D. 
 
 
Co-Investigators: 
 
 
Sandra Demaria, M.D. 
 
Peter Schiff, M.D., Ph.D. 
 
Harvey Pass, M.D. 
 
Kent Friedman, M.D. 
 
Divya Sridhar, M.D. 
 
Jean Lee, M.D. 
 
Judith Goldberg, Sc.D. 
 
Christine Hitchen, M.S. 
 
Adriana Heguy, Ph.D. 
 
Research Nurse: 
Olivier Maisonet, NP 
 
Natalia Cherkassky, NP 
 
Melissa Martinez, NP 
 
Eliana Ferriera, NP 
 
Jennifer Hull, RN 
 
 


 
2
VERSION 2.3 12/04/2015 
 
 
Summary of Changes 
Version 
Date 
1. Adding Adriana Heguy, Ph.D.  as a Co-Investigator 
on the trial.  
2. Removing the following personnel no longer at NYU: 
Ralph Vatner, M.D., Ph.D., Keith DeWyngaert, Ph.D., 
Maria Fenton-Kerimian, NP 
2.3 
12/04/2015 
1. Changing the Principal Investigator to Dr. Abraham 
Chachoua 
2. Revising section 8.9 to include statement that 
anonymous data will be shared with Weill Cornell 
Medical College due to the re-location of personnel- Dr. 
Encouse Golden.  Inclusion of statement that 
anonymous data will only be shared after a transfer 
agreement is executed. 
 
1. Changing the Principal Investigator to Dr. 
Encouse Golden 
2. Changing the Principal Investigator information in 
the informed consent.  
3. Adding risk information to the informed consent 
 
 
2.2 
 
 
 
 
 
 
 
2.0 
10/12/2015 
 
 
 
 
 
 
 
03/23/2015 
1. Adding +/- 7 days window to PET/CT/MRI scan 
prior to enrollment 
2. Changing study calendar to reflect screening 
28days (+/- 7 days) 
3. Including MRI in study calendar along with 
PET/CT 
4. Removing the phrase “within one month” from the 
inclusion criteria # 12. 
5. Removing BHC site from the protocol 
6. Appendix 2 – Lab correlatives have been updated 
(Rationale : Heparin may interfere with some of the 
planned assays. It was decided to collect blood using EDTA 
which will not pose this potential problem) 
7. Added Jean Lee, M.D. Co-Investigator 
8. No changes to the informed consent 
1.4 
1.4 
1.4 
1.4 
 
1.4 
1.4 
 
1.3 
1.5 
08/21/2014 
 
08/21/2014 
08/21/2014 
08/21/2014 
 
08/21/2014 
08/21/2014 
 
10/08/2014 
 


 
3
 
Added:  
Co-Investigator: Keith DeWyngaert, Ph.D. 
                           Christine Hitchen, M.S. 
                           Jean Lee, M.D. 
Research Nurse: Jennifer Hull, RN 
Changed: 
Protocol Synopsis: 
Inclusion Criteria: 
11. Added: “…or greater than 2 weeks post- gamma 
knife therapy…” 
12  Added : “Brain Scan (CT/MRI) within a month prior 
to enrollment” 
4 Subject Selection criteria: 
   11. Added "...or greater than 2 weeks post- gamma 
knife therapy…”    
   4.3.6.2 Treatment: 
      Removed: “as a reference set.” 
      Added: “…or orthogonals (for IMRT) on first day.” 
      Removed: “In addition to the portal imaging…” 
                      “If shifts are made based upon the CBCT 
images, the portal images will be repeated.” 
   4.4.1 Prohibited Therapies: 
      Removed: “…or treatments…” 
Events Schedule: 
     Removed: duplicate Endocrine Panels line 
     Moved: from day 4 to day 2: 
                  Physical Examination 
                  Vital Signs 
                  AE Assessment 
                  Serum chemistry 
                  Endocrine panels    
Eligibility Worksheet 
8. Added: “…or greater than 2 weeks post- gamma knife 
therapy…”   


 
4
“Brain Scan (CT/MRI) within a month prior to enrollment” 
Refined Inclusion Criteria (Page 9): 
1. “8. Performance status ECOG 0-1, removed 
Karnofsky >50%” 
 
Refined Inclusion Criteria (Page 30) 
1. “8. Performance Status ECOG 0-1 removed 
Karnofsky >50%” 
1.6 
10/29/2014 
Corrected Version Number in header (1.6) 
Removed “Karnofsky >50%” from Eligibility Checklist (pg 
56) 
 
Section 4.3.6.2 Treatment: 
1. Removed “ to an isodose surface encompassing 
> 90% of the PTV” 
2. Added “Part B fractionation: the PTV will receive 
28.5 Gy in 3 fractions of 9.5 Gy each, delivered 
on alternate days within 1 week, with a minimum 
of 36 hours between fractions.” 
3. Section 8.5- Laboratory correlative studies –    
             Adding language  
     4. Section 8.7 – Shipping of Samples 
1.7 
02/13/2015 
 
 


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5
Table of Contents 
- ............................................................................................................................................................................. 2 
1 
INTRODUCTION .......................................................................................................................................... 13 
1.1 
RESEARCH HYPOTHESES ................................................................................................................................................................... 13 
1.2 
THERAPEUTIC RATIONALE ................................................................................................................................................................. 13 
1.2.1. 
 CTLA-4 and T-Cell Activation ........................................................................................................................................... 13 
1.2.2 
 CTLA-4 receptor blockade ................................................................................................................................................ 14 
1.2.3 
 RT+ CTLA-4 blockade: pre-clinical studies ....................................................................................................................... 15 
1.2.4 
 Abscopal effect of radiotherapy ...................................................................................................................................... 15 
1.2.5 
 Harnessing the pro-immunogenic effects of radiation in cancer treatment: a   new paradigm ..................................... 15 
1.2.6 
 Abscopal effect of RT + ipilimumab in metastatic NSCLC: a case report ......................................................................... 16 
1.2.7 
 Experience of anti-CTLA-4 agents in NSCLC ..................................................................................................................... 18 
1.2.8 
 Immunological checkpoint blockade in NSCLC with anti-PD1 ......................................................................................... 19 
1.2.9  Choice of radiotherapy dose ................................................................................................................................................. 20 
1.2.10 
 Summary of the rationale for the combination .......................................................................................................... 20 
1.3 
 SUMMARY OF RESULTS OF IPILIMUMAB INVESTIGATIONAL PROGRAM ...................................................................................................... 21 
1.3.1 
 Pharmacology ................................................................................................................................................................. 21 
1.3.2 
 Pre-Clinical Toxicology ..................................................................................................................................................... 21 
1.3.3 
 Clinical Safety .................................................................................................................................................................. 22 
1.3.4 
 Immune-Related Adverse Events (irAEs) ......................................................................................................................... 23 
1.3.5 
 Clinical Efficacy ................................................................................................................................................................ 23 
1.4 
OVERALL RISK/BENEFIT ASSESSMENT ................................................................................................................................................. 24 
1.5. 
STUDY RATIONALE ................................................................................................................................................................ 26 
1.5.1 
Combining RT and CTLA-4 blockade ................................................................................................................................. 26 
2 
STUDY OBJECTIVES ..................................................................................................................................... 26 
OBJECTIVE 1 ........................................................................................................................................................................................... 26 
OBJECTIVE  2 ........................................................................................................................................................................................... 26 
3 
STUDY DESIGN ........................................................................................................................................... 26 
3.1 OBJECTIVE 1 ...................................................................................................................................................................................... 26 
3.2 OBJECTIVE 2: .................................................................................................................................................................................. 27 
4 
SUBJECT SELECTION CRITERIA .................................................................................................................... 31 
4.1 
INCLUSION CRITERIA ........................................................................................................................................................................ 31 
4.2 
EXCLUSION CRITERIA ....................................................................................................................................................................... 32 
4.3 
STUDY THERAPY ............................................................................................................................................................................. 32 
4.3.1 
Ipilimumab ....................................................................................................................................................................... 32 
4.3.2 
Dose Modifications ........................................................................................................................................................... 34 
4.3.3 
Discontinuation of Therapy .............................................................................................................................................. 35 
4.3.4 
Immune Related Adverse Events (irAEs): Definition, Monitoring, Treatment .................................................................. 36 
4.3.5 
 Other Guidance ............................................................................................................................................................... 36 
4.3.6 
 Radiation Therapy Guidelines ......................................................................................................................................... 37 
4.4.  
PROHIBITED AND RESTRICTED THERAPIES DURING THE STUDY ............................................................................................................. 39 
4.4.1 
Prohibited Therapies ........................................................................................................................................................ 39 
5 
STUDY PROCEDURES AND OBSERVATIONS (TABLE 4) ................................................................................. 40 
5.1. 
PROCEDURES BY VISIT ................................................................................................................................................................. 41 
5.1.1 
Study Completion or Early Discontinuation Visit .............................................................................................................. 41 
5.1.2 
Study Drug Discontinuation ............................................................................................................................................. 41 
5.2 
DETAILS OF PROCEDURES ................................................................................................................................................................. 41 


Version 2.3 12/04/2015 
 
 
6
5.2.1 
Study Materials ................................................................................................................................................................ 41 
5.2.2 
Safety Assessments .......................................................................................................................................................... 41 
5.2.3 
Cost to Subjects ................................................................................................................................................................ 41 
5.3.1 
Safety Evaluation ............................................................................................................................................................. 42 
5.3.2 
Efficacy Evaluation ........................................................................................................................................................... 42 
5.3.3 
 Definition of Tumor Response using irRC ........................................................................................................................ 43 
5.3.4 
Response Endpoints ......................................................................................................................................................... 45 
5.3.5 
Study Suspension Criteria ................................................................................................................................................. 46 
6 
ADVERSE EVENT REPORTING ...................................................................................................................... 46 
6.1 
COLLECTION OF SAFETY INFORMATION ............................................................................................................................................... 46 
6.2 
REPORTING OF SERIOUS ADVERSE EVENTS (SAES) ................................................................................................................................ 47 
6.3 
PREGNANCY .................................................................................................................................................................................. 48 
7 
STATISTICAL METHODOLOGY ..................................................................................................................... 49 
8 
ADMINISTRATIVE SECTION ......................................................................................................................... 52 
8.1 
COMPLIANCE WITH THE PROTOCOL AND PROTOCOL REVISIONS ............................................................................................................... 52 
8.2 
INFORMED CONSENT ....................................................................................................................................................................... 52 
8.3 
RECORDS AND REPORTS ................................................................................................................................................................... 53 
8.4 
RECORDS RETENTION ...................................................................................................................................................................... 53 
8.5 
LABORATORY CORRELATIVE STUDIES .................................................................................................................................................. 53 
8.6 
STORAGE OF SAMPLES ..................................................................................................................................................................... 53 
8.7 SHIPPING OF SAMPLES ......................................................................................................................................................................... 54 
8.8 
GENETIC TESTING ........................................................................................................................................................................... 54 
9.0 
RESEARCH CONFLICT OF INTEREST ...................................................................................................................................................... 55 
APPENDIX 2: 
LABORATORY CORRELATE MANUAL VERSION 1.4  8.21.2014 ................................................... 61 
APPENDIX 3:   
SUGGESTED WORK-UP AND TREATMENT FOR IMMUNE     RELATED ADVERSE EVENTS (IRAE)S 63 
APPENDIX 4: ........................................................................................................................................................ 65 
APPENDIX 5: ........................................................................................................................................................ 66 
 ............................................................................................................................................................................ 66 
APPENDIX 6: ........................................................................................................................................................ 67 
APPENDIX 7: ........................................................................................................................................................ 68 
 ............................................................................................................................................................................ 68 
APPENDIX 8: ........................................................................................................................................................ 69 
APPENDIX 9:   
LIST OF ABBREVIATIONS........................................................................................................... 70 
REFERENCES ........................................................................................................................................................ 74 
 
LIST OF TABLES 
TABLE 1: BIOLOGICAL EFFECTIVE DOSES OF REGIMENS ........................................... 16 
TABLE 2: RESPONSE AND IMMUNE MEDIATED EVENTS - SUBJECTS EVALUABLE FOR EFFICACY IN MDX-
010-05 (N = 56) ................................................................... 24 
TABLE 3: LIST OF NSCLC ANTIGENS ....................................................................... 24 
TABLE 4: STUDY PROCEDURES AND OBSERVATIONS……………………………………34 
TABLE 5: IRRC DEFINITIONS ................................................................................... 44 


Version 2.3 12/04/2015 
 
 
7
 
 
Protocol Synopsis 
Protocol Title: 
PHASE II STUDY OF COMBINED IONIZING RADIATION AND 
IPILIMUMAB IN METASTATIC NSCLC 
Sites  
NYU Clinical Cancer Center 
160 E. 34th Street 
New York, NY 10016 
Tisch Hospital 
560 First Ave  
 
 
Investigator Names: 
 
Abraham Chachoua, M.D. 
Sandra Demaria, M.D. 
Peter Schiff, M.D., Ph.D. 
Harvey Pass, M.D. 
Kent Friedman M.D. 
Divya Sridhar, M.D. 
Judith Goldberg, Sc.D. 
Olivier Maisonet, NP 
 


Version 2.3 12/04/2015 
 
 
8
Study Schema:  
(Drugs / Doses / 
Length of 
Treatment) 
Eligible patients have metastatic NSCLC who have progressed 
on chemotherapy and who have at least 2 measurable sites of 
disease.  A biopsy of one of the measurable lesions will be 
performed in patients who consent to this optional biopsy. 
Patients will receive ipilimumab (Ipi) 3mg/kg i.v. over 90 minutes, 
within 24 hours of starting radiotherapy (RT) to the biopsied 
lesion, 6 Gy x5 (conformally or by intensity modulated RT (IMRT) 
with image guidance to maximally spare normal tissue). 
Ipilimumab is repeated on days 22, 43 (for patients who consent 
to the first biopsy), and 64. Repeat biopsy will be performed 
between day 22-29, and patients will be re-imaged between day 
81-88 and evaluated for response (defined as an objective 
response by irRC of the measurable metastatic sites outside the 
radiation field). This response will be evaluated assessing clinical 
and computed tomography (CT) responses in the non-irradiated 
measurable metastatic sites using the modified WHO criteria. If 
the initial Phase II trial is terminated after the first stage of the two 
stage design, new patients will be enrolled in Part B at the 
following dosing: 9.5 Gy x3 fractions, with the same dose and 
schedule for ipilimumab.  
Trial Objectives: 
(Primary and 
Secondary) 
Objective 1: Evaluate the safety and therapeutic efficacy of 
anti-CTLA-4 mAb and concurrent local RT in NSCLC patients 
with metastatic disease. 
An open label phase II trial will evaluate the preliminary efficacy 
of the combination of Ipi and RT, applied to a single metastatic 
site. Efficacy is measured with respect to systemic tumor 
responses (abscopal response, outside the field of therapy) 
defined by immune-related Response Criteria (irRC) in all non-
irradiated measurable lesions, as a demonstration of an effective 
anti-tumor immune response. Secondary endpoints include local 
response in the RT treated tumor, progression free survival, and 
overall survival. 
Objective  2: Determine the effects of RT and anti-CTLA-4 
mAb on development of anti-tumor immunity. 
We hypothesize that RT will convert the irradiated tumor into an 
in situ vaccine (3) and elicit an endogenous tumor-specific 
cellular and humoral immune response, which in the presence of  
cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) blockade 
will promote immune-mediated destruction of the irradiated and 
abscopal metastases. Pre- and post-treatment tumor biopsies will 
be examined for changes in immune contexture (4), and blood for 
evidence of emerging anti-tumor immune responses. 
Associations with clinical response will be explored.  


Version 2.3 12/04/2015 
 
 
9
Study Design: 
 
An optimal two-stage Simon design is used to conduct this phase 
II study. Ten patients will be treated in Stage 1; if there are no 
abscopal responses, the trial will be terminated. If there are one 
or more abscopal responses in Stage 1, the trial will proceed to 
enroll an additional 19 patients. If the trial is terminated at the end 
of Stage 1 due to a lack of response, then a second phase II trial 
with an identical design will be conducted using the 9.5 Gy x3 
regimen of radiotherapy and the same dose and schedule of 
ipilimumab. 
Accrual Goal: 
(Total number of 
patients) 
 
We expect to accrue up to a total of 29 patients (29+10=39 
patients if the trial proceeds to the 9.5 Gy x3 regimen) over 2.5 
years. We do not plan to enroll vulnerable populations. 
Accrual Rate: 
(Number of patients 
expected per year) 
15-20 patients 
FPFV: 
(first patient first visit) 
LPLV: 
(last patient last visit) 
Follow Up: 
March 1st, 2014 
 
August 31st, 2016  
 
3 years or until patient’s death  
Correlative Studies: 
(e.g., PK/PD) 
The following exploratory analyses will be carried out using 
descriptive statistics and graphical approaches:  
1. Summary of changes in antibody and T-cells from baseline to 
response evaluation. 
2. Association between abscopal responses and antibody and T-
cell changes from baseline. 
All patients will be followed for progression and survival. Kaplan-
Meier curves for progression-free survival and survival will be 
provided to summarize the results. 


Version 2.3 12/04/2015 
 
 
10 
Inclusion Criteria: 
 
1) Ability to understand and the willingness to sign a written 
informed consent document;  
2) Histologic diagnosis of metastatic NSCLC; 
3) Any Kras or EGFR status is permitted; 
4) Patients must have at least two distinct measurable 
metastatic sites, with one of at least 1 cm or larger in its 
largest diameter. Patients may have additional non-
measurable metastatic lesions (e.g., bone metastases); 
5) Patients must have prior treatment with at least  one line of 
therapy for metastatic NSCLC. Any prior therapy is 
permitted except prior therapy with ipilimumab; 
6) An interval of 2 weeks from last previous therapy is 
required;  
7) Patients must have adequate organ and marrow function 
as defined by initial laboratory tests:  
 
WBC  
 2000/uL 
 
ANC 
 1000/uL 
 
Platelets  
 50 x 103/uL 
 
Hemoglobin   8 g/dL 
 
Creatinine  
 3.0 x ULN 
 
AST/ALT  
 2.5 x ULN, 
or 
 5 x ULN 
if 
liver 
metastases are present.   
 
Bilirubin    3.0 x ULN, (except patients with Gilbert’s 
Syndrome, who must have a total bilirubin  3.0 mg/dL; 
8) Performance status ECOG 0-1; 
9) Men and women, ages > 18 years of age; 
10) Life expectancy > 3 months; 
11) Patients may have brain metastases if these are stable for 
at least 4 weeks or greater than 2 weeks post gamma knife 
therapy and patient is not steroid dependent; 
12) Brain Scan (CT/MRI) prior to enrollment 
13) Women of childbearing potential (WOCBP) must be using 
an adequate method of contraception to avoid pregnancy 
throughout the study and for up to 8 weeks after the last 
dose of Ipi. 


Version 2.3 12/04/2015 
 
 
11 
Exclusion Criteria: 
1) Patients having no lesions outside the field of radiation 
thus nullifying the ability to measure an abscopal effect; 
2) Autoimmune disease: Patients with a history of 
inflammatory bowel disease are excluded from this study 
as are patients with a history of symptomatic disease 
(e.g., rheumatoid arthritis, progressive systemic sclerosis 
[scleroderma]), systemic lupus erythematosus, 
autoimmune vasculitis [e.g., Wegener’s granulomatosis]; 
3) Any underlying medical or psychiatric condition, which in 
the opinion of the Investigator, will make the 
administration of study drug hazardous or obscure the 
interpretation of adverse events (AEs), such as a 
condition associated with frequent diarrhea;  
4) Concomitant therapy with any of the following: IL-2, 
interferon or other non-study immunotherapy regimens; 
cytotoxic chemotherapy; immunosuppressive agents; 
other investigation therapies; or chronic use of systemic 
corticosteroids;  
5) Prior therapy with ipilimumab or another anti-CTLA-4 
antagonist; 
6) Women who are unwilling or unable to use an acceptable 
method to avoid pregnancy for the entire study period and 
for at least 8 weeks after the last dose of Ipi, or have a 
positive pregnancy test at baseline, or are pregnant or 
breastfeeding;  
7) Prisoners or subjects who are compulsorily detained 
(involuntarily incarcerated) for treatment of either a 
psychiatric or physical (e.g., infectious) illness. 


Version 2.3 12/04/2015 
 
 
12 
 
Criteria for 
Evaluation: 
(Efficacy, safety, 
stopping rules, etc.) 
1) CLINICAL ENDPOINTS 
Tumor Response will be evaluated using the irRC best response 
(Partial Response (PR) + Complete Response (CR)). Modified 
WHO criteria will be used for measurement of tumors. The 
irradiated lesion will be excluded from the assessment of 
response. 
2) IMMUNOLOGICAL ENDPOINTS 
We propose to analyze immunological changes that reflect both 
local and systemic responses, and investigate both general 
immune activation as well as tumor antigen-specific T- and B-cell 
responses. Serial blood samples will be collected for serum and 
peripheral blood mononuclear cells (PBMC): at baseline (pre-
treatment), 3 weeks after initiation of Ipi (end of first cycle), end of 
third cycle of Ipi (~9 weeks), and at evaluation of response (3 
months). An additional sample will be collected at 6 months 
follow up. Small aliquots of PBMC (~106 cells) will be used ex 
vivo for preparation of DNA and RNA, and the remainder 
preserved frozen until evaluation by flow cytometry and/or by 
functional assays. Optional tissue biopsies will be obtained at 
baseline in all patients as well as a post-treatment biopsy, 
performed at 3 weeks in patients who receive RT to an 
accessible metastasis.  
Statistics 
The abscopal response rate with confidence limits will be 
estimated at the end of the second stage with a total of 29 
patients from both stages combined. If the true response rate is 
20%, a 96.7% confidence interval equal to the observed 
proportion +/-14.5% will be produced with 29 patients. 
The distribution of types of outcomes with respect to target (non-
irradiated & measurable) and non-target (irradiated) lesions will 
be summarized. 
  


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13 
1 
INTRODUCTION 
1.1 
Research Hypotheses 
a) Through a combination of local RT and ipilimumab an anti-tumor immune response is 
elicited at the irradiated site, as an in vivo, individualized immunization that is systemically 
effective, as reflected by objective responses outside the RT field (abscopal effect). 
b) The immune response can be prospectively monitored among the treated patients. 
1.2 
Therapeutic Rationale 
Manipulation of the immune system to recover a patient’s endogenous anti-tumor immune response 
is a strategy that has the advantages of being both natural and potentially long-lasting.(5, 6) We 
propose to combine immunotherapy with radiotherapy directed at a metastatic site with the goal of 
creating a hub for in vivo immunization against the tumor in order to enable immune mediated tumor 
rejection at other metastatic sites. This approach to in vivo immunization is explored as a viable 
alternative to an individualized vaccine. Pre-clinical data generated by us and others support the 
initiation of a proof of principle clinical trial that may open the field to an alternative use of 
radiotherapy in a novel partnership with cancer immunotherapy.(7-9) 
In addition, we will perform immune monitoring of the patients accrued to the trial to generate 
important information for hypothesis driven laboratory research investigating the mechanisms behind 
the clinical findings. 
1.2.1.  
CTLA-4 and T-Cell Activation 
Figure 1.2.1 Mechanism of Action 
 
Advances in the understanding of the mechanisms that regulate T-cell activation have allowed the 
rational design of new strategies for immunotherapy of tumors. Engagement of the T-cell antigen 
receptor by itself is not sufficient for T-cell activation; a second co-stimulatory signal is required for 
induction of IL-2 production, proliferation and differentiation to effector function of naive T-cells. 
Abundant data now indicate that the primary source of this co-stimulation is mediated by engagement 
of CD28 on the T-cell surface by ligands of the B7 family on the antigen presenting cell (APC).(10) 
Refer to Figure 1.2.1. Expression of B7 has been shown to be limited to “professional” antigen 
presenting cells; that is, specialized cells of the hematopoietic lineage, including dendritic cells, 


Version 2.3 12/04/2015 
 
 
14 
activated macrophages, and activated B cells. It has been suggested that this sharply-defined 
restriction of B7 expression is a fail-safe mechanism for maintenance of peripheral T-cell tolerance, 
insuring that T-cell activation can only be stimulated by appropriate APCs.(11) The fact that tumor 
cells do not express B7 contributes to their poor capacity to elicit immune responses.(12, 13) The 
demonstration that induction of expression of B7 on many tumor cells by transfection, transduction, or 
other mechanisms, can heighten tumor immunogenicity led to great interest in pursuing this as an 
approach to tumor immunotherapy. As demonstrated in vivo in murine tumor models, the utility of B7 
expression as a vaccination approach is limited by the following factors: (1) B7-expressing tumor cell 
vaccines are only effective when the tumor cells have a high degree of inherent immunogenicity; (2) 
while B7-expressing vaccines have been shown in many cases to be effective in inducing protective 
immune responses, they have demonstrated only limited utility in inducing responses to established 
tumors; and (3) inactivation of tumor cells by radiation has been shown to destroy the immuno-
enhancing activity of the B7 gene product.(14, 15) 
 
In the past few years it has become apparent that co-stimulation is even more complex than originally 
thought. After activation, T-cells express CTLA-4, a close homologue to CD28. CTLA-4 binds 
members of the B7 family with a much higher affinity than CD28.(16) Although there was initially some 
controversy as to the role of CTLA-4 in regulating T-cell activation, it has become clear that CTLA-4 
down-regulates T-cell responses.(17) This was initially suggested by the following in vitro 
observations: (1) blockade of CTLA-4/B7 interactions with antibody enhanced T-cell responses; 
(2) cross-linking of CTLA-4 with CD3 and CD28 inhibited T-cell responses; and (3) administration of 
antibodies to CTLA-4 in vivo enhanced the immune response to peptide antigens or superantigens in 
mice.(18-21) Blocking CTLA-4-B7 interaction while preserving signaling via CD28 resulted in 
enhanced T-cell responses in vitro.(19) 
1.2.2  
CTLA-4 receptor blockade 
The identification of multiple tumor-associated antigens (TAA) in recent years has provided many 
good potential targets for vaccination. The ability of cytotoxic T-cells (CTL) to eradicate cancers has 
been unequivocally demonstrated in experimental models.(22) Clinical trials have also provided the 
proof of principle that it is possible to treat cancer successfully by immune manipulation.(23, 24) 
However, significant clinical responses of patients with established vascularized tumors are difficult to 
achieve with most immunotherapy (IT) strategies. Major recognized obstacles are the tolerance that 
is established by the time a tumor becomes clinically apparent, and the immunosuppression 
associated with tumor progression. The inhibitory CTLA-4 receptor is a key player in tolerance 
maintenance.(25) Although CTLA-4 is required for normal lymphoid homeostasis, in conditions of 
suboptimal APC function such as in tumor-bearing hosts, the transient removal of CTLA-4-mediated 
inhibition (CTLA-4 blockade) has been shown to induce effective anti-tumor immunity.(26, 27) 
However, the efficacy of CTLA-4 blockade as a single treatment is limited to intrinsically immunogenic 
tumors. For poorly immunogenic tumors, like most human cancers, CTLA-4 blockade needs to be 
combined with a granulocyte-macrophage colony-stimulating factor (GM-CSF)-producing vaccine 
that, by itself, is otherwise effective in a prophylactic but not therapeutic setting.(28, 29) Results from 
recent clinical trials show that CTLA-4 blockade is one of the most powerful strategies to induce 
active anti-tumor immunity, and emphasize the importance of integration of this modality with some 
form of vaccination.(30) 


Version 2.3 12/04/2015 
 
 
15 
1.2.3  
RT+ CTLA-4 blockade: pre-clinical studies 
Ionizing radiation has been shown to alter the tumor milieu by enhancing trafficking of immune cells, 
induction of cytokines and co-stimulatory molecules and promotion of cross-priming (reviewed in 
ref (7)). We have applied the term “abscopal” (ab-scopus, away from the target, originally introduced 
by Mole et al.(31) in a different setting) to define a systemic effect elicited by radiotherapy in the 
presence of immunotherapy.(32) 
We have shown in the poorly immunogenic 4T1 mouse mammary carcinoma model that local 
radiation therapy to established primary tumors elicits effective CD8+ T cell mediated anti-tumor 
responses when combined with CTLA-4 blockade.(33) The elicited immune response was effective 
against spontaneous lung metastases as well as the primary tumor. Regressing primary tumors had 
increased infiltration by activated CD8+ T-cells, and an expanded pool of tumor-specific memory 
CD8+ T-cells could be demonstrated in cured mice. These results demonstrate that RT to the primary 
tumor in combination with CTLA-4 blockade induces a therapeutically effective anti-tumor response, 
and it may provide antigenic stimulation similar to vaccination with irradiated autologous tumor cells. 
1.2.4  
Abscopal effect of radiotherapy 
Originally described by R.H. Mole in 1953, the abscopal effect of radiotherapy is a remote effect of 
ionizing radiation on malignancy outside the radiation field.(31) The phenomenon was named the 
abscopal effect, from the Latin ab (position away from) and scopus (mark or target). Other 
investigators, over the years, have reported findings consistent with the abscopal effect definition, 
possibly as an occasional result of recovered anti-tumor immunity after radiotherapy.(34-36) The 
mechanism remains unexplained, although a variety of mechanisms can be hypothesized,(37) and 
recent research has re-focused on the immunological effects mediated by radiation.(32, 37, 38) 
1.2.5  
Harnessing the pro-immunogenic effects of radiation in cancer treatment: a  
 
new paradigm 
Experimental work done in two syngeneic mouse models of Lewis lung tumors and mammary 
carcinoma, testing radiotherapy with FLT-3 ligand (a growth factor for dendritic cells), demonstrated 
the induction of an immune response that reduced tumor growth outside the field of radiation (32, 39). 
The findings inspired a trial testing the combination of subcutaneous GM-CSF (125 μg/m2) with 
radiotherapy to a metastatic site in patients with metastatic solid tumors. GM-CSF increases the 
percentage of dendritic cells and their maturation, facilitating cross-presentation of newly released 
antigens after cell death at the site of radiotherapy. With a standard radiation fractionation of 3.5 Gy 
x10 fractions, an abscopal response was detected in 27% of the patients accrued to the trial(40). 
Abscopal responses were also detected among 15 patients with low-grade B-cell lymphoma treated 
by low-dose radiotherapy to a single tumor site that was injected with a synthetic 
oligodeoxynucleotide (also referred to as CpG) that targets TLR9 (pf-3512676). These compounds 
can activate both lymphoma B-cells as well as nearby antigen-presenting cells, particularly 
plasmacytoid DC, as previously demonstrated in a murine lymphoma model (41). 
Another combination strategy to overcome immune tolerance consists of the blockade of CTLA-4, a 
negative regulator of T-cell activation. Prolonged survival and some cures occurred in a syngeneic 
model of poorly immunogenic, metastatic breast carcinoma, a process requiring CD8+ T-cells (33). 
Postow et al.(42) recently reported a clinical case report with the same combination. A melanoma 
patient with disease progression while receiving ipilimumab, a monoclonal antibody that targets 
CTLA-4, was treated with hypo-fractionated radiotherapy to a pleural-based paraspinal metastasis; 


Version 2.3 12/04/2015 
 
 
16 
several other pre–existing metastases in the spleen and in the right lung hilum, (outside the radiation 
field) completely regressed, and remained controlled for an additional eight months. Importantly, 
immuno-monitoring of several markers, including antibody response to NY-ESO-1 mirrored the 
clinical course. Seromic analysis detected 10 antigenic targets with enhanced antibody responses 
after radiotherapy. A similar effect was previously reported in a study of radiation with a recombinant 
cancer vaccine to prostate cancer (43). These results, although still anecdotal, support the concept 
that local radiotherapy and immunotherapy can synergize to produce a therapeutically effective anti-
tumor immune response. 
Combining radiotherapy with immunotherapy presents considerable advantages. Because of its 
localized nature, radiotherapy is devoid of most systemic effects commonly encountered with 
chemotherapy, and it limits interference with systemic immunotherapy. Moreover, a radiotherapy-
focused intervention on the tumor may selectively subvert its micro-environment and in combination 
with the optimal immune intervention, may ideally render the cancer an in situ, individualized, vaccine. 
The phase III randomized trial of ipilimumab (3 mg/kg) alone versus ipilimumab (3 mg/kg) with gp100 
vaccine versus gp100 vaccine alone in previously treated metastatic melanoma patients 
demonstrated an improvement in overall survival in both ipi alone and ipi with vaccine arms of 4 
months when compared to vaccine alone. The best overall response rate was 11%. 46% of ipi treated 
patients were alive at 1 year and 24% were alive at 2 years demonstrating prolonged disease 
control.(44) Because of the ability of local radiotherapy to convert the irradiated tumor in an 
individualized vaccine, we predict that its role as an adjuvant to ipilimumab may be more successful. 
To test this hypothesis we are currently conducting a trial of metastatic melanoma where patients are 
randomly assigned to first line ipilimumab or ipilimumab plus radiation to a selected metastatic lesion: 
endpoint of the trial are objective response rate and survival (NCT01689974).  
Finally, the promising data on the effect of ipilimumab in melanoma and our pre-clinical data in murine 
models of mammary and colorectal carcinomas suggest that this effect of RT with ipilimumab is 
translatable to all solid tumor types. Consistently we attempted the combination in a patient with 
metastatic NSCLC, and confirmed the abscopal effect. 
1.2.6  
Abscopal effect of RT + ipilimumab in metastatic NSCLC: a case report 
We recently reported the first abscopal case in a NSCLC patient who had undergone radiotherapy to 
a metastatic lesion followed by 4 cycles of ipilimumab (45). 
A 64 year-old Caucasian male with a 70 cigarette-pack-year history presented in March 2010 with a 
palpable left supraclavicular node. An excisional biopsy of the mass demonstrated metastatic 
adenocarcinoma with an immunohistochemical profile consistent with a lung primary (CK7 and TTF--‐1 
positive and CK20 and CDX2 negative). The patient’s initial PET/CT demonstrated 2 right upper lobe 
nodules, a left lower lobe nodule, and right supraclavicular and bilateral hilar/mediastinal adenopathy. 
He was staged T1bN3M1a (stage IV), according to the American Joint Commission Cancer 7th 
edition cancer staging manual. The patient was initiated on pemetrexed 500 mg/m2 and carboplatin 
(area under the curve, 5) given every 3 weeks for 6 cycles. After the 6th cycle, PET/CT demonstrated 
a decrease in size and metabolic activity of both the right supraclavicular adenopathy (from 2.8 x 1.7 
cm and SUV of 10.2 to 2.0 x 1.2 cm and SUV of 3.8) and the left lower lobe nodule (from 6 mm and 
SUV of 2.3 to 3 mm and undetectable SUV). The 2 right upper lobe nodules and hilar/mediastinal 
nodal disease remained stable in size and metabolic activity. 
The patient, thereafter, continued maintenance therapy with pemetrexed 500 mg/m2 BSA alone, given 
every 3 weeks. However, after 3 cycles, he developed severe lower extremity cellulitis, at which point 


Version 2.3 12/04/2015 
 
 
17 
the pemetrexed was temporarily discontinued. After antibiotic treatment and resolution of the cellulitis, 
the patient received an additional 3 cycles of pemetrexed and subsequently underwent a repeat 
PET/CT. The PET/CT revealed stable disease in the right upper lobe and left lower lobe nodules and 
improvement in the size and metabolic activity in the right supraclavicular (now 1.0 x 0.8 cm, SUV 3.3) 
and hilar/mediastinal adenopathy (now subcentimeter, SUV 3.4). 
From February 2011 to April 2011, systemic chemotherapy was interrupted to start RT to the 
metabolically active right lung nodules and the right supraclavicular, hilar, and mediastinal 
adenopathy to a total dose of 59.4 Gy distributed over 33 fractions. The patient’s subsequent chest 
CT in May and July 2011, in comparison to his RT pretreatment imaging, demonstrated a decrease in 
size of the irradiated pulmonary nodules and adenopathy. However, in September 2011, a 
surveillance PET/CT revealed increased metabolic activity and size of the right upper lobe nodule 
(now 1.9 x 1.0 cm, SUV 4.7, and a separate ill defined but growing mass, SUV 3.3 up from 1.7) and 
the previously seen left lower lobe nodule (now 0.9 x 0.7 cm, SUV 4.3). The patient resumed 
treatment with pemetrexed 500 mg/m2 BSA alone, given every 3 weeks for an additional 10 cycles. 
A June PET/CT revealed progression with new FDG avid hepatic lesions, new periaortic 
adenopathy, and a new bony lesion in the sacrum. Additionally, the right upper lobe and left lower 
lobe nodules and hilar/mediastinal adenopathy demonstrated an increase in metabolic activity. The 
patient was then treated with gemcitabine 750 mg/m2 and vinorelbine 30 mg/m2 given every 2 
weeks. After the 4th cycle, in August 2012, a PET/CT demonstrated further disease progression, 
including multiple new hypermetabolic foci in the liver without CT correlate (SUV 14), growth of 
multiple new lytic lesions in the bony pelvis (SUV 53 on left, SUV 12.8 on right, SUV 6.6 in midline, 
SUV 23 in lateral left iliac wing lesion, and 5.3 in medial lesion), thoracolumbar spine (SUV 21.6 in 
T6, 56 in L2, and 8.5 in L4 lesions), and right humerus. In addition to the new skeletal lesions, the 
disease in the chest also progressed, including the left lower lobe nodule (now 1.9 x 1.2 cm, SUV 
23.1), mediastinal lymph node (now 1.4 x 1.2 cm, SUV 7), right hilar lymphadenopathy (e.g., 
superior LN 1.1 x 1.1 cm, SUV 13.2, and inferior LN 1.8 x 1.2, SUV 23).  
The 
patient 
was 
thereafter 
initiated 
on 
ipilimumab 
(received 
as 
a 
compassionate 
exemption) and local RT to one of the hepatic 
metastases with the intent to generate an 
abscopal response. The experimental nature of 
this approach was extensively discussed with 
the patient, who was informed of the only two 
available reports in melanoma and the lack of 
available evidence for NSCLC patients. The 
patient was simulated in the supine position and 
his CT/simulation was registered to the August 
2012 PET/CT for treatment planning purposes 
(Figure 2). The most metabolically active liver 
mass, located in the caudate lobe, was selected 
as the RT target and contoured as the gross 
tumor volume (GTV). An additional 0.5 cm 
margin was added to create a clinical target 
volume (CTV) and another 0.5 cm margin was 
added to the CTV to create a planning target 
volume (PTV) (Figure 1). RT to a total dose of 30 
Gy distributed over 5 fractions was delivered 
Figure 2. PET/CT images and match CT-Simulation 
cuts with isodose distribution for treatment of a single 
metastatic liver lesion. 


Version 2.3 12/04/2015 
 
 
18 
over a period of 10 days with 6-MV photons and a coplanar 5-field intensity-modulated technique 
(Figure 2). The day after the first RT fraction, the patient was infused with ipilimumab (3 mg/kg). 
Thereafter, the patient completed 3 more cycles of ipilimumab (3 mg/kg) infused at 3 week intervals. 
The patient tolerated RT and ipilimumab without any treatment related adverse events. Maintenance 
infusions of ipilimumab were not given afterwards.  
After treatment with RT in combination with ipilimumab, a post-treatment chest CT (November 2012) 
and PET/CT (January 2013) demonstrated a dramatic treatment response of the patient’s known 
disease with a near complete response. Not only was an objective response detected in the RT field, 
but striking responses were also observed at distant sites. The multiple hypermetabolic liver 
metastases completely resolved, both within and outside of the site of RT. Additionally, there was 
complete resolution of the myriad non-irradiated osseous metastases. Furthermore, there was a 
decrease in the size and metabolic activity of the left lower lobe nodule (now 0.9 x 0.7 cm with 
minimal FDG avidity, down from 1.9 x 1.1 cm, SUV 17.2) and complete resolution of the previously 
irradiated right upper lobe nodule. The one area of increased metabolic activity was in the right hilar 
lymph nodes, which went from SUV 4 up to 5.4. 
An increase in absolute lymphocyte count (ALC) and absolute eosinophil count (AEC) were noticed 
after ipilimumab treatment, two biomarkers that were associated with improved survival in ipilimumab-
treated melanoma patients (Figure 3A). We observed that the ALC increased after RT and ipilimumab 
treatment (1100/µl of whole blood at baseline, 2700/µl of whole blood at peak levels, and 2200/µl of 
whole blood prior to the third infusion of Ipi) and that the AEC increased between the first two 
infusions of Ipi (200/µl of whole blood prior to the first infusion and 470/µl of whole blood prior to the 
second infusion of Ipi). Additionally, the post-treatment CEA levels 
returned 
to 
normal 
after 
reaching a peak of 119.6 ng/ml one week following RT to the liver 
lesion. 
A recent PET/CT on September 15, 2013 documented a persistent radiographic response with 
minimal systemic disease.  
1.2.7  
Experience of anti-CTLA-4 agents in NSCLC 
There is evidence that ipilimumab combined with chemotherapy is effective and safe in patients with 
recurrent or stage IIIB/IV NSCLC. In a phase II study by Lynch, et al, 204 patients were randomized 
to treatment with carboplatin (area under the curve = 6) and paclitaxel (175 mg/m2) infused every 
three weeks with or without ipilimumab (10 mg/kg). Patients receiving Ipi were divided into two 
groups, a concurrent group who received Ipi starting with the first dose of chemotherapy, and a 
phased group who started Ipi with the third cycle of chemotherapy. Patients without disease 
progression or adverse effects from ipilimumab continued with maintenance therapy once every 12 
weeks. The study met its primary endpoint of improved immune-related PFS (irPFS, which takes into 
account tumor regression in the presence of new lesions) with the phased regimen (median 5.7 
months, hazard ratio (HR) 0.72, p = 0.05), but not with the concurrent regimen (median 5.5 months, 
HR 0.81, p = 0.13), as compared to chemotherapy alone (median 4.6 months). The phased regimen 
was also associated with a significant improvement over chemotherapy alone in PFS (median 5.1 
months vs. 4.2 months) and immune-related best overall response rate (irBORR, 32% vs. 18%), an 
improvement not seen in the concurrent Ipi group (median PFS 4.1 months, irBORR 21%). Of note, 
on subset analysis there appeared to be a greater improvement in PFS for the phased Ipi regimen for 
patients with squamous cell carcinoma (HR 0.4 [95% CI, 0.18 to 0.87]) as compared with patients 
with non-squamous cell histology (HR 0.82 [95% CI, 0.52 to 1.28]). All three regimens had tolerable 
safety profiles, with grade 3 or 4 treatment related AE rates of 39% for the phased regimen, 41% for 
the concurrent group, and 37% for the chemotherapy alone group, with more immune-related AEs 


Version 2.3 12/04/2015 
 
 
19 
reported in the groups that received Ipi (e.g., rash, pruritus, and diarrhea) (46).  
Anti-CTLA-4 treatment has also been tested as monotherapy in patients with locally advanced or 
metastatic NSCLC after ≥4 cycles first-line platinum based chemotherapy, albeit with less success. 
Zatloukal, et al, presented in abstract form the results of a smaller randomized phase II study (n = 87) 
comparing a humanized immunoglobulin G (IgG)2 monoclonal antibody (mAb) antagonist of CTLA--‐4 
(tremelimumab) with best supportive care in patients without radiographic evidence of disease 
progression by Response Evaluation Criteria in Solid Tumors (RECIST). Tremelimumab (15 mg/kg, 
based on phase I and II trials in melanoma) was administered intravenously (i.v.) every 90 days until 
disease progression. Tremelimumab was generally well tolerated, with 20.5% of patients 
experiencing grade 3 or 4 AEs, and while the only 2 partial responses were in the tremelimumab arm, 
the treatment did not significantly improve PFS (20.9% vs. 14.3%).(47)  
1.2.8  
Immunological checkpoint blockade in NSCLC with anti-PD1 
Based on the promising results of immunotherapy using checkpoint inhibitors such as Ipi in the 
malignant melanoma trials, and the early results seen with NSCLC, interest in other immune 
checkpoints and their inhibitors have grown rapidly. One such immune checkpoint is regulated by the 
programmed death receptor 1 (PD1). Engagement of PD1 on activated T-cells by its ligands PD-L1 
and PD-L2 results in T-cell inactivation and functions as part of the network of immune checkpoints to 
prevent uncontrolled inflammation and autoimmunity. Some tumors can subvert anti-tumor immunity 
and induce immune tolerance by expressing PD-L1. Monoclonal antibodies that block the PD-L1 
interaction with PD1 can effectively release this “break” on the anti-tumor immune response and 
restore T-cell activation and effector function. 
BMS-936558 is a humanized IgG4 mAb with high affinity for PD1, blocking its binding to both PD-L1 
and PD-L2. This antibody was recently evaluated as monotherapy in a phase IB clinical trial with an 
expansion cohort in NSCLC.(48) Patients (n = 122) with advanced NSCLC refractory to at least one 
prior chemotherapy regimen were treated with this mAb infused i.v. every 2 weeks for up to 2 years. 
Eligibility criteria included ECOG performance status ≤1, and patients could have no history of 
autoimmune conditions or any evidence of brain metastases. Overall, therapy was well tolerated with 
only 9% (n = 11) experiencing a grade 3 or higher toxicity, including fatigue (n = 2), pneumonitis (n = 
2) and elevated AST (n = 2). Overall response rate by RECIST 1.0 criteria was 16%. Responses 
tended to be long lasting, although follow-up interval was insufficient to determine duration of 
response or OS, however, PFS at 24 weeks was 33%. There was an initial suggestion that patients 
with squamous cell carcinoma may be slightly more responsive to the treatment, but more recent data 
presented in abstract form shows no difference in response based on tumor histology (49).  
More modest results were obtained in the first in human trial of a mAb antagonist of PD-L1, BMS 
936559. In this phase I trial, anti-PD-1L mAb was administered i.v. (dose escalation from 0.3 to 10 
mg/kg) every two weeks to 207 patients with advanced cancers, including 75 with NSCLC.(50) Of the 
75 patients with NSCLC, 49 patients were evaluable for response. Objective response was seen in 
five of the 49 patients. Tumor response was seen in squamous (1 of 13 patients, 8%) and non-
squamous (4 of 36 patients, 11%) histologies. An additional six (12%) patients had stable disease for 
at least six months. The most common treatment related adverse events were fatigue, infusion 
reactions, and diarrhea.  


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20 
These trials demonstrate that checkpoint blockade is a safe and potentially effective treatment option 
for patients with NSCLC, and that immunological manipulation can be successful even in patients 
with advanced NSCLC.  
1.2.9  Choice of radiotherapy dose 
We have shown in two syngeneic murine tumor models from mice of different genetic background, 
mammary carcinoma TSA (BALB/c) and colorectal carcinoma MCA38 (C57BL/6), that fractionated  
RT regimens (6 Gy x5 and 8 Gy x3) were able to convert these unresponsive tumors into tumor 
responsive to anti-CTLA-4 mAb (51). Conversely a single RT dose of 20 Gy failed to show efficacy. In 
collaboration with Drs. MJ Aryankalayil and CN Coleman (NCI Experimental Therapeutics Section, 
Radiation Oncology Branch), we have analyzed the gene expression profiles in TSA tumors in vivo 
immediately after RT. Data show the rapid induction of immune response genes by the fractionated 
but not single dose RT regimen with a dominant type I IFN response emerging, which was confirmed 
by qRT-PCR. Data suggest that fractionated RT can convert an unresponsive tumor into one 
responsive to anti-CTLA-4 at least in part by inducing an active immune microenvironment, an 
hypothesis that will be tested in the proposed studies. 
While the pre-clinical data support the choice of fractionated radiotherapy for the proposed 
combination with anti-CTLA-4, the optimal radiation dose per fraction remains undetermined.  Table 1 
reports the currently available clinical data. Based on the linear-quadratic model (52) and with the 
assumption of α/β = 10 Gy for tumor, none of 
the regimens used in the 2 published clinical 
reports of abscopal effects during CTLA-4 
blockade in melanoma and in our case of 
NSCLC, used biological effective doses 
(BEDs) for tumor control comparable to those 
attributed to an ablative regimen of 20 Gy x3 
(equivalent to BED10=180).(53) Despite a 
much lower BED than that predicted to result 
in tumor ablation, in each of the examples 
quoted in Table 1 a complete remission was 
observed at the irradiated site, supporting a 
direct contribution of the immune system. 
Interestingly, the BEDs for the regimens used 
in the cases of abscopal responses were 
within a close range. In the NSCLC case report summarized above the regimen used (6 Gy x5, 
BED10=48) successfully and persistently eliminated the liver metastasis in the field, suggesting a 
contribution of the immunotherapy with anti-CTLA-4. Importantly, no complications associated with 
the combination in this dose range of RT and ipilimumab were reported. This limited but relevant 
information has informed the design of the proposed trial. Noticeably, the regimen used by Postow et 
al, adopted a dose per fraction of 9.5 Gy. Dose per fraction in excess of a threshold of 8 Gy have 
shown to cause endothelial cell death and best leverage the radiation effects on the tumor 
vasculature (54). Whether these effects are also required for an optimal combination of RT and 
immunotherapy remains to be determined. 
1.2.10  
Summary of the rationale for the combination 
In metastatic NSCLC, the use of radiotherapy is reserved to palliation. We have shown in different 
Table1: Biological Effective Doses of Regimens 
Biological effective doses (BED) of regimens used in case 
reports of abscopal responses from RT and ipilimumab, 
compare to RTOG-defined ablative dose  
 References 
RT 
regimen 
used 
BED10  
Postow et al(1) 
9.5 Gy x3 
55.57 
Stamell et al(2) 
8 Gy x3 
43.2 
Golden et al (45) 
6 Gy x5 
48 
RTOG ablative dose 
20 Gy x3 
180 


Version 2.3 12/04/2015 
 
 
21 
mouse tumor models that RT is a potent partner for anti-CTLA-4 and can convert tumors 
resistant to single agent anti-CTLA-4 into susceptible ones.(51, 55, 56) Importantly, anti-tumor 
CD8 T-cells activated by the combination of local RT and anti-CTLA-4 not only contributed to the 
response within the irradiated field but also inhibited metastases outside of the RT field, and long-
term protective memory responses were generated in mice achieving complete tumor rejection (51, 
55-58). An analogous effect was recently reported in a case of melanoma (59) and the first reported 
case of NSCLC described above. Therefore, anti-tumor immune responses generated by the 
combination of RT and anti-CTLA-4 in pre-clinical models and clinical settings resistant to anti-CTLA-
4 monotherapy (60, 61) suggest a role for RT as a powerful immune adjuvant that can recruit 
into response otherwise non responsive patients to treatment with anti-CTLA-4.  
Since CTLA-4 blockade alone has demonstrated limited activity in NSCLC, abscopal responses in 
this trial are very likely to reflect the specific efficacy of the combination, as inferred by our pre-clinical 
data(62). Based on this background and rationale we are proposing a phase II study of combined 
ionizing radiation and ipilimumab in metastatic NSCLC. 
The optimal regimen for this combination has yet to be defined: we will start with the regimen 
successful at inducing an abscopal effect in the NSCLC patient reported above. Within a Simon 
design, patient accrual will continue to the second stage only if at last one abscopal response is 
observed among the first 10 patients. Conversely, in the absence of an abscopal response within  the 
first 10 patients treated with 6 Gy x5, a new group of 10 patients will be treated with the same dose 
and schedule of ipilimumab but at a higher dose of RT, 9.5 Gy x3, the dose-fractionation regimen 
from the Postow case report of abscopal response.(1) If testing at the higher dose-fractionation level 
proves effective at inducing abscopal effects, it will suggest a key role for endothelial cell death and 
will stimulate more pre-clinical work in such a direction. 
1.3 
 
Summary of Results of Ipilimumab Investigational Program 
1.3.1  
Pharmacology 
Ipilimumab is a humanized IgG1κ anti-CTLA-4 monoclonal antibody. Studies performed in vitro with 
ipilimumab have demonstrated that it binds specifically to CTLA-4, actively inhibits CTLA-4 
interactions with B7.1 and B7.2, does not show any cross-reactivity with human cell lines deficient of 
B7.1 and B7.2, and stains the appropriate cells without non-specific cross-reactivity in normal human 
tissues, as demonstrated by immunohistochemistry. Ipilimumab does cross-react with CTLA-4 in non-
human primates including cynomolgus monkeys. 
Ipilimumab was originally produced and purified from a B-cell hybridoma clone. Subsequently, a 
transfectoma (CHO cell) was generated that is capable of producing more ipilimumab on a per cell 
basis than the hybridoma. Material from the transfectoma will be utilized in this and future ipilimumab 
clinical studies. Biochemical, immunologic, and in vivo pre-clinical primate assessments 
demonstrated similarity between hybridoma and transfectoma derived ipilimumab.  
1.3.2  
Pre-Clinical Toxicology 
Complete information on the pre-clinical toxicology studies can be found in the ipilimumab 
Investigator Brochure (IB). Non-clinical toxicity assessments included in vitro evaluation for the 
potential of ipilimumab to mediate complement-dependent cytotoxicity (CDC) or antibody-dependent 
cellular cytotoxicity (ADCC), and toxicology assessments in cynomolgus monkeys alone and in the 
presence of vaccines. 


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22 
The in vitro studies demonstrated that ipilimumab did not mediate CDC or ADCC of PHA- or anti-
CD3-activated human T-cells. These data are consistent with the requirement of high levels of 
antigen expression on the surface of target cells for efficient ADCC or CDC. Since ipilimumab is a 
human IgG1, an isotype capable of mediating CDC and ADCC, the lack of these activities is likely 
due to a very low expression of CTLA-4 on activated T-cells. Therefore, these data suggest that 
ipilimumab treatment would not result in depletion of activated T-cells in vivo. Indeed, no depletion of 
T-cells or T-cell subsets were noted in toxicology studies in cynomolgus monkeys. 
No mortality or signs of toxicity were observed in three independent 14 day intravenous toxicology 
studies in cynomolgus monkeys at multiple doses up to 30 mg/kg/dose. Furthermore, ipilimumab was 
evaluated in sub-chronic and chronic toxicology studies in cynomolgus monkeys with and without 
Hepatitis B vaccine and melanoma vaccine. Ipilimumab was well tolerated alone or in combination in 
all studies. There were no significant changes in clinical signs, body weight, clinical pathology values 
or T-cell activation markers. In addition, there were no significant histopathology changes in the 
stomach or colon. 
1.3.3  
Clinical Safety 
Ipilimumab immunotherapy was FDA approved for the treatment of metastatic melanoma in March 
2011. Randomized phase III trials demonstrated an overall survival benefit, and patients who 
responded had an extended duration of response with almost 50% of responders alive at one year 
and 25% alive at two years, as reported in the original publication of this trial.(44) Recently, updated 
long term survival data was presented in abstract form at the European Cancer Conference 2013 with 
pooled patient data from 12 studies with a total of 1861 patients treated with Ipi, including the 790 
patients enrolled in the two major phase III trials, MDX010-20 and CA184-024. They reported an OS 
of 22% at 3 years with most of these patients surviving at 10 years (63). 
Ipilimumab has been administered to over 14,000 patients with different cancers with a dose range 
between 0.1 mg/kg and 20 mg/kg. Most experience with ipilimumab exists at the 3 mg/kg and 
10 mg/kg dose levels. Patients who received ipilimumab at 3 mg/kg were treated in clinical trials 
conducted early in the development program and received either a single or multiple injections. 
Based on a Phase III randomized trial,(44) ipilimumab was FDA approved for the treatment of 
metastatic melanoma in 2010 at the recommended dose of 3 mg/kg. This will be the dosage used in 
this trial. 
1.3.3.1 
Drug Related Serious Adverse Events (SAEs): 
Drug-related adverse events were reported in studies with ipilimumab as monotherapy as well as in 
combination in which ipilimumab was administered with vaccines, cytokines or chemotherapy. 
The AE profile of ipilimumab is relatively well characterized with drug-related AEs mostly being 
immune-related adverse events (irAEs), which are considered to be associated with the mechanism 
of action of ipilimumab. Most common irAEs are colitis and diarrhea, rash, pruritus, deficiencies of 
endocrine organs (pituitary, adrenal or thyroid), hepatitis, and uveitis. Rare complications are bowel 
perforations (~1%) resulting from underlying severe colitis, which have required surgical intervention.  
Drug-related Grade 3 or 4 SAEs include: rash/desquamation, pruritus, uveitis, speech impairment, 
abdominal pain, diarrhea/colitis, nausea/vomiting, transaminase elevation, adrenal insufficiency, 
panhypopituitarism and atrial fibrillation. Some of these events, such as rash/desquamation, pruritus, 
uveitis, diarrhea/colitis, transaminase elevation, adrenal insufficiency and panhypopituitarism, may 


Version 2.3 12/04/2015 
 
 
23 
represent drug induced irAEs (see Section 4.3.4). Please refer to the most recent version of 
Investigator’s Brochure for the latest update on SAEs. 
1.3.4  
Immune-Related Adverse Events (irAEs) 
Many of the adverse events considered related to ipilimumab may be immune in nature and 
presumably a consequence of the intrinsic biological activity of ipilimumab. An immune-related 
adverse event is defined as any adverse event associated with drug exposure and consistent with an 
immune-mediated event. Disease progression, infections and other etiologic causes are ruled out or 
deemed unlikely as contributing to the event. Supportive data, such as autoimmune serology tests or 
biopsies, are helpful but not necessary to deem an event an irAE. Events of unclear etiology which 
were plausibly “immune mediated” have been conservatively categorized as irAEs even if serologic or 
histopathology data are absent. These irAEs likely reflect a loss of tolerance to some self antigens or 
an unchecked immune response to gut or skin flora. Some breakthrough of immunity may be 
inseparably linked to the clinical antitumor activity of ipilimumab. 
Approximately 60% of subjects developed any grade irAEs which predominately involved the GI tract, 
endocrine glands, or skin. Based on data from the safety database, the number of subjects with 
serious irAEs was approximately 17%, including 10% for serious GI irAEs (diarrhea and/or colitis), 3% 
of serious endocrinopathy (primarily hypophysitis/hypopituitarism) and 2% of serious skin irAEs. 
Bowel perforation was reported in less than 1% of subjects. With few exceptions these irAEs were 
clinically manageable and reversible with supportive care or corticosteroids. In responding patients, 
addition of corticosteroids does not appear to have a temporal relationship to change in objective 
tumor response. 
Additionally, the Surgery Branch at the National Cancer Institute reported an increased rate of bowel 
wall perforation in some patients administered high-dose IL-2 following treatment with ipilimumab 
(64). Of 22 patients administered high-dose IL-2, 3 patients experienced bowel wall perforations. This 
is a higher rate than would be expected with high-dose IL-2 treatment alone. All 3 patients had 
metastatic melanoma and had previously received their last dose of ipilimumab > 77 days before the 
first dose of IL-2. Two of the patients had clinically significant ipilimumab-related diarrhea or colitis 
and the symptoms had completely resolved prior to IL-2 administration. One patient did not 
experience ipilimumab-related diarrhea. It is unknown whether this observation represents a true 
association or is mechanistically unrelated to prior ipilimumab exposure. 
1.3.4.1 
Drug Related Deaths 
Drug related deaths are relatively rare with ipilimumab treatment (~1%). The most common cause of 
drug related death was GI perforation. Other causes included multiorgan failure, sepsis, hypotension, 
acidosis and adult respiratory distress syndrome. For details on all drug-related deaths please refer to 
the most recent version of the IB. 
1.3.5  
Clinical Efficacy 
Treatment with ipilimumab has demonstrated clinically important and durable tumor responses in 
several malignancies including melanoma, prostate cancer, and renal cell carcinoma. There is a 
phase II study showing promising results from a combination of Ipi and chemotherapy in patients with 
recurrent or stage IIIB/IV NSCLC, which is reviewed in detail above in section 1.2.7. However, the 
most extensively studied tumor type has been malignant melanoma, providing objective data 
demonstrating durable responses in randomized clinical trials. 


Version 2.3 12/04/2015 
 
 
24 
Specifically, there are two phase III randomized clinical trials demonstrating the efficacy of 
ipilimumab. The first trial, by Hodi et al, compared treatment with ipilimumab (3 mg/kg) alone versus 
ipilimumab (3 mg/kg) with gp100 vaccine versus gp100 vaccine alone in patients previously treated 
for metastatic melanoma patients. This trial demonstrated an improvement in overall survival in both 
groups treated with Ipi alone and Ipi with vaccine. Of the Ipi treated patients, 46% were alive at 1 year 
and 24% were alive at 2 years, demonstrating prolonged disease control.(44) 
A second phase III randomized trial of ipilimumab in patients with metastatic melanoma compared 
treatment with Ipi alone versus Ipi with dacarbazine in previously untreated patients. This study 
demonstrated similar response and survival rates as compared to the Hodi study of patients with prior 
treatment, with 1 and 2 year overall survival of 47% and 29%, respectively. The higher dose of Ipi 
used in this trial (10 mg/kg) apparently provided no additional benefit.(65) These responses at 2 years 
are generally durable based on the reported 10 year follow-up data (63).  
Based on the data above, this trial will use the FDA approved dosing recommendation of 3 mg/kg i.v. 
over 90 minutes every 3 weeks for 4 doses. Further details on clinical results can be found in the 
current version of the Investigator Brochure.  
1.3.5.1 
Relationship between Response and Immune Breakthrough Events in  
 
 
Subjects with Metastatic Melanoma 
Approximately 51% of subjects treated with ipilimumab have developed drug-related adverse events 
of any grade considered to be immune-mediated in nature. These irAEs, most often Grade 1 or 2, are 
an expected consequence of inhibiting CTLA-4 function. Interestingly, there may be an association 
between objective response to ipilimumab and the occurrence of higher grade irAEs. For example, in 
a preliminary analysis of subjects treated at 3 mg/kg of Ipi in the MDX-010-05 study, there was a 
statistically significant association between subjects who responded to ipilimumab and subjects who 
developed severe/serious irAEs (P = 0.0219). See Table 2 for information.  
While no data is available for NSCLC patients, careful clinical monitoring will be implemented for early 
detection and treatment of potential immune mediated events. 
 
P = 0.0219 by Fisher’s Exact Test 
aSevere is defined as  Grade 3 
bDefined as subjects with a best objective response of CR or PR. 
1.4 
Overall Risk/Benefit Assessment 
This study will test the combination of two safe, well-characterized cancer treatments, the 
immunomodulator ipilimumab, and RT in patients with metastatic NSCLC. In terms of the risks of 
treatment under this protocol, ipilimumab, although it is safe and FDA approved for the treatment of 
metastatic melanoma, it is associated with AEs which can cause morbidity and (rarely) even death. 
Table 2: 
Response and Immune Mediated Events - Subjects 
Evaluable for Efficacy in MDX-010-05 (N = 56) 
 
Subjects with Severe/Seriousa 
Immune-mediated 
Events 
Subjects without 
Severe/Serious 
Immune-mediated 
Events 
Non-responders 
12 
37 
Respondersb 
5 
2 


Version 2.3 12/04/2015 
 
 
25 
Specifically, at the dose used in this protocol (3 mg/kg, the FDA approved dose) the risk of irAEs is 
approximately 60% based on the clinical trials in metastatic melanoma. Of these AEs, only 17% of 
patients had Grade 3-5 irAEs, with about 1% risk of fatal AEs, although the risk is probably lower now 
that an effective approach to AE management has been developed for Ipi. The most common of 
these SAEs were diarrhea and/or colitis (10%), endocrinopathy (usually hypophysitis/hypopituitarism, 
3%), and skin reactions (2%), with bowel perforation reported in <1% of subjects, and these are 
almost always manageable and reversible with supportive care or corticosteroids. Radiation therapy 
also has its associated risks, which depend on the dose, fractionation, volume treated, and site of 
treatment. The volume and site of treatment will be patient dependent, but generally the volume is 
extremely localized, and the risk of any Grade 3-5 AE from RT is minimal (<<1%). It is true that the 
combination of Ipi and RT has not been utilized enough in NSCLC to determine its safety, but there 
have been no reported SAEs related to this combination, either in NSCLC or in melanoma, a disease 
for which probably over 1000 patients have been treated with RT while undergoing treatment with Ipi. 
In addition to the clinical risks of the treatment, there are also inherent risks associated with 
phlebotomy, the potential for loss of confidentiality, biopsy, and PET/CT.  
On the contrary, there are reports correlating treatment with Ipi and RT with a significant response in 
systemic disease both in melanoma and NSCLC, an effect we hope to replicate with this combination 
in our study. Additionally, Ipi does have activity in metastatic NSCLC, as reported by Lynch, et al. 
These investigators found a significant improvement in median irPFS from 4.6 to 5.7 months in this 
phase 2 study. These findings, along with the rationale for this combination of RT and Ipi, the pre-
clinical data supporting our hypothesis, and the case report of a near CR in a patient with metastatic 
NSCLC receiving RT-Ipi, all suggest there is a significant potential benefit to this combined treatment.  
In addition to the potential risks and benefits of treatment outlined above, it is also important to 
consider the natural history of metastatic NSCLC. To state it plainly, the prognosis of this disease is 
grim. Upon diagnosis with stage IV disease, median survival is less than one year even with the best 
treatments available. Although second, third, and fourth line chemotherapy may extend survival for a 
minority of patients, usually on the order of months, this cannot be considered a standard of care, and 
new approaches to therapy are needed. 
In summary, it is clear that ipilimumab is generally tolerable with little severe morbidity, as 
demonstrated by mature studies of its use in thousands of patients with melanoma, and more recent 
phase II data in patients with NSCLC. The profile of AEs has been well characterized and an effective 
approach to their management has been developed. Despite this, grade 3 and 4 AEs can occur, and 
there is an approximately 1% risk of treatment associated mortality from ipilimumab. However, any 
risk/benefit assessment must weigh the potential benefits of treatment not only against the potential 
risks of the experimental treatment, but also against the known risk of the standard of care and the 
natural history of the disease. In the case of patients with metastatic NSCLC that has progressed 
through first line chemotherapy, the prognosis is poor with a median survival on the order of months, 
even with the best cytotoxic chemotherapy and all of its associated morbidity. The potential benefits 
of this experimental treatment are therefore at least comparable to, and possibly better than, 
alternative options including the estimated risks of the experimental treatment as well as the known 
risks and limited benefit associated with the standard of care. 


Version 2.3 12/04/2015 
 
 
26 
1.5. 
STUDY RATIONALE 
1.5.1 Combining RT and CTLA-4 blockade 
The availability of ipilimumab, the phase I and II experience already accrued with the antibody in 
NSCLC, and the phase III data demonstrating its impressive utility in malignant melanoma make it 
compelling to translate to the clinic the pre-clinical findings of an abscopal effect in poorly 
immunogenic syngeneic murine tumors treated by CTLA-4 blockade and RT. Additionally, the 
experience described above in a case of metastatic NSCLC and the emerging evidence of response 
to checkpoint blockade in NSCLC patients have motivated the design of the current study. 
 
2 
STUDY OBJECTIVES 
Objective 1 
Evaluate the safety and therapeutic efficacy of anti-CTLA-4 mAb and concurrent local RT in 
NSCLC patients with metastatic disease. 
An open label phase II trial will evaluate the preliminary efficacy of the combination of Ipi and RT, 
applied to a single metastatic site. Efficacy is measured with respect to systemic tumor responses 
(abscopal response, outside the field of therapy) defined by irRC in all non-irradiated measurable 
lesions, as a demonstration of an effective anti-tumor immune response. Secondary endpoints 
include local response in the RT treated tumor, progression free survival, and overall survival. 
Objective  2 
Determine the effects of RT and anti-CTLA-4 mAb on development of anti-tumor immunity. 
We hypothesize that RT will convert the irradiated tumor into an in situ vaccine (3) and elicit an 
endogenous tumor-specific cellular and humoral immune response, which in the presence of CTLA-4 
blockade will achieve immune-mediated destruction of the irradiated and abscopal metastases. Pre- 
and post-treatment tumor biopsies will be examined for changes in immune contexture (4), and blood 
for evidence of emerging anti-tumor immune responses. Associations with clinical response will be 
explored.  
 
3 
STUDY DESIGN  
 
3.1 Objective 1 
To estimate, in metastatic NSCLC patients, the response rate (as defined by irRC) in all 
measurable abscopal metastatic sites after ipilimumab and local RT directed to a single 
metastatic site. 
A phase II study of combined RT and Ipi (RT-Ipi) in metastatic NSCLC is proposed. Bristol-Myers 
Squibb (BMS) will provide drug support (ipilimumab) to patients on study (see letter of commitment 
from BMS). The clinical protocol has received approval by the NYU Cancer Institute Lung Cancer 
Disease Management Program and by the Protocol Monitoring and Review Committee, and is 


Version 2.3 12/04/2015 
 
 
27 
currently undergoing review by the NYU Institutional Review Board. The protocol is attached and is 
summarized below. 
Eligibility criteria: Patients >18 years of age with histologically proven metastatic NSCLC, at least two 
measurable sites of disease, either relapsed or progressive after one or more lines of systemic 
therapy, adequate organ and bone marrow function, ECOG PS 0-1 or Karnofsky > 50%, and informed 
consent for participation. Systemic or local anti-cancer therapies must be completed at least 2 weeks 
before the start of treatment. Baseline PET/CT is required within 4 weeks from accrual. 
Treatment: At study entry all measurable metastatic lesions identified clinically or at PET/CT are 
recorded. Choice of the metastasis to be biopsied before and after RT-Ipi is based on ease of access 
(lymph nodes and subcutaneous metastases are preferred) and the estimated lowest risk for 
complications associated with tissue acquisition. The treatment starts a week after biopsy (during this 
week patients undergo CT simulation for radiation therapy). A regimen of 6 Gy x5 daily fractions will 
be delivered to the biopsied lesion. Patients will receive Ipi 3 mg/kg i.v. over 90 minutes initiated 
within 24 hours of the first dose of RT to the biopsied measurable lesion, conformally or by IMRT, with 
image guidance to maximally spare normal tissue. Ipi infusion is repeated on days 22, 43, and 64. 
Patients will be re-imaged by PET/CT between days 81-88 and evaluated for response. If the initial 
phase II trial is terminated after the first stage of the two stage Simon design due to lack of response, 
additional patients will be enrolled in a second identical two stage Simon design trial (Part B) which 
will test RT at 9.5 Gy x3 fractions with the same dose and schedule for Ipi.  
Assessment of response: Response is defined as an objective radiographic response of the 
measurable metastatic site(s) outside the radiation field evaluated by PET/CT at 3 months after the 
start of treatment. Lesions will be measured using the modified WHO criteria, and immune-related 
Response Criteria will be used, as described (66), and best response (PR + CR) based on these 
criteria will be recorded. To reduce confounding, the irradiated lesion will be excluded from baseline 
measurement and measurement for the assessment of in-field response will be recorded separately.  
Sample size considerations. The optimal Simon two-stage design to test the null hypothesis that, at 
the 6 Gy x5 fractions RT regimen, the probability of abscopal response to RT-Ipi is <0.05 versus the 
alternative that the probability of abscopal response is of >0.20 has an expected sample size of 17.62 
and a probability of early termination of 0.599. If RT-Ipi is actually not effective in inducing an 
abscopal effect, there is a 0.047 probability of concluding that it is effective (the target for this value 
was 0.05). If RT-Ipi is actually effective in inducing an abscopal effect, there is a 0.199 probability of 
concluding that it is not effective (the target for this value was 0.20, power =0.80). After treating 10 
patients in the first stage, the trial will be terminated if no patients have an abscopal response (and a 
new cohort of 10 patients will be studied with RT doses of 9.5 Gy x3). If there is a response and the 
trial goes on to the second stage, a total of 29 patients will be studied. If the total number of patients 
responding with an abscopal effect is  3 then the RT-Ipi dose will be rejected (PASS 2008, NCSS, J. 
Hintze, Kaysville, UT). 
Accrual Rate. An accrual rate of 10-15 patients/year is planned. By the end of the first year 10 
patients will be accrued, and the study will either progress to the second stage or be terminated. If it 
continues to the end of the second stage, we will accrue a total of 29 patients. If the trial concludes at 
the end of the first stage with no observed abscopal CR/PR after the 12 week evaluation, the trial will 
be restarted with the same design but with a higher dose of radiation, 9.5 Gy x3. 
3.2 OBJECTIVE 2:  
Determine the effects of RT and anti-CTLA-4 mAb on development of anti-tumor immunity. 


Version 2.3 12/04/2015 
 
 
28 
An important goal of our study is to gather evidence in patients in support of the hypothesis that RT 
plays a unique role as an immune adjuvant that, when combined with anti-CTLA-4 mAb, enhances 
the response to anti-CTLA-4. 
A comprehensive approach is proposed to analyze immunological changes that reflect both local and 
systemic responses, and investigate both general immune activation as well as tumor antigen-specific 
T- and B-cell responses. To this end, serial blood samples will be collected for serum and peripheral 
blood mononuclear cells (PBMC): at baseline (pre-treatment), 3 weeks after initiation of Ipi (end of 
first cycle), end of third cycle of Ipi (~9 weeks), and at evaluation of response (3 months). An 
additional sample will be collected at 6 months follow up. Small aliquots of PBMC (~106 cells) will be 
used ex vivo for preparation of DNA and RNA, and the remainder preserved frozen until evaluation by 
flow cytometry and/or by functional assays. Tissue biopsies will be obtained at baseline in all patients. 
An initial biopsy is obtained under Standards of Care practices to establish a diagnosis; a second 
optional pre-treatment biopsy will be performed in patients who consent to at an accessible lesion, 
purely for research purposes. An optional post-treatment biopsy will be performed at 3 weeks in 
patients who receive RT to an accessible metastasis. We expect approximately 50% of the patients to 
comply with the second tissue acquisition. We believe that even a limited number of biopsy sets 
(before and after RT) can provide invaluable information about the mechanism of action of the 
combination. The specimens acquired will enable the following studies: 
1) Evaluation of systemic T-cell populations and Myeloid-derived Suppressor Cells (MDSC). 
The activity of anti-CTLA-4 mAb is though to be mainly dependent on modulating the quantity and 
quality of T-cells in cancer patients, and the correlation of some parameters such as ALC and ICOS+ 
T-cells with response supports this notion (67). Therefore, CD4 and CD8 T-cell subsets will be 
characterized by multi-color flow cytometry for the expression of ICOS, CD27 (marker of activation 
and memory T-cells), CD134 (marker of acutely activated T-cells and involved in maintenance of 
response), CD137 (expressed mainly on CD8 T-cells and involved in T-cell proliferative responses 
post-activation), CD154/CD40L (acutely activated CD4 T-cells), CD152/CTLA-4, CD272/BTLA, 
CD279/PD-1 and TIM-3, which are expressed post-activation and associated with suppression/T-cell 
exhaustion (68). Additionally, T-cells will be stained for the proliferation/cycling marker Ki67 (67, 69), 
and for the transcription factor EOMES, since changes in these markers have been reported to be 
associated with outcome and irAEs (69). CD8 T and NK cells will also be stained for NKG2D 
expression, a receptor implicated in functionality of these effector cells and response to anti-CTLA-4 
(58, 70). Regulatory T-cells will be characterized for expression of cell surface markers (CD4, CD25, 
CD127, CD45RA) and transcription factors (FoxP3, Helios) (71). Finally, MDSC (Lin-CD14+HLA-
DRneg/low) will be evaluated since their levels were shown to correlate with response, and to decrease 
after RT (59, 72). 
 
 
2) Evaluation of tumor antigen-specific cellular and humoral responses. Tumor tissue (archived 
at study entry) will be tested for the expression of seven antigens frequently expressed in NSCLC 
(Table 3), and for which reagents are available (recombinant proteins, tetramers and/or overlapping 
peptide pools (OLP) to allow us to test for the presence of specific antibodies and/or T-cells across 
one or more HLA-haplotypes. Immunohistochemistry (IHC) procedures follow standard techniques as 
previously  
published by our group in other cancers (73). 
Table 3: List of NSCLC antigens 


Version 2.3 12/04/2015 
 
 
29 
Antigen-specific T-cell responses will be studied ex vivo by MHC 
tetramer staining to a sub-panel of 5 antigens including NY-ESO-1, 
using high grade purified tetramer reagents from the Ludwig Institute for 
Cancer Research by Serametrix (Carlsbad, CA) (74). The epitopes 
used are confidential but the service covers most HLA haplotypes and 
detection of CD4+ as well as CD8+ T-cells. In addition, T-cell responses 
to NY-ESO-1, MAGE-A3 and survivin will be monitored by intracellular 
cytokine staining utilizing OLP pools, as previously described (75, 76). 
This method is suited for analysis of cryopreserved PBMCs, allows the 
detection of CD4 and CD8 T-cell responses (optimized by use of 15-
mer peptides with an overlap by 11 amino acid residues) and an 
assessment if multiple cytokines are being secreted by single cells. 
These assays are performed routinely by the NYUCI Immunomonitoring 
Core Lab according to standardized SOPs. OLP ProMixes, purchased from Proimmune, will include 
two controls, CEF and MOG. Samples are acquired on a BD LSR II flow cytometer. Seven color 
compensation (parallel controls using cells singly stained for each color) and data analysis are done 
with FlowJo flow cytometry analysis software (TreeStar). Boolean analysis is used determine the 
percentage of single, double and triple cytokine-producing CD4 and CD8 T-cells. The induction or 
boosting of tumor antigen-specific T-cell immunity is defined as a post-treatment value of at least 3-
fold higher than baseline that is also 3-fold or greater than parallel negative controls (and at least 
0.03). If necessary, in vitro stimulated T-cell responses will be assessed, as described (75). 
Antigen-specific antibody responses will be evaluated using two methods. First, antibody titers for 
antigens expressed by each patient tumor as evaluated by IHC will be measured by ELISA. At least 5 
of the most common NSCLC antigens, including MAGE-A3, NY-ESO-1, and survivin, will be tested 
for all sample to capture cases with low expression in the tumor that may be undetectable by IHC, 
and because an integrated antibody and CD8 T-cell response can be evaluated for these antigens, as 
described (74). Changes will be considered significant if seroconversion occurs or pre-existing 
antibody titers will increase (or decrease) by 5-fold between two time points. In patients with 
antibodies to NY-ESO-1 we will consider evaluating antibodies against different domain of the protein 
(N-terminal, central and C-terminal), since changes in reactivity against different epitopes were 
described after RT in a melanoma patient (59).   
In addition, a comprehensive evaluation of the repertoire of antibody responses post-RT and Ipi, will 
be performed by seromics, an antibody profiling method utilizing protein microarrays with the capacity 
to detect >9000 antigens induced by a vaccine. Assays will be performed as described previously (77, 
78). Plasma/serum collected pre-treatment and at time of disease evaluation (post) will be plated onto 
ProtoArrays (v4.0; Invitrogen) and incubated with fluorescent antibodies.  Arrays will be scanned at 
10uM resolution using microarray scanner (Axon 4200AL with GenePix Pro Software; Molecular 
Devices) to detect fluorescence. After normalization, performed as described (78), the ratio of the 
pre/post values for each antigen will be calculated and considered to be a response if it exceeds 5-
fold difference (59).  
3) Evaluation of the tumor immune environment. Evaluation of tumor tissue obtained pre-
treatment and at 3 weeks post-treatment will be performed in two ways: (a) IHC on tumor sections to 
assess density, location and functional orientation of tumor infiltrating lymphocytes (TILs) (4). 
Sections will be stained for CD3, CD8, and CD45RO, TIA-1 and FoxP3. These markers provide 
limited information about functional orientation of the T-cells but have been shown to strongly 
correlate with prognosis and response to treatment in other malignancies (4, 79-81). In fact, a change 
in density and location of TILs and ratio of CD8/FoxP3+ cells was seen in our patient post-treatment 
C-T Antigen 
Expression 
in NSCLC 
(%)
Mage-A1 
46 
Mage-A3
45
Mage-B2 
25 
Mage-C1 
18 
Bage 
17 
Gage 
41 
NY-ESO-1 
27 
KK-LC-1 
34 


Version 2.3 12/04/2015 
 
 
30 
(45). TILs will be evaluated by counting T-cells positive for each marker in 10 high power fields using 
a semi-automated system as we have previously described (82). Distribution of TILs will be 
categorized as restricted to perivascular location or diffuse. Median and mean number of TILs 
positive for each marker will be determined and cases with values above or below the mean by at 
least 2 standard deviations (SD) classified as high or low, respectively. Association of total TILs 
numbers and distribution, expression of each marker, and ratio of CD8/FoxP3+ with response will be 
explored. 
(b) Gene expression profiling will be performed at the NYU Genome Technology Center using U133A 
2.0 Affymetrix microarrays as described (83). To identify genes differentially expressed between pre- 
and post-treatment samples a minimum 1.5-fold difference will be used, and changes in expression of 
key genes will be confirmed by qRT-PCR. Pathway analysis will be performed using the IPA tool. 
Gene expression in pre-treatment tumor samples of responders and non-responders will be 
compared to explore its association with response. 
4) Evaluation of T-cell repertoire changes in blood and tumor following treatment. A remarkable 
breadth of diversity in T-cell receptors (TCRs) is generated by combinatoric shuffling of gene 
segments in somatic cells. The TCR is composed of two peptide chains, encoded by the TCRA and 
TCRB genes respectively. The antigenic specificity of αβ T lymphocytes is in large part determined by 
the amino acid sequence in the hypervariable complementarity-determining region 3 (CDR3) regions 
of TCR (84). The existence of multiple Vα and Jα gene segments in the TCRA locus and multiple Vβ, 
Dβ, and Jβ gene segments in the TCRB locus permits a large combinatorial diversity in TCR 
composition, and template-independent deletion or insertion of nucleotides at the Vα-Jα, Vβ-Dβ, and 
Dβ-Jβ junctions further adds to the potential diversity (85). A healthy adult has approximately 10 
million different TCRB chains contained within their 1012 circulating T-cells (86). Adaptive 
Biotechnologies has developed a novel method that amplifies rearranged TCR CDR3 sequences (87) 
and exploits the capacity of high-throughput sequencing technology to sequence tens of thousands of 
TCR CDR3 chains simultaneously.  Because the technology utilizes genomic DNA, the frequency of 
sequenced CDR3 chains is representative of the relative frequency of each CDR3 sequence in the 
starting population of T-cells. Here we will use this technology to determine: (a) whether TIL 
repertoire is distinct from the repertoire in peripheral blood at baseline; (b) whether TIL and peripheral 
blood repertoire is significantly altered after treatment with RT and Ipi. To this end, we will sequence 
40,000 genomes at each time point, for each sample. Genomic DNA (2 
g) will be prepared from 
snap frozen tumor tissue and PBMC before treatment and at 3 weeks. If <2
g are obtained, all 
available extracted DNA will be used. Amplification and sequencing of TCRB CDR3 regions will be 
carried out using the ImmunoSEQ platform at Apative Biotechnologies. For each tumor sample, 
percentage of T-cell infiltration in the tumor will be estimated using a droplet digital PCR technique 
(88). TCRB overlap between tumor and blood, and between each site before and after treatment, will 
be calculated for each patient as described (88), using Adaptive Biotechnologies bioinformatics 
software.  
 (5) Measuring tumor and serum MICA and NKG2D expression on Natural Killer (NK) and T-
cells during treatment. We have shown that mAb-mediated blockade of NKG2D on CD8 T-cells 
abrogated the formation of immune synapses between CD8 TILs and tumor cells and tumor rejection 
in mice treated with RT and anti-CTLA-4 mAb (58). In humans, a similar block of NKG2D is mediated 
by soluble MICA (sMICA), which is released by some tumors and reaches high levels in the serum 
(89). To determine if this occurs in the patients treated with RT + Ipi, serially collected serum will be 
tested for levels of sMICA, and expression levels of NKG2D in CD8 T-cells and NK cells will be 
assessed by flow cytometry. Importantly, there are reports that sMICA levels can drop after initiation 
of Ipi due to increased clearance from the generation of anti-sMICA antibodies (90). Decreased levels 


Version 2.3 12/04/2015 
 
 
31 
of sMICA were associated with increased expression of NKG2D in T and NK cells, and with response 
to treatment. Anti-sMICA antibodies and sMICA levels will be measured in serum with ELISA by using 
recombinant MICA protein and anti-human MICA monoclonal antibodies, as described (90). Because 
RT is known to upregulate MICA on the surface of tumor cells (91), pre and post-treatment tumor 
sections will be tested for expression of MICA. 
4 
SUBJECT SELECTION CRITERIA 
For entry into the study, the following criteria MUST be met: 
4.1 
Inclusion Criteria 
1) Ability to understand and the willingness to sign a written informed consent document;  
2) Histologic diagnosis of metastatic NSCLC; 
3) Any Kras or EGFR status is permitted; 
4) Patients must have at least two distinct measurable metastatic sites, with one of at least 1 cm 
or larger in its largest diameter. Patients may have additional non-measurable metastatic 
lesions (e.g., bone metastases); 
5) Patients must have prior treatment with at least one line of therapy for metastatic NSCLC. Any 
prior therapy is permitted except prior therapy with ipilimumab; 
6) An interval of 2 weeks from last previous therapy is required;  
7) Patients must have adequate organ and marrow function as defined by initial laboratory tests:  
 WBC  
 2000/uL 
 ANC 
 1000/uL 
 Platelets  
 50 x 103/uL 
 Hemoglobin   8 g/dL 
 Creatinine  
 3.0 x ULN 
 AST/ALT  
 2.5 x ULN, or  5 x ULN if liver metastases are present.   
 Bilirubin    3.0 x ULN, (except patients with Gilbert’s Syndrome, who must have a total 
bilirubin  3.0 mg/dL; 
8) Performance status ECOG 0-1; 
9) Men and women, ages > 18 years of age; 
10) Life expectancy > 3 months; 
11) Patients may have brain metastases if these are stable for at least 4 weeks, or greater than 2 
weeks post- gamma knife therapy and patients are not steroid dependent; 
12) Brain Scan (CT/MRI) prior to enrollment 
13) Women of childbearing potential (WOCBP) must be using an adequate method of contraception 
to avoid pregnancy throughout the study and for up to 8 weeks after the study. 
WOCBP include any female who has experienced menarche and who has not undergone successful 
surgical sterilization (hysterectomy, bilateral tubal ligation or bilateral oophorectomy) or is not 
postmenopausal [defined as amenorrhea  12 consecutive months; or women on hormone 
replacement therapy (HRT) with documented serum follicle stimulating hormone (FSH) level 


Version 2.3 12/04/2015 
 
 
32 
 35 mIU/mL]. Even women who are using oral, implanted or injectable contraceptive hormones or 
mechanical products such as an intrauterine device or barrier methods (diaphragm, condoms, 
spermicides) to prevent pregnancy or practicing abstinence or where partner is sterile (e.g., 
vasectomy), should be considered to be of child bearing potential. 
WOCBP must have a negative serum or urine pregnancy test (minimum sensitivity 25 IU/L or 
equivalent units of human chorionic gonadotropin (hCG)) within 72 hours prior to the start of study 
medication. 
 
4.2 
Exclusion Criteria 
1. Patients having no lesions outside the field of radiation thus nullifying the ability to measure an 
abscopal effect; 
2. Autoimmune disease: Patients with a history of inflammatory bowel disease are excluded from 
this study as are patients with a history of symptomatic disease (e.g., rheumatoid arthritis, 
progressive systemic sclerosis [scleroderma]), systemic lupus erythematosus, autoimmune 
vasculitis [e.g., Wegener’s granulomatosis]; 
3. Any underlying medical or psychiatric condition, which in the opinion of the Investigator, will 
make the administration of study drug hazardous or obscure the interpretation of adverse 
events (AEs), such as a condition associated with frequent diarrhea;  
4. Concomitant therapy with any of the following: IL-2, interferon or other non-study 
immunotherapy regimens; cytotoxic chemotherapy; immunosuppressive agents; other 
investigation therapies; or chronic use of systemic corticosteroids;  
5. Prior therapy with ipilimumab or another anti-CTLA-4 antagonist; 
6. Women who are unwilling or unable to use an acceptable method to avoid pregnancy for the 
entire study period and for at least 8 weeks after cessation of study drug, or have a positive 
pregnancy test at baseline, or are pregnant or breastfeeding;  
7. Prisoners or subjects who are compulsorily detained (involuntarily incarcerated) for treatment 
of either a psychiatric or physical (e.g., infectious) illness. 
 
4.3 
Study Therapy 
4.3.1 Ipilimumab 
Each patient will receive ipilimumab intravenously at 3 mg/kg every three weeks. Infusions will be 
given over 90 minutes (not bolus or i.v. push).  
Ipilimumab will be administered on Days 1, 22, 43, and 64. 
Radiation will be delivered daily, Monday-Friday, for five consecutive days, either at the NYU Clinical 
Cancer Center or Tisch Hospital. A dose of 6 Gy x5 days will be tested. All patients will be re-imaged 
by PET/CT between Days 81 and 88. 
Ipilimumab (Yervoy) 
Ipilimumab is a humanized IgG1κ anti-CTLA-4 mAb. In vitro studies were performed with ipilimumab 
to demonstrate that it is specific for CTLA-4, actively inhibits CTLA-4 interactions with B7.1 and B7.2, 


Version 2.3 12/04/2015 
 
 
33 
does not show any cross-reactivity with human B7.1, B7.2 negative cell lines, and stains the 
appropriate cells without non-specific cross-reactivity in normal human tissues, as demonstrated by 
immunohistochemistry. Ipilimumab does cross-react with CTLA-4 in non-human primates including 
cynomolgus monkeys. 
Dose Calculations 
Total dose should be calculated as follows:  
Subject body weight in kg x 3 mg/kg = total dose, mg 
Total infusion volume should be calculated as follows: 
 
Total dose in mg ÷ 5 mg/mL = infusion volume, mL 
Rate of infusion should be calculated as follows: 
 
Infusion volume in mL ÷ 90 minutes = rate of infusion, mL/min 
For example, a patient weighing 114 kg (250 lb) would be administered 342 mg of ipilimumab (114 kg 
x 3 mg/kg = 342 mg). If the patient weighs more than 125.0 kg, the treating physician needs to be 
contacted to discuss the total infusion volume, infusion rate, and infusion duration. 
4.3.1.1 
Preparation and Administration of Ipilimumab 
The study drug will be administered in the NYU Clinical Cancer Center. Ipilimumab will be stored, 
handled, and prepared by the NYU Investigational Pharmacy. The supplies needed for ipilimumab 
preparation and administration include the following items:  
 Calibrated syringes 
 Infusion containers 
Note: Filtration of the infusate is not required. 
3) As ipilimumab is stored at refrigerated temperatures (2-8ºC), allow the appropriate number of vials 
of ipilimumab to stand at room temperature for approximately five minutes. 
4) Aseptically withdraw the required volume of ipilimumab solution into a syringe. Insert the needle at 
an angle into the ipilimumab vial by placing the needle – bevel side down – against the glass, with 
the tip touching the neck of the vial. The initial solution concentration is 5 mg/mL. [Note: A 
sufficient excess of ipilimumab is incorporated into each vial to account for withdrawal losses].  
5) Ensure that the ipilimumab solution is clear colorless and essentially free from particulate matter 
on visual inspection. If multiple vials are needed for a subject, it is important to use a separate 
sterile syringe and needle for each vial to prevent problems such as dulling of needle tip, stopper 
coring, repeated friction of plunger against syringe barrel wall, etc. 
6) Inject ipilimumab solution withdrawn into an appropriate size evacuated infusion bag to produce a 
final infusion volume that has been calculated from the weight of the patient.  
7) If the total dose calculates to less than 90 mL of solution then the total dose needed should be 
diluted to a total volume of 90 mL in 0.9% sodium chloride. An in-line filter is not required. 
8) Mix by GENTLY inverting several times. DO NOT shake. 
9) Visually inspect the final solution. If the initial diluted solution or final dilution for infusion is not 
clear or contents appear to contain precipitate, the solution should be discarded. 
10) Do not draw into each vial more than once. Any partial vials should be safely discarded and 
should not be stored for reuse. 


Version 2.3 12/04/2015 
 
 
34 
 
Ipilimumab should be administered under the supervision of a physician experienced in the use of 
intravenous agents. Ipilimumab is administered as an i.v. infusion only. 
 
4.3.1.2 
Packaging and Labeling  
Ipilimumab injection, 50 mg/10 mL (5 mg/mL) or 200 mg/40 mL (5 mg/mL), is formulated as a clear to 
slightly opalescent, colorless to pale yellow, sterile, non-pyrogenic, single-use, isotonic aqueous 
solution that may contain particles. Ipilimumab Injection, 50 mg/10 mL and 200 mg/40 mL, is supplied 
in 10-cc or 50-cc Type I flint glass vials, respectively, stoppered with gray butyl stoppers and sealed 
with aluminum seals. The drug product is formulated at a concentration of 5 mg/mL at a pH of 7.0. 
The label text for the study drug will include the contents of the vial (i.e., ipilimumab 50 mg/10 mL), lot 
number, appropriate caution statement, and storage conditions.  
4.3.1.3 
Drug Shipment and Storage  
BMS will arrange the shipment of the study drug to the Investigational Pharmacy at NYU. The study 
drug will be shipped overnight for next day delivery. Shipments will be made on Monday through 
Thursday only. No shipments will be made on Friday, Saturday, or Sunday. Upon receipt by the 
Investigator or designee, the study drug must be stored at 2 to 8°C, in a limited-access area until 
preparation for infusion.  
4.3.1.4 
Agent Accountability  
All investigational drugs are stored with the Investigational Pharmacy. A separate binder is issued to 
each study as well as a bin for storage. The bins and binder are labeled with the protocol number and 
drug name. The Investigational Pharmacy is located in the NYU Clinical Cancer Center. There is 
limited access, and only the pharmacists and support personnel working in the Investigational 
Pharmacy have access. After normal hours of operation, the room is locked and only accessible by 
authorized personnel.  
4.3.2 Dose Modifications 
Ipilimumab related toxicities must be resolved to baseline or ≤ Grade 1 prior to administering the next 
dose. No dose reductions for ipilimumab are allowed. Study drug treatment may be delayed up to 28 
days if the reason for the delay is toxicity/AE. Subjects will have the opportunity to receive all 4 doses 
of Induction Phase ipilimumab. Treatment modifications will be made based on safety criteria 
specified below: 
 
At the discretion of the investigator, it may be necessary to delay ipilimumab administration for the 
following AE(s):  
 Any Grade 2 non-skin related AE, except for laboratory abnormalities; 
 Any Grade 3 laboratory abnormality; 
 
It is necessary to delay ipilimumab dosing for the following AE(s): 
 Any Grade 3 skin-related AE, regardless of causality. 


Version 2.3 12/04/2015 
 
 
35 
 Any AE, laboratory abnormality or inter-current illness which, in the judgment of the 
investigator, warrants delaying the dose of study medication. 
 Elevated liver function tests  3 fold above baseline. 
4.3.3 Discontinuation of Therapy 
Subjects MUST be discontinued from study therapy AND withdrawn from the study for the following 
reasons: 
 Withdrawal of informed consent (subject’s decision to withdraw for any reason) 
 Any clinical adverse event, laboratory abnormality or intercurrent illness which, in the opinion of 
the Investigator, indicates that continued treatment with study therapy is not in the best interest of 
the subject 
 Pregnancy: All WOCBP should be instructed to contact the Investigator immediately if they 
suspect they might be pregnant (e.g., missed or late menstrual period) at any time during study 
participation. Institutional policy and local regulations should determine the frequency of on study 
pregnancy tests for WOCBP enrolled in the study. 
 Imprisonment or the compulsory detention for treatment of either a psychiatric or physical (e.g., 
infectious disease) illness.  
 
4.3.3.1 
Permanent Discontinuation of Ipilimumab 
Ipilimumab must be discontinued if at least 1 of the following related adverse event(s) occurs: 
 Grade 3 or 4 motor neuropathy, regardless of causality. 
 Any ≥ Grade 2 eye pain or reduction of visual acuity that does not respond to topical therapy 
and does not improve to Grade 1 severity within 2 weeks of starting therapy OR requires 
systemic treatment. 
 Any other ≥ Grade 3 non-skin adverse event with the exception of laboratory abnormalities, 
Grade 3 nausea and vomiting, Grade 3 and 4 neutropenia, Grade 3 and 4 thrombocytopenia 
 Any Grade 4 laboratory abnormalities, except AST, ALT, or total bilirubin: 
o AST or ALT > 8 x ULN 
o Total bilirubin > 5 x ULN 
 Any other Grade 4 AE. 
 Any AE, laboratory abnormality or inter-current illness which, in the judgment of the 
investigator, presents a substantial clinical risk to the subject with continued administration of 
the study drug.  
 Subject experiences an allergic/infusion reaction while receiving study drug at a slower 
infusion rate due to a prior allergic/infusion reaction. 
 
Patients with endocrinopathy related to the study drug may resume treatment once asymptomatic 
with or without hormone substitution. Experience is limited for treatment continuation in patients who 
experienced a ≥ Grade 3 endocrine event (e.g., adrenal crisis).  
 
Please contact the medical monitor, Franco M. Muggia, M.D., before continuing treatment with 
ipilimumab in these cases. 


Version 2.3 12/04/2015 
 
 
36 
4.3.4 Immune Related Adverse Events (irAEs): Definition, Monitoring, Treatment 
Blocking CTLA-4 function may permit the emergence of auto-reactive T-cells and resultant clinical 
autoimmunity. Rash/vitiligo, diarrhea/colitis, uveitis/episcleritis, hepatitis and hypopituitarism were 
drug-related, presumptive autoimmune events, now termed irAEs, noted in previous ipilimumab 
studies. 
For the purposes of this study, an irAE is defined as an AE of unknown etiology, associated with drug 
exposure and is consistent with an immune phenomenon. Efforts should be made to rule out 
neoplastic, infectious, metabolic, toxin or other etiologic causes prior to labeling an AE an irAE. 
Serological, immunological, and histological (biopsy) data should be used to support the diagnosis of 
an immune-mediated toxicity. Suspected irAEs must be documented on an AE or SAE form.  
Patients should be informed of and carefully monitored for evidence of clinically significant systemic 
irAE (e.g., systemic lupus erythematosus-like diseases) or organ-specific irAE (e.g., rash, colitis, 
uveitis, hepatitis or thyroid disease). If an irAE is noted, appropriate work-up (including biopsy if 
possible) should be performed, and steroid therapy may be considered if clinically necessary (see 
Appendix 3 through 8 for suggested work-up and treatment of irAEs).  
It is unknown if systemic corticosteroid therapy has an attenuating effect on ipilimumab activity. 
However, clinical anti-tumor responses have been maintained in patients treated with corticosteroids 
and discontinued from ipilimumab. If utilized, corticosteroid therapy should be individualized for each 
patient. Prior experience suggests that colitis manifested as ≥ Grade 3 diarrhea requires 
corticosteroid treatment. See Appendix 4 for additional details. 
4.3.5  
Other Guidance 
4.3.5.1 
Infusion Reactions Associated with Ipilimumab 
Infusion reactions should be graded according to Common Terminology Criteria for Adverse Events 
(CTCAE) Version 4.0 Allergic reaction/hypersensitivity criteria. Severe infusion reactions require the 
immediate interruption of study drug therapy and permanent discontinuation from further treatment. 
Appropriate medical therapy including epinephrine, corticosteroids, intravenous antihistamines, 
bronchodilators, and oxygen should be available for use in the treatment of such reactions. Subjects 
should be carefully observed until the complete resolution of all signs and symptoms. In each case of 
an infusion reaction, the investigator should institute treatment measures according to the best 
available medical practice. The following treatment guidelines are suggested: 
 CTCAE Grade 1 Allergic reaction/hypersensitivity (transient flushing or rash, drug fever 
< 38°C). 
o Treatment: Decrease the study drug infusion rate by 50% and monitor closely for any 
worsening. 
 CTCAE Grade 1 or Grade 2 Allergic reaction/hypersensitivity manifesting only as 
delayed drug fever (starting after the completion of the study drug infusion). 
o Treatment: Maintain blinded study drug dose and infusion rate for future infusions. 
o Consideration could be given to administration of acetaminophen or a non-steroidal 
anti-inflammatory drug (NSAID) prior to the subsequent study drug infusion, if not 
otherwise contraindicated in subjects. Dose and schedule of these agents is entirely at 
the investigator’s discretion. 
 CTCAE Grade 2 Allergic reaction/hypersensitivity (Rash, flushing urticaria, dyspnea, 
drug fever ≥ 38°C). 


Version 2.3 12/04/2015 
 
 
37 
o Treatment: Interrupt blinded study drug infusion. Administer bronchodilators, oxygen, 
etc. as medically indicated. Resume infusion at 50% of previous rate once infusion 
reaction has resolved or decreased to Grade 1 in severity, and monitor closely for any 
worsening. 
 CTCAE Grade 3 or Grade 4 Allergic Reaction/Hypersensitivity: A CTCAE Grade 3 
hypersensitivity 
reaction 
(symptomatic 
bronchospasm, 
requiring 
parenteral 
medication(s), 
with 
or 
without 
urticaria; 
allergy-related 
edema/angioedema; 
hypotension) or a Grade 4 hypersensitivity reaction (anaphylaxis).  
o Treatment: Stop the study drug infusion immediately and disconnect infusion tubing 
from 
the 
subject. 
Administer 
epinephrine, 
bronchodilators, 
antihistamines, 
glucocorticoids, intravenous fluids, vasopressor agents, oxygen, etc., as medically 
indicated. Contact the Medical Monitor and document as a serious adverse event 
(Section 6.1). No further study drug treatment to be administered. 
4.3.5.2 
Treatment of Ipilimumab Related Isolated Drug Fever 
In the event of isolated drug fever, the Investigator must use clinical judgment to determine if the 
fever is related to the ipilimumab or to an infectious etiology. 
If a patient experiences isolated drug fever, for the next dose, pre-treatment with acetaminophen or 
non-steroidal anti-inflammatory agent (Investigator discretion) should be instituted and a repeated 
antipyretic dose at 6 and 12 hours after ipilimumab infusion should be administered. The infusion rate 
will remain unchanged for future doses. 
If a patient experiences recurrent isolated drug fever following premedication and post dosing with an 
appropriate antipyretic, the infusion rate for subsequent dosing should be decreased to 50% of the 
previous rate. If fever recurs following infusion rate change, the Investigator should assess the 
patient’s level of discomfort with the event and use clinical judgment to determine if the patient should 
receive further ipilimumab. 
4.3.6  
Radiation Therapy Guidelines 
4.3.6.1 
Planning 
After informed consent is obtained, a measurable lesion that is accessible for biopsy is selected by 
the treating physician as the site for local radiotherapy under Standard of Care practices to establish 
a diagnosis. The area of interest is imaged at CT planning for conformal treatment. There is no 
contrast media used in the CT planning. There is an exposure to small amounts of radiation with the 
use of CT scan. CT scan thickness should be ≤0.5 cm through the tumor bed region. These images 
will be used in 3D treatment planning in accordance with the dose specification constraints. 
The CTV is defined as the lesion of interest with the expected motion changes, while the PTV is the 
CTV plus a margin  1 cm, dependent on the anatomical location, to account for setup uncertainty. 
While gating is not part of the current conformal setting at NYU, efforts are made to consistently treat 
chest and abdominal lesions with the patient maintaining shallow breathing, to limit the movement of 
the volume treated during respiration. 
4.3.6.2 
Treatment 
Radiotherapy is delivered by external beam using linear accelerators capable of delivering ≥ 4 MV x-
rays. The PTV will encompass all or part of the biopsied NSCLC lesion, and will be defined by the 


Version 2.3 12/04/2015 
 
 
38 
treating physician. The PTV will be treated daily, Monday-Friday. A dose of 30 Gy in 5 fractions of 
6 Gy each is delivered, daily. Part B fractionation: the PTV will receive 28.5 Gy in 3 fractions of 9.5 Gy 
each, delivered on alternate days within week 1, with a minimum of 36 hours between fractions. 
Radiation Dose specification: The planning target volume receives a minimum of 90% of the 
prescription dose. 
Treatment Machine: A linear accelerator with ≥ 4 MV x-rays is required. 
Immobilization Technique: Patients will be set-up for treatment and CT scanning, and planned for 
treatment. The specific immobilization technique will be determined at the discretion of the treating 
physician. 
Target Positioning Verification: Digitally acquired radiographic images will be used to verify the 
position of the target with respect to the treatment machine’s isocenter using digitally reconstructed 
radiographs (DRRs) or orthogonals (for IMRT) on first day.  Both kV and MV images may be used to 
verify setup. 
IGRT Target Localization: Cone-beam CT (CBCT) images will be acquired prior to treatment for each 
fraction.  By using IGRT to image the tumor bed in “real-time”, the operator may automatically align 
the tumor bed with the treatment machine on each day of treatment.   
Treatment Planning: 3D-Conformal or IMRT treatment planning is allowed. This includes “field-in-
field” beams as well as the use of dynamic multi-leaf collimator (MLC) derived using inverse planning 
or electronic compensator techniques. Field arrangements and technique should be chosen that 
satisfy the PTV dose coverage constraints and normal tissue dose constraints using Dose-Volume 
Histogram (DVH) analysis. By carefully selecting the gantry and table angle combinations that do not 
enter or exit through other organs of the body, the dose can be confined to the traditional treatment 
volumes.  Non-coplanar beam arrangements are encouraged, but not required. Dose calculations 
with tissue inhomogeneity correction must be used. 
In view of the GI pattern of toxicity of ipilimumab, particular attention will be applied to limit exposure 
to the bowel. To mitigate this risk, normal tissue constraints of abdominal and pelvic organs will be 
employed from recommendations from AAPM Task Group 101 (92) and the H. Lee Moffitt Cancer 
Center experience using this fractionation schedule (93).  
After completion of the first radiation + ipilimumab dose on Day 1 (or within 24 hours of RT), the 
patient is followed and treated with ipilimumab on Days 22, 43, and 64. Re-imaging with PET/CT will 
be performed during Days 81-88. 
4.3.6.3 
Treatment Modifications for Radiation Adverse Events: 
Dosing delay: Except for radiation-associated mucositis and skin toxicity, the patient should have 
resolution or return to pre-treatment baseline of all grade 3-4 toxicities prior to the start of the next 
immunotherapy treatment. 
4.3.7.2 
On Study Evaluations 
As summarized in the Study Calendar, patients are evaluated pre-treatment for definition of 
metastatic sites with PET/CT. At least two measurable metastatic sites are identified, and one of 
these lesions will be selected by the investigator for RT treatment with the goal of minimizing potential 
toxicity from RT. All lesions are followed per modified WHO criteria. 
Off Study Criteria 


Version 2.3 12/04/2015 
 
 
39 
 
Intercurrent illness that prevents further administration of treatment, 
 
Unacceptable toxicity (defined in Section 4.3.3.1), 
 
Patient decides to withdraw from the study, or 
 
General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator. 
Authorized Physicians must notify the data manager and Principle Investigator when a patient is 
taken off study. 
4.4.  Prohibited and Restricted Therapies during the Study 
4.4.1 Prohibited Therapies 
Patients in this study may not use vaccines for the treatment of cancer for up to one month pre and 
post dosing with ipilimumab. Concomitant systemic or local anti-cancer medications are prohibited in 
this study while receiving ipilimumab treatments. 
Patients may not use any of the following therapies during the study: 
 
Any non-study anti-cancer agent (investigational or non-investigational); 
 
Any other investigational agents; 
 
Any other (non-CA184024 related) CTLA-4 inhibitors or agonists; 
 
Immunosuppressive agents; 
 
Chronic systemic corticosteroids; 


        Version 2.3 12/04/2015 
 
40 
5 STUDY PROCEDURES AND OBSERVATIONS (TABLE 4) 
Flow Chart/Time and Events Schedule 
Procedure 
Screening 
Visit (within 28 
days ( +/- 7 
days) 
Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
22 
 
Day 
43 
 
Day 
64 
 
EOT 
(Day 81- 
88) 
F/U 
q 12 wks 
for 3 yrs 
(+/7days) 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
Pregnancy Test 
Xa 
 
 
 
 
 
Xa 
Xa 
Xa 
 
 
Physical Examination 
X 
 
X 
 
 
 
X 
X 
X 
X 
X 
Vital Signs 
X 
 
X 
 
 
 
X 
X 
X 
X 
X 
Adverse Events 
Assessment 
 
 
X 
 
 
 
X 
X 
X 
X 
X 
Serum Chemistryb 
X 
 
X 
 
 
 
X 
X 
X 
X 
X 
Hematologyb 
X 
 
X 
 
 
 
X 
X 
X 
X 
X 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 Endocrine Panelsc 
     X 
 
X 
 
 
 
    X 
    X 
    X 
 
 
Radiation Therapye 
 
X 
X 
X 
    X 
X 
 
 
 
 
 
  Ipilimumab Treatment  
 
X 
 
 
     
 
    X 
    X 
    X 
 
 
 Bloods/T-cell Response 
    X 
 
 
 
    
 
    Xg 
   
    Xg 
 
      Xh 
  Tumor biopsy 
    Xi 
 
 
 
 
 
    Xj 
 
 
 
 
PET/CT Imaging 
    X 
 
 
 
 
 
 
 
 
    Xd 
Q 12 W 
Efficacy assessment 
 
 
 
 
 
 
 
 
 
   X 
 
a. Only for pre-menopausal female patients 
  
 
 
b. SOC labs (COMP, CBC w/diff,) 
c. TSH, T3, T4 
 
 
 
 
d. Scans day 81-88. 
e. 6 Gy X5,  daily 
f. See Appendix 2 for details.   
 
 
g. to be collected PRIOR to ipilimumab dose 
h. only at 6 month follow up visit 
i. Anytime prior to Day 1. 
j. Day 22-29.


Version 2.3 12/04/2015 
41 
5.1. 
Procedures by Visit 
5.1.1 Study Completion or Early Discontinuation Visit 
At the time of study early withdrawal, the reason for early withdrawal and any new or continuing 
AEs should be documented. 
5.1.2 Study Drug Discontinuation 
 Intercurrent illness that prevents further administration of treatment, 
 Unacceptable toxicity (defined in Section 4.3.3.1), 
 Patient decides to withdraw from the study, or 
 General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator. 
5.2 
Details of Procedures 
5.2.1 Study Materials 
Ipilimumab is an FDA approved therapy for metastatic melanoma, and is not FDA approved for 
NSCLC. Study drug will be provided by BMS, the manufacturer. 
The radiotherapy component of this study is a standard procedure for palliation of metastatic 
NSCLC lesions and will be covered by the patients’ insurance. 
Patients will not incur costs associated with the study drug. 
5.2.2 Safety Assessments 
All patients who receive at least one dose of ipilimumab will be considered evaluable for safety 
parameters. Additionally, any occurrence of a SAE from time of consent forward, up to and 
including follow-up visits will be reported. Refer to safety reporting Section 6.2 
Safety will be evaluated for all treated patients using the NCI CTCAE version 4.0 
(http://ctep.cancer.gov). Safety assessments will be based on medical review of AE reports and 
the results of vital sign measurements, physical examinations and clinical laboratory tests. 
5.2.3 Cost to Subjects 
Each subject or their insurance company will be charged and held responsible for the costs of 
care provided as part of this study. The study drug (Ipi) will be provided free of charge by BMS. 
Radiotherapy is a standard treatment for metastatic NSCLC and will be billed to subjects and 
their insurance companies. 
 


Version 2.3 12/04/2015 
42 
5.3 
Criteria for Evaluation 
5.3.1 Safety Evaluation 
This protocol will be monitored by the NYUCI Data Safety Monitoring Committee which 
oversees the safety of all NYUCI investigator initiated clinical trials. The trial will be monitored 
for all adverse events, laboratory abnormalities, and serious adverse events at least once every 
12 months and at the time of the completion of the first 10 patients in stage 1 of the two-stage 
design. In addition, serious adverse events are monitored for all studies on a monthly basis. 
5.3.2 Efficacy Evaluation   
Definition of Tumor Responses using irRC 
5.3.2.1 
Definition of Measurable/Non-Measurable and Index/Non-Index Lesions 
Definitions of lesions in this study are based on irRC. For the purpose of this study, the 
irradiated lesion will be excluded from baseline measurement and measurement for the 
assessment of response. In field response will be recorded separately.  
5.3.2.2 
Definition of Measurable/Non-Measurable Lesions 
 
Measurable lesions are lesions that can be accurately measured in 2 perpendicular diameters, 
each measuring at least 10 mm x 10 mm. The area will be defined as the product of the largest 
diameter with its perpendicular. Skin lesions can be considered measurable. 
 
Non-measurable (evaluable) lesions are all other lesions, including unidimensionally measurable 
disease and small lesions measuring less than at least 10 mm x 10 mm., and any of the following: 
Lesions occurring in a previously irradiated area (unless they are documented as new lesions 
since the completion of radiation therapy), bone lesions, leptomeningeal disease, ascites, 
pleural or pericardial effusion, lymphangitis cutis/pulmonis, abdominal masses that are not 
pathologically/cytologically confirmed and followed by imaging techniques and cystic lesions. 
All measurable and non-measurable lesions should be measured at Screening and at the 
defined tumor assessment time-points (see Section 5, Table 4). Extra assessments may be 
performed as clinically indicated if there is a suspicion of progression. 
5.3.2.3 
Definition of Index/Non-Index Lesions 
All measurable lesions (defined in Section 5.3.2.2), up to a maximum of five lesions per organ 
and ten lesions in total, should be identified as index lesions to be measured and recorded on 
the medical record at Screening. The index lesions should be representative of all involved 
organs. In addition, index lesions should be selected based on their size (lesions with the 
longest diameters), their suitability for accurate repeat assessment by imaging techniques, and 
how representative they are of the patient’s tumor burden. At Screening, the sum of the 
products of diameters (SPD) for all index lesions will be calculated and considered the baseline 
sum of the products of diameters. Response criteria to be followed are listed below. The 


Version 2.3 12/04/2015 
43 
baseline sum will be used as the reference point to determine the objective tumor response of 
the index lesions at tumor assessment (TA). 
Measurable lesions, other than index lesions, and all sites of non-measurable disease, will be 
identified as non-index lesions. Non-index lesions will be recorded on the medical record and 
should be evaluated at the same assessment time points as the index lesions. In subsequent 
assessments, non-index lesions will be recorded as “stable or decreased disease”, “absent”, or 
“progression”. 
5.3.3  
Definition of Tumor Response using irRC 
The SPD at tumor assessment using the irRC for progressive disease incorporates the 
contribution of new measurable lesions. Each net Percentage Change in Tumor Burden per 
assessment using irRC accounts for the size and growth kinetics of both old and new lesions as 
they appear. 
Definition of Index Lesions Response using irRC 
 irComplete Response (irCR): Complete disappearance of all index lesions. This category 
encompasses exactly the same subjects as “CR” by the mWHO criteria. 
 irPartial Response (irPR): Decrease, relative to baseline, of 50% or greater in the sum of 
the products of the two largest perpendicular diameters of all index and all new 
measurable lesions (i.e., Percentage Change in Tumor Burden). Note: the appearance of 
new measurable lesions is factored into the overall tumor burden, but does not 
automatically qualify as progressive disease until the SPD increases by ≥25% when 
compared to SPD at nadir. 
 irStable Disease (irSD): Does not meet criteria for irCR or irPR, in the absence of 
progressive disease. 
 irProgressive Disease (irPD): At least 25% increase Percentage Change in Tumor 
Burden (i.e., taking sum of the products of all index lesions and any new lesions) when 
compared to SPD at nadir. 
Definition of Non-Index Lesions Response using irRC 
 irComplete Response (irCR): Complete disappearance of all non-index lesions. This 
category encompasses exactly the same subjects as “CR” by the mWHO criteria. 
 irPartial Response (irPR) or irStable Disease (irSD): non-index lesion(s) are not 
considered in the definition of PR, these terms do not apply. 
 irProgressive Disease (irPD): Increases in number or size of non-index lesion(s) does not 
constitute progressive disease unless/until the Percentage Change in Tumor Burden 
increases by 25% (i.e., the SPD at nadir of the index lesions increases by the required 
amount). 


Version 2.3 12/04/2015 
44 
Impact of New Lesions on irRC 
New lesions in and by themselves do not qualify as progressive disease. However their 
contribution to total tumor burden is included in the SPD which in turn feeds into the irRC for 
tumor response. Therefore, new non-measurable lesions will not discontinue any subject from 
the study. 
Definition of Overall Response Using irRC Will Be Based on the Following Criteria: 
 Immune-related Complete Response (irCR): Complete disappearance of all tumor lesions 
(index and nonindex together with no new measurable/unmeasurable lesions) for at least 
4 weeks from the date of documentation of complete response.  
 Immune-related Partial Response (irPR): The sum of the products of the two largest 
perpendicular diameters of all index lesions is measured and captured as the SPD 
baseline. At each subsequent tumor assessment, the sum of the products of the two 
largest perpendicular diameters of all index lesions and of new measurable lesions are 
added together to provide the Immune Response Sum of Product Diameters (irSPD). A 
decrease, relative to baseline of the irSPD compared to the previous SPD baseline, of 
50% or greater is considered an immune Partial Response (irPR).  
 Immune-related Stable Disease (irSD): irSD is defined as the failure to meet criteria for 
immune complete response or immune partial response, in the absence of progressive 
disease.  
 Immune-related Progressive Disease (irPD): It is recommended in difficult cases to 
confirm PD by serial imaging. Any of the following will constitute progressive disease: 
 At least 25% increase in the sum of the products of all index lesions over baseline 
SPD calculated for the index lesions. 
 At least a 25% increase in the sum of the products of all index lesions and new 
measurable lesions (irSPD) over the baseline SPD calculated for the index lesions. 
 
Table 5: 
irRC Definitions 
Index Lesion 
Definition 
Non-Index 
Lesion 
Definition 
New measurable 
Lesions 
New 
unmeasurable 
Lesions 
% change 
in tumor burden 
(including 
measurable new 
lesions when 
present) 
Overall 
irWHO 
Response 
Complete 
Response 
Complete 
Response 
No 
No 
-100% 
irCR 
Partial 
Response 
Any 
Any 
Any 
> -50% 
irPR 
<-50% to <+25% 
irSD 


Version 2.3 12/04/2015 
45 
Index Lesion 
Definition 
Non-Index 
Lesion 
Definition 
New measurable 
Lesions 
New 
unmeasurable 
Lesions 
% change 
in tumor burden 
(including 
measurable new 
lesions when 
present) 
Overall 
irWHO 
Response 
>+25% 
irPD 
Stable 
Disease 
Any 
Any 
Any 
<-50% to <+25% 
irSD 
>+25% 
irPD 
Progressive 
Disease 
Any 
Any 
Any 
>+25% 
irPD 
 
Immune Related Best Overall Response Using irRC (irBOR)  
irBOR is the best confirmed irRC overall response over the study as a whole, recorded between 
the date of first dose until the last TA prior to subsequent therapy (except for local palliative 
radiotherapy for painful bone lesions) for the individual subject in the study. For the assessment 
of irBOR, all available assessments per subject are considered. 
irCR or irPR determinations included in the irBOR assessment must be confirmed by a second 
(confirmatory) evaluation meeting the criteria for response and performed no less than 4 weeks 
after the criteria for response are first met. 
5.3.4 Response Endpoints  
Ipilimumab is expected to trigger immune-mediated responses, which require activation of the 
immune system prior to the observation of clinical responses. Such immune activation may take 
weeks to months to be evident. Some patients may have objective volume increase of tumor 
lesions or other disease parameters (based on study indication, i.e., hematologic malignancies) 
within 12 weeks following start of ipilimumab dosing. Such patients may not have had sufficient 
time to develop the required immune activation or, in some patients, tumor volume or other 
disease parameter increases may represent infiltration of lymphocytes into the original tumor or 
blood. In conventional studies, such tumor volume or relevant laboratory parameter increases 
during the first 12 weeks of the study would constitute PD and lead to discontinuation of imaging 
to detect response, thus disregarding the potential for subsequent immune-mediated clinical 
response.  
Therefore, patients with tumor volume increase detected or lack of laboratory parameter 
response documentation prior to week 12 but without rapid clinical deterioration should continue 
to be treated with ipilimumab and clinically observed with a stringent imaging schedule to allow 
detection of a subsequent tumor response. This will improve the overall assessment of the 
clinical activity or ipilimumab and more likely capture its true potential to induce clinical 
responses. Tumor assessments will be made using modified WHO criteria.  


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46 
Radiotherapy in the dose and fractionation proposed in this study is a standard palliation 
tool for metastatic lesions. It is expected that approximately 50% of the irradiated lesions 
will achieve an objective response (PR+CR). For the purpose of this study, the irradiated 
lesion will be excluded from baseline measurement and measurement for the 
assessment of response. In field response will be recorded separately.  
5.3.5 Study Suspension Criteria  
The study will be terminated after Stage 1 (first 10 subjects) if there are no abscopal responses. 
If the trial is terminated at the end of Stage 1 due to a lack of response, then a second phase II 
trial with an identical design will be conducted using the 9.5 Gy x3 regimen of radiotherapy and 
the same dose and schedule of ipilimumab. If there are no abscopal responses in Stage 1 of 
this second trial, the study will be terminated. 
6 
ADVERSE EVENT REPORTING 
6.1 
Collection of Safety Information 
An Adverse Event (AE) is defined as any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product and that does not necessarily have 
to have a causal relationship with this treatment. An AE can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding, for example), symptom, or disease 
temporally associated with the use of an investigational (medicinal) product (IP), whether or not 
considered related to the IP.  
During clinical trials, adverse events can be spontaneously reported or elicited during open-
ended questioning, examination, or evaluation of a subject. (In order to prevent reporting bias, 
subjects should not be questioned regarding the specific occurrence of one or more adverse 
events.) 
A serious AE or reaction is any untoward medical occurrence that at any dose:  
 results in death,  
 is life-threatening (defined as an event in which the patient or subject was at risk of death at 
the time of the event; it does not refer to an event which hypothetically might have caused 
death if it were more severe),  
 requires inpatient hospitalization or prolongation of existing hospitalization, (refer to note for 
exceptions), 
 results in persistent or significant disability/incapacity,  
 is a congenital anomaly/birth defect,  
 is an important medical event (defined as a medical event(s) that may not be immediately 
life-threatening or result in death or hospitalization but, based upon appropriate medical and 
scientific judgment, may jeopardize the patient/subject or may require intervention (e.g., 
medical, surgical) to prevent one of the other serious outcomes listed in the definition 
above). 


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47 
NOTE: 
 Pregnancy: Incidence of pregnancy is not considered a SAE; pregnancy must, however, be 
reported immediately to investigator. Cancer/Overdose: An overdose is defined as the 
accidental or intentional ingestion of any dose of a product that is considered both excessive 
and medically important. Hospitalizations (exceptions): Criteria for hospitalizations not 
reported as SAEs include admissions for: 
 Planned as per protocol medical/surgical procedure 
 Routine health assessment requiring admission for baseline/trending of health status 
documentation (e.g., routine colonoscopy) 
 Medical/surgical admission for purpose other than remedying ill health state (planned 
prior to entry into study trial; appropriate documentation required)  
 Admission encountered for other life circumstance that carries no bearing on health 
status and requires no medical/surgical intervention (e.g., lack of housing, economic 
inadequacy, care-giver respite, family circumstances, administrative) 
An SAE report should be completed for any event where doubt exists regarding its status of 
seriousness. 
6.2 
Reporting of Serious Adverse Events (SAEs) 
Following the subject’s written consent to participate in the study, all SAEs should be collected 
and reported, including those thought to be associated with clinical trial procedures. SAE 
terminology and severity grading will be based on CTCAEv4. 
This is an NYULMC investigator-sponsored study in which the study drug will be provided by 
BMS. The principal investigators are responsible for reporting SAEs to the IRB and the FDA or 
other applicable regulatory authority. The principal investigator is responsible for submitting 
follow-up reports for all SAEs regarding the patient’s subsequent course until the SAE has 
resolved or until the patient’s condition stabilizes (in the case of persistent impairment), or the 
patient dies. Reports of SAEs will be submitted to the NYULMC IRB through the institution’s 
web-based portal, Research Navigator. 
The following categories and definitions of causal relationship to study drug should be used for 
all clinical studies: 
 Certain: There is a reasonable causal relationship between the study drug and the AE. The 
event responds to withdrawal of study drug (dechallenge), and recurs with rechallenge when 
clinically feasible. 
 Probable: There is a reasonable causal relationship between the study drug and the AE. The 
event responds to dechallenge. Rechallenge is not required. 
 Possible: There is reasonable causal relationship between the study drug and the AE. 
Dechallenge information is lacking or unclear. 
 Not likely: There is a temporal relationship to study drug administration, but there is not a 
reasonable causal relationship between the study drug and the AE.  


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48 
 Not related: There is not a temporal relationship to study drug administration (too early, or 
late, or study drug not taken), or there is a reasonable causal relationship between another 
drug, concurrent disease, or circumstance and the AE. 
 Adverse events classified as "serious" require expeditious handling and reporting to NYU to 
comply with regulatory requirements.  
- 
All SAEs whether related or unrelated to the ipilimumab, must be immediately reported to 
NYU and BMS (by the investigator or designee) within 24 hours of becoming aware of the 
event. If only limited information is initially available, follow-up reports are required. The 
original SAE form must be kept on file at the study site. All SAEs should be reported to 
NYU and BMS via confirmed facsimile (fax) transmission, or scanned and reported via 
electronic mail to:  
SAE Email Address: Worldwide.Safety@BMS.com 
SAE Fax Number: 609-818-3804 
 
 
Collection of complete information concerning SAEs is extremely important. Full 
descriptions of each event will be followed by NYU. Thus, follow-up information which 
becomes available as the SAE evolves, as well as supporting documentation (e.g., 
hospital discharge summaries and autopsy reports), should be collected subsequently, if 
not available at the time of the initial report, and immediately sent using the same 
procedure as the initial SAE report. 
 
An overdose is defined as the accidental or intentional ingestion of any dose of a product 
that is considered both excessive and medically important. For reporting purposes, NYU 
considers an overdose, regardless of adverse outcome, as an important medical event. 
 
AEs should be followed to resolution or stabilization, and reported as SAEs if they 
become serious. This also applies to subjects experiencing AEs that cause interruption or 
discontinuation of ipilimumab, or those experiencing AEs that are present at the end of 
their participation in the study; such subjects should receive post-treatment follow-up as 
appropriate. 
 
All SAEs must be collected which occur within 90 days of discontinuation of dosing or 
completion of the patient’s participation in the study if the last scheduled visit occurs at a 
later time. In addition, the Investigator should notify NYU of any SAE that may occur after 
this time period which they believe to be certainly, probably, or possibly related to 
ipilimumab. 
6.3 
Pregnancy 
Sexually active women of childbearing potential must use an effective method of birth control 
during the course of the study, in a manner such that risk of failure is minimized.  
Before enrolling women of childbearing potential in this clinical trial, Investigators must review 
the guideline about study participation for WOCBP which can be found in the GCP Manual for 
Investigators. The topics include the following: 


Version 2.3 12/04/2015 
49 
 General Information 
 Informed Consent Form 
 Pregnancy Prevention Information Sheet 
 Drug Interactions with Hormonal Contraceptives 
 Contraceptives in Current Use 
 Guidelines for the Follow-up of a Reported Pregnancy 
Prior to study enrollment, WOCBP must be advised of the importance of avoiding pregnancy 
during trial participation and the potential risk factors for an unintentional pregnancy. The subject 
must sign an informed consent form documenting this discussion.  
All WOCBP MUST have a negative pregnancy test within 72 hours prior to receiving 
ipilimumab. The minimum sensitivity of the pregnancy test must be 25 IU/L or equivalent units of 
hCG. If the pregnancy test is positive, the subject must not receive ipilimumab and must not be 
enrolled in the study. 
In addition, all WOCBP should be instructed to contact the Investigator immediately if 
they suspect they might be pregnant (e.g., missed or late menstrual period) at any time 
during study participation. Additionally, all pregnancies must be reported to BMS via 
confirmed facsimile (fax) transmission, or scanned and reported via electronic mail to:  
SAE Email Address: Worldwide.Safety@BMS.com 
SAE Fax Number: 609-818-3804 
If following initiation of study treatment, it is subsequently discovered that a trial subject is 
pregnant or may have been pregnant at the time of ipilimumab exposure, including during at 
least 6 half-lives after product administration, the ipilimumab will be permanently discontinued in 
an appropriate manner (e.g., dose tapering if necessary for subject safety). Exceptions to 
ipilimumab discontinuation may be considered for life-threatening conditions only after 
consultation with the Principal Investigator or as otherwise specified in this protocol. Protocol-
required procedures for study discontinuation and follow-up must be performed on the subject 
unless contraindicated by pregnancy (e.g., x-ray studies). Other appropriate pregnancy follow-
up procedures should be considered if indicated. In addition, the course of the pregnancy, 
including perinatal and neonatal outcome. Infants should be followed for a minimum of eight 
weeks. 
Follow-up information regarding the course of the pregnancy, including perinatal and neonatal 
outcome and, where applicable, offspring information can be reported on a Pregnancy 
Surveillance Form provided by BMS. Any pregnancy that occurs in a female partner of a male 
study participant should be reported to BMS. 
7 
STATISTICAL METHODOLOGY 
OBJECTIVE 1: 
Assessment of response: Response is defined as an objective response of metastatic site(s) 
outside the radiation field evaluated at 3 months after the start of treatment, assessing clinical 


Version 2.3 12/04/2015 
50 
and CT responses. Immune-related Response Criteria will be used, as described (66), and best 
response (PR + CR) based on these criteria will be recorded. To reduce confounding, the 
irradiated lesion will be excluded from baseline measurement and measurement for the 
assessment of response. In field response will be recorded separately.  
Sample size considerations. The optimal Simon two-stage design to test the null hypothesis 
that, at the 6 Gy x5 fractions RT regimen, the probability of abscopal response to RT-Ipi is <0.05 
versus the alternative that the probability of abscopal response is of >0.20 has an expected 
sample size of 17.62 and a probability of early termination of 0.599. If RT-Ipi is actually not 
effective in inducing an abscopal effect, there is a 0.047 probability of concluding that it is 
effective (the target for this value was 0.05). If RT-Ipi is actually effective in inducing an 
abscopal effect, there is a 0.199 probability of concluding that it is not effective (the target for 
this value was 0.20, power =0.80). After treating 10 patients in the first stage, the trial will be 
terminated if no patients have an abscopal response (and a new cohort of 10 patients will be 
studied with RT doses of 9.5 Gy x3). If the trial goes on to the second stage, a total of 29 
patients will be studied. If the total number of patients responding with an abscopal effect is <3 
then RT-Ipi dose will be rejected (PASS 2008, NCSS, J. Hintze, Kaysville, UT). 
Accrual Rate. An accrual rate of 10-15 patients/year is planned. By the end of the first year 10 
patients will be accrued, and the study will either progress to the second stage or be terminated. 
If it continues to the end of the second stage, we will accrue a total of 29 patients. If the trial 
concludes at the end of the first stage with no observed abscopal CR/PR after the 12 week 
evaluation, Part B of the trial will commence with the same design, with newly accrued patients 
with the only modification regarding the dose of radiation, 9.5 Gy x3. 
Statistical Analysis: Patient and disease characteristics will be summarized at baseline using 
descriptive statistics and graphical displays. The abscopal response rate will be estimated at the 
end of the second stage with 29 patients along with exact 95% confidence limits. If the observed 
response rate is 20%, an exact 95% confidence interval for the true rate of 7.6% to 38.9% will 
be obtained with 29 patients. If the first trial is halted at the end of stage 1, the second trial 
analysis will proceed in the same manner. The distribution of types of outcomes with respect to 
non irradiated & measurable and irradiated lesions will be summarized. All patients will be 
followed for progression and survival for up to 2 years following the entry of the last patient. 
Kaplan-Meier curves for progression-free survival and survival will be provided to summarize the 
results. 
OBJECTIVE 2: 
An important goal of our study is to gather evidence in patients in support of the hypothesis that 
RT plays a unique role as an immune adjuvant that, when combined with anti-CTLA-4 mAb, 
enhances the response to anti-CTLA-4. To this end, serial blood samples will be collected for 
serum and PBMCs: at baseline (pre-treatment), 3 weeks after initiation of Ipi (end of first cycle), 
end of third cycle of Ipi (~9 weeks), and at evaluation of response (3 months). An additional 
sample will be collected at 6 months follow up. Small aliquots of PBMC (~106 cells) will be used 
ex vivo for preparation of DNA and RNA, and the remainder preserved frozen until evaluation by 
flow cytometry and/or by functional assays. A diagnostic tissue biopsy will be obtained at 
baseline in all patients as a standard of care practice to confirm metastatic diagnosis. A second 


Version 2.3 12/04/2015 
51 
optional pre-treatment biopsy will be performed in patients who consent to at an accessible 
lesion, purely for research purposes. Post-treatment biopsy will be performed at 3 weeks in 
patients who receive RT to an accessible metastasis.  We expect approximately 50% of the 
patients to comply with the second tissue acquisition. We believe that even a limited number of 
biopsy sets (before and after RT) can provide invaluable information about the mechanism of 
action of the combination.  
Statistical considerations. The distributions of baseline levels of each of the cell subsets/markers 
analyzed (pretreatment) will be summarized using descriptive statistics (means, SD, medians, 
percentiles, etc.) and graphical displays including boxplots. Bivariate scatterplots at baseline will 
also be provided along with correlation coefficients. Distributions of these markers at each of the 
subsequent repeated time points and of changes from pre-treatment levels at each time point 
will be summarized similarly. These serial measurements will be summarized over time using 
mixed effects regression models for longitudinal data that incorporate the repeated observations 
over time within the same patient and incorporate missing observations over time.  In these 
models, we will incorporate a random effect for each patient with fixed effects for RT dose and 
time. Models will be used to test whether changes from baseline vary over time (94). 
Appropriate transformations of marker expression levels will be carried out to meet the 
assumptions of the models (e.g., log transformations). Subject specific effects will be examined 
in relation to response status at 3 months; however, we recognize that these analyses are 
exploratory with the small number of expected responders. With 29 patients in the Phase II trial, 
we can detect a difference of |0.54| SD in the change from baseline for a single marker at a 
single time point with 2-sided alpha of 0.05 and power of 80% based on a paired t-test (no 
adjustment for multiplicity). With 10 patients in the first stage of the initial trial (should it not 
continue), we can detect changes from baseline of |0.99| SD. [Calculations from PASS 2008, 
cited above].  
For each of the tested antigens, changes over time from baseline in the percentage of antigen-
specific T-cells or antibody titers will be summarized with descriptive statistics and graphical 
displays. Each patient will be classified at baseline and at each post treatment observation by 
the presence of T-cell and/or antibody responses to each of the antigens and by pattern of 
antibody responses to one or more of the identified antigens; responses will be summarized in 
frequency tables. The proportion of patients with responses to each antigen and patterns of 
responses including at least one antibody response (as defined above) will be estimated with 
95% confidence intervals at each time point. Time to immune response (at least one antibody 
response) will also be summarized with life table methods for censored data. Sample size 
considerations for the changes from baseline (T-cells % or Ab titers) are as above for 29 
patients.  
All patients who consent, will have a pre-treatment biopsy of the lesion to be irradiated. 
However, only patients with accessible biopsy sites are likely to have a post-treatment biopsy. 
At baseline, TIL markers based on IHC will be summarized using descriptive statistics and 
graphical displays. Changes from baseline will be estimated in the approximately 50% of 
patients who are expected to have a repeat biopsy. With 5-15 patients, based on a paired t-test 
with 2-sided alpha of 0.05 and power of 80%, for a single marker, a change from baseline to 
post treatment of |1.68| - |0.78| SD is detectable. Appropriate transformations of marker levels 


Version 2.3 12/04/2015 
52 
will be carried out to meet the assumptions of the t-test. We will also compare the patient and 
disease characteristics as well as baseline levels for each of these markers in the group of 
patients with a repeat sample with those who do not have a repeat sample to identify potential 
sources of bias in the group with repeat samples. For the analysis of changes from baseline to 
post-treatment biopsy based on the microarray gene expression profiling, with a false discovery 
rate (FDR) of 10%, with 15 (5) pairs of biopsies, we can detect a change in a single gene of |1.3| 
(|4.9|) SD in expression level with overall power of 80% assuming 10% of the genes have a true 
expression level greater than that specified. Genes that exceed the threshold for a single gene 
alpha of 0.0009 (2–sided) will be ranked and the highest identified changes will be validated with 
qRT-PCR. 
The changes in serum samples for sMICA concentration and anti-sMICA antibody titers, and 
expression levels of NKG2D in circulating CD8 and NK cells will be plotted over time for each of 
these measurements to identify the nature of the changes and summarized over time using the 
same statistical approaches that are described in 2.1 and 2.2. Baseline levels and changes from 
baseline at the time of the post-treatment biopsy will be plotted for each of these markers and 
correlation coefficients with 95% confidence intervals will be estimated to evaluate the 
association between the serum and tumor marker levels. 
8 
ADMINISTRATIVE SECTION 
8.1 
Compliance with the Protocol and Protocol Revisions 
The study will be conducted as described in the final approved protocol. Documentation of 
approval signed by the chairperson or designee of the IRB(s) will be sent to the NYU protocol 
manager.  
All revisions (protocol amendments, administrative letters, and changes to the informed 
consent) will be submitted to the NYU protocol manager. The Investigator will not implement any 
deviation or change to the protocol without prior review and documented approval/favorable 
opinion from the IRB of an Amendment, except where necessary to eliminate an immediate 
hazard(s) to study patients. 
8.2 
Informed Consent 
The Investigator will ensure that patients are clearly and fully informed about the purpose, 
potential risks, and other critical issues regarding clinical trials in which they volunteer to 
participate. Preparation of the consent form is the responsibility of the Investigator and will 
include all elements required by the Code of Federal Regulations 21 Part 50.25 and the local 
IRB. Written informed consent will be obtained by physicians and nurse practitioners listed on 
the title page of this protocol. The informed consent form will be signed by the subject and the 
registering physician. Once signed, a copy will be given to the subject and one will be 
maintained with the subject’s medical record. Once eligibility is confirmed and informed consent 
is documented, the patient will be registered by the study coordinator/data manager. In this 
protocol, blood and biopsies will be procured and stored with barcoded identifiers. The study 


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53 
samples obtained will be for the purpose of immune-monitoring study when funds become 
available. 
8.3 
Records and Reports 
Adequate and accurate case histories designed to record all observations and other data 
pertinent to the investigation (e.g., case report form) will be prepared and maintained on each 
individual treated with ipilimumab. The investigator will retain, in a confidential manner, the data 
pertinent to the study. 
8.4 
Records Retention 
The Investigator will retain source documents, and case histories designed to record all 
observations and other data pertinent to the investigation (e.g., case report form) for the 
maximum period required by applicable regulations and guidelines, or Institution procedures. 
If the Investigator withdraws from the study (e.g., relocation, retirement), the records shall be 
transferred to a mutually agreed upon designee (e.g., another Investigator, IRB). Documentation 
of such transfer will be provided to NYU. 
8.5 
Laboratory Correlative Studies 
Serial blood samples for immune monitoring, Genomics and T-cell response will be collected at 
baseline, and at selected time points as outlined in Section 3.1 and Appendix 2.  
Approximately 4-6 mm of tissue will be obtained from four Core punch biopsies will be 
performed at baseline and at end of treatment.   
Depending on the availability of novel assays that can improve our ability to analyze the anti-
tumor immune response, samples of blood (PBMC and/or plasma fractions) may also be sent 
for analysis to other collaborators at sites outside of NYU. Samples will be de-identified and no 
other information except for the unique code will be provided. 
8.6 
Storage of Samples 
All blood and tissue samples will be processed immediately and stored indefinitely for later 
analysis in a locked -80°C freezer in the NYU Biorepository for research purposes only. These 
specimens will not be linked to any clinical data and will be de-identified in the clinical research 
database, Velos. Only the data manager will have access to the master list with the patient 
name and an identification number. This master list will be secured in a locked cabinet at the 
NYU Clinical Cancer Center. Only the investigators listed on this protocol will have access to 
these samples. After both blood and tissue samples are analyzed at a later date, any unutilized 
samples will be preserved indefinitely in the NYU Biorepository for potential future research.  
All patients enrolled will be given a unique identifier (study ID number). Only the data manager 
will know the code linking patient and study ID number. Patients will be assigned a unique code 
number. All specimens collected will be deidentified and assigned the same unique study 
number of the corresponding patient and will also be marked with the collection time point. 


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54 
Clinical information regarding toxicities and response will likewise be stored in a deidentified 
database using only the unique identifier (study ID number). 
Serial blood samples will be collected for serum and PBMCs: at baseline (pre-treatment), 3 
weeks after initiation of Ipi (end of first cycle), end of third cycle of Ipi (~9 weeks), and at 
evaluation of response (3 months). An additional sample will be collected at 6 months follow up. 
Small aliquots of PBMC (~106 cells) will be used ex vivo for preparation of DNA and RNA, and 
the remainder preserved frozen until evaluation by flow cytometry and/or by functional assays. 
 A diagnostic tissue biopsies is obtained at baseline in all patients, as per Standard of Care. 
Access to this histological specimen is required for the study to establish pre-treatment 
immunological infiltrate. In patients who consent to a pre and post-treatment biopsy of any 
irradiated lesions tissue will be acquired before the first radiotherapy and first Ipilimumab 
treatment and again at 3 weeks in patients who receive RT to an accessible metastasis and 
consent to these OPTIONAL research biopsy. These blood and tissue samples will be utilized 
for correlative studies as outlined above (section 3.2, page 24). 
 
All blood and tissue samples will be stored indefinitely until appropriate funding has been 
obtained to perform correlative studies or until subject withdraws consent for banking of study 
specimens. If consent is withdrawn by the study subject, samples will be destroyed as per 
standard practices. 
The storage of your blood and tissue is optional and you may withdraw your consent for the 
banking of these specimens at any time. You may make this request by writing to the Principal 
Investigator Abraham Chachoua, M.D. at NYU Cancer Institute 160 East 34th Street New York, 
NY 10016. 
8.7 Shipping of Samples  
Frozen blood specimens de-identified as descriibed above may be shipped at -80C to other 
sites for novel analyses that become available to better study the immune response.  
8.8 
Genetic Testing 
No genetic research will be performed on the study samples acquired in this clinical trial. 
8.9  
Confidentiality 
The medical, hospital and research records associated with this study are considered 
confidential. Members of the treating team and designated study assistants will have access to 
the records as required to administer treatment and comply with the protocol. Neither the name 
nor any other identifying information for an individual will be used for reporting or publication 
regarding this study. All laboratory and baseline data will be de-identified and transferred via 
secure links at NYU School of Medicine. Patient records will be made available for inspection to 
auditing agencies to satisfy regulatory requirements.  Anonymous data will be shared with Weill 
Cornell Medical College due to the relocation of study personnel so that a paper may be 


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55 
published on the findings of this study.  The anonymous data will only be shared with Weill 
Cornell Medical College after a transfer agreement is fully executed. 
9.0 
Research Conflict of Interest  
There are no conflicts of interest to report. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Version 2.3 12/04/2015 
56 
 
Appendix 1: 
Eligibility and Registration Worksheets 
Patient Initial ______________ 
 
Patient ID ______________ 
 
REGISTRATION WORKSHEET 
NYU S14-00208 
Patient Name ___________________________________ Patient ID  _______  
 
Birth Date (mm/dd/yyyy) _____________________ 
 
SS # __________________________ 
 
Gender (circle one)  
Male 
Female 
 
Race (circle the most appropriate choice) White 
 
Black or African American 
 
Native Hawaiian/Pacific Islander/Filipino 
 
Asian 
 
Native American or Alaska Native 
 
Other 
 
If other, please specify______________ 
Ethnicity (circle the most appropriate choice) Hispanic or Latino 
 
Non-Hispanic 
 
Other 
 
If other, please specify __________  
Address ________________________________________________________  
 
(City)  
(State) 
(Zip) 
Phone # 
 _____________________________________  
Referring MD 
 _____________________________________  
RT Medical Record # 
 _____________________________________  
Patient Initial ______________ 
 
 
Patient ID ______________ 


Version 2.3 12/04/2015 
57 
NYU S14-00208 
 
ELIGIBILITY WORKSHEET 
Inclusion Criteria: 
 
 
YES NO 
Procedure 
 
Date 
1. ___ 
___ 
_______ 
Ability to understand and the willingness to sign a written 
informed consent document. 
 
2. ___ 
___ 
_______ 
Histologically confirmed metastatic NSCLC 
 
3. ___ 
___ 
_______ 
No prior therapy with ipilimumab or another anti-CTLA-4 
monoclonal antibody 
 
4. ___ 
___ 
_______ 
Have at least 2 distinct measurable metastatic sites which are at 
least 1 cm in their largest diameter. 
 
5. ___ 
___ 
_______ 
Age >18 years 
 
6. ___ 
___ 
_______ 
ECOG performance status 0-1  
 
7. ___ 
___ 
_______ 
Life expectancy > 3 months 
 
8. ___ 
___ 
_______ 
Any brain metastases must be stable for at least 4 weeks or 
greater than 2 weeks post- gamma knife therapy and not steroid 
dependent. 
 
9. ____   _____    _______     Brain Scan (CT/MRI) within a month prior to enrollment 
10. Have adequate organ and marrow function as defined below: 
 
 
___ 
___ 
_______ 
Leukocyte count ≥ 2000/uL 


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___ 
___ 
_______ 
Absolute neutrophil count ≥ 1000/uL 
 
 
___ 
___ 
_______ 
Platelets ≥ 50,000/uL 
 
 
___ 
___ 
_______ 
Hemoglobin ≥ 8 g/dL 
 
 
___ 
___ 
_______ 
Total bilirubin ≤ 3.0 x ULN (or ≤ 3.0 mg/dL for patients with 
Gilbert’s Syndrome) 
 
 
___ 
___ 
_______ 
AST(SGOT)/ALT(SGPT) ≤ 2.5 x ULN (or ≤ 5 x ULN if liver  
 
 
 
 
 
metastases are present) 
 
 
___ 
___ 
_______ 
Serum creatinine ≤ 3.0 x ULN 
 
11. ___ 
___ 
_______ 
Women of childbearing potential must agree to use adequate 
contraception (barrier method of birth control) prior to study entry 
and for the duration of study participation. Should a woman 
become pregnant or suspect she is pregnant while she or a 
participating spouse are enrolled in this study, she should inform 
her treating physician immediately. 
 
Exclusion Criteria:  
 
12. ___ ___ _______ 
No lesions outside the field of radiation. 
 
13. ___  ___ _______ 
Presence of autoimmune disease, including inflammatory bowel 
disease, rheumatoid arthritis, progressive systemic sclerosis 
(scleroderma), systemic lupus erythematosus, and autoimmune 
vasculitis (e.g., Wegener’s granulomatosis). 
 
14. ___ ___ _______ 
Treatment with cytotoxic chemotherapy within 2 weeks prior to 
entering the study. 
 


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59 
15. ___ ___ _______ 
Treatment with IL-2, interferon, or other non-study immunotherapy 
within 2 weeks prior to entering the study. 
 
16. ___ ___ _______ 
On steroid therapy or other immunosuppressive therapy. 
 
17. ___ ___ _______ 
Undergoing therapy with other investigational agents. 
 
18. ___ ___ _______ 
Any underlying medical or psychiatric condition, which in the opinion 
of the Investigator, will make the administration of study drug 
hazardous or obscure the interpretation of adverse events (AEs), 
such as a condition associated with frequent diarrhea. 
 
19. ___ ___ _______ 
Prior therapy with ipilimumab or another anti-CTLA-4 antagonist. 
 
20. ___ ___ _______ 
Unstable brain metastases or steroid dependent. 
 
21. ___ ___ _______ 
Uncontrolled inter-current illness including, but not limited to ongoing 
or active infection, symptomatic congestive heart failure, myocardial 
infarction within the past 6 months, unstable angina pectoris, or 
unstable cardiac arrhythmia requiring assessment for clinical 
intervention. 
 
22. ___ ___ _______ 
Women who are unwilling or unable to use an acceptable method to 
avoid pregnancy for the entire study period and for at least 8 weeks 
after cessation of study drug, or have a positive pregnancy test at 
baseline. 
 
23. ___ ___ _______ 
Pregnant or nursing. 
 
24. ___ ___ _______ 
Prisoners or subjects who are compulsorily detained (involuntarily 
incarcerated) for treatment of either a psychiatric or physical (e.g., 
infectious) illness. 
If the answer to all Inclusion criteria is “Yes” and all Exclusion criteria is “No” then the 
patient is considered to be protocol eligible. 
 


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60 
Is the patient protocol eligible? YES 
NO 
 
 
Signature (Dr.Chachoua) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 2: 
LABORATORY CORRELATE MANUAL VERSION 1.4  8.21.2014 
At Baseline: 
BIOPSIES: a core biopsy from the lesion selected to be irradiated is 
obtained placed in a dry clean container (plastic jar) and immediately 
placed on ice and transported by BioRepository Center (BRC) personnel to 
pathology. Before transport call Dr. Demaria’s lab (212-263-7306/8). Dr. 
Demaria or her designee will come immediately to collect half of the tissue. 
Tissue collected will be placed in Trizol-containing tube and stored frozen in 
Demaria’s lab for later RNA/DNA isolation. The other half will be fixed in 
formalin and paraffin-embedded.  
 
and delivered to Dr. Demaria’s lab. 
Half core will be assigned for histology and half for RNA/DNA. 
 
 
 
Blood: Six 10 mL purple top (EDTA) tubes—to Immune Monitoring Core 
 
 
 
One 10 mL red top (serum) tube—serum to be processed  
 
 
 
 
 
and frozen by Immune Monitoring Core (or BioRepository Center (BRC))  
 
 
 
 
(Total research blood draw this day 70 mL) 
 
Day 22: 
RE-BIOPSY original irradiated lesion: a core biopsy from the lesion 
selected to be irradiated is obtained and delivered at Dr. Demaria’s lab  
Half core will be assigned for histology and half for RNA/DNA. 
Blood: Six 10 mL purple top (EDTA) tubes—to Immune Monitoring Core 
 
 
 
One 10 mL red top (serum) tube—serum to be processed  
 
 
 
 
 
and frozen by Immune Monitoring Core (or BRC)  
 
 
 
 
(Total research blood draw this day 70 mL) 
 
 
Day 64: 
 
Blood: Three 10 mL purple top (EDTA) tubes—to  Immune Monitoring Core 
 
 
 
 
(Total research blood draw this day 30 mL) 
 
 
Day 88: 
 
Blood: Six 10 mL purple top (EDTA) tubes—to Immune Monitoring Core 
 
 
 
One 10 mL red top (serum) tube—serum to be processed  
 
 
 
 
 
and frozen by Immune Monitoring Core (or BRC)  
 
 
 
 
(Total research blood draw this day 70 mL) 
 


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Follow up visit (at 6 months from starting treatment): 
Blood: Six 10 mL purple top (EDTA) tubes—to Immune Monitoring Core 
 
 
 
One 10 mL red top (serum) tube—serum to be processed  
 
 
 
 
 
and frozen by Immune Monitoring Core (or BRC)  
 
 
 
 
(Total research blood draw this day 70 mL) 
 
BLOOD PROCESSING:  
PBMC:  
aliquot obtained PBMC as follows: 
- 2 aliquots of 2x106 cells, pellet and freeze dry (Store in liquid nitrogen) 
- The remainder preserved frozen for flow cytometry/functional assays in 10x106 cell aliquots 
 
PLASMA: collect from EDTA-blood and freeze 5 aliquots of 1-ml each.  
 
Rationale for using EDTA tubes instead of heparin :  
Heparin may interfere with some of the planned assays. It was decided to collect blood using EDTA which will not 
pose this potential problem 
 
 


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63 
APPENDIX 3:   SUGGESTED WORK-UP AND TREATMENT FOR IMMUNE  
 
 
 
RELATED ADVERSE EVENTS (IRAE)S 
As discussed in Section 4.3.4, an irAE is defined as an adverse event of unknown etiology, 
associated with drug exposure and is consistent with an immune phenomenon. Efforts should 
be made to rule out neoplastic, infectious, metabolic, toxin or other etiologic causes prior to 
labeling an adverse event a non-dermatologic, immune-mediated event. Serological, 
immunological, and histological (biopsy) data should be used to support the diagnosis of an 
immune-mediated toxicity. Documentation of test results should be included in the patient’s 
medical record. 
Gastrointestinal (diarrhea) and skin (rash)-related toxicities have been the most common irAEs 
noted in prior studies with ipilimumab. Suggested work-up procedures for suspected irAEs of the 
gastrointestinal tract, liver, skin, eye, pituitary, and adrenal gland are listed below. When 
symptomatic therapy is inadequate or inappropriate, an irAE should be treated with steroids 
followed by a slow taper. 
Gastrointestinal tract: Diarrhea (defined as either first watery stool, or increase in frequency 
50% above baseline with urgency or nocturnal bowel movement, or bloody stool) should be 
further evaluated and infectious or alternate etiologies ruled out. Patients should be advised to 
inform the Investigator if any diarrhea occurs, even if it is mild. An algorithm for working up 
patients with diarrhea or suspected colitis is provided in Appendix 4. 
If the event is of significant duration or magnitude or is associated with signs of systemic 
inflammation or acute phase reactants (e.g., increased CRP or platelet count; or bandemia), it is 
recommended that sigmoidoscopy (or colonoscopy, if appropriate) with colonic biopsy with 3 to 
5 specimens for standard paraffin block be performed. If possible, 1 to 2 biopsy specimens 
should be snap frozen and stored. All patients with confirmed colitis should also have an 
ophthalmological examination, including a slit-lamp exam, to rule out uveitis. Tests should also 
be performed for WBCs and for stool calprotectin. 
Patients with colitis should discontinue any non-steroidal anti-inflammatory medications or any 
other medications known to exacerbate colitis symptoms. Investigators should use their clinical 
judgment as to whether corticosteroids are necessary to treat colitis associated with ipilimumab 
therapy and as to what dose should be used. As guidance prior experience suggests that colitis 
manifested as ≥ Grade 3 diarrhea requires corticosteroid treatment. For severe symptoms, 
prednisone 60 mg or equivalent may be required to control initial symptoms and the dose should 
be gradually tapered over at least one month in duration. Lower doses of prednisone may be 
considered for less severe cases of colitis. It is suggested that prednisone (for oral 
administration) or solumedrol (for intravenous administration) be corticosteroid of choice in the 
treatment of colitis.  
Liver: Elevation of LFTs  3 fold from baseline should instigate an investigation into the 
underlying etiology for suspected irAEs. Neoplastic, concurrent medications, viral hepatitis, and 
toxic etiologies should be considered and addressed, as appropriate. Imaging of the liver, gall 
bladder, and bile duct should be performed to rule out neoplastic or other causes for the 
increased LFTs. An ANA, pANCA, and anti-smooth muscle antibody test should be performed if 


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an autoimmune etiology is considered. Consultation with a hepatologist is appropriate for a 
suspected liver irAE and a biopsy should be considered. 
Patients presenting with right upper-quadrant abdominal pain and/or unexplained nausea or 
vomiting should have LFTs performed immediately and reviewed before administering the next 
dose of study drug. Treating physicians should discuss, with the CRO Medical Monitor, 
unexplained increases in LFTs  3 fold from baseline prior to any additional study drug 
administration. 
Pancreas: Symptoms of abdominal pain associated with elevations of amylase and lipase, 
suggestive of pancreatitis, may rarely be associated with anti-CTLA-4 monoclonal antibody 
administration. The differential diagnosis of acute abdominal pain should include pancreatitis. 
Appropriate workup should include serum amylase and lipase tests.  
Skin: A dermatologist should evaluate persistent and/or severe rash or pruritus. A biopsy should 
be performed if appropriate and if possible, photos of the rash should also be obtained. Low-
grade ipilimumab mediated rash and pruritus irAEs have been treated with symptomatic therapy 
(e.g., antihistamines). Topical or parenteral corticosteroids may be required for more severe 
symptoms. 
Eye: An ophthalmologist should evaluate visual complaints with examination of the conjunctiva, 
anterior and posterior chambers and retina; visual field testing and an electroretinogram should 
also be performed. Patients with ipilimumab related uveitis or episcleritis have been treated with 
topical corticosteroid eye drops. 
Endocrine: Patients with unexplained symptoms such as fatigue, myalgias, impotence, mental 
status changes, or constipation should be investigated for the presence of thyroid, pituitary or 
adrenal endocrinopathies. An endocrinologist should be consulted if an endocrinopathy is 
suspected. TSH and free T4 levels should be obtained to determine if thyroid abnormalities are 
present. TSH, prolactin and a morning cortisol level will help to differentiate primary adrenal 
insufficiency from primary pituitary insufficiency. Appropriate hormone replacement therapy 
should be instituted if an endocrinopathy is documented.  
Suspected irAEs should be documented in the patient’s medical record.  
 


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APPENDIX 4: 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 5:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 6:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 7: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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APPENDIX 8: 


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APPENDIX 9:   LIST OF ABBREVIATIONS 
Abbreviation 
Term 
ADCC 
Antibody Dependent Cellular Cytotoxicity 
AE 
Adverse Event 
AEC 
Absolute Neutrophil Count 
ALC 
Absolute Lymphocyte Count 
ANC 
Absolute Neutrophil Count 
APC 
Antigen Presenting Cell 
BED 
Biologically Effective Dose 
BMS 
Bristol-Myers Squibb 
CBC 
Complete Blood Count 
CBCT 
Cone-Beam CT 
CDC 
Complement Dependent Cytotoxicity 
CDR3 
Complementarity Determining Region 3 
CR 
Complete Response 
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTL 
Cytotoxic T-Lymphocyte 
CTV 
Clinical Target Volume 
DRR 
Digitally Reconstructed Radiograph 
DVH 
Dose-Volume Histogram 
ECOG 
Eastern Cooperative Oncology Group  


Version 2.3 12/04/2015 
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Abbreviation 
Term 
FDR 
False Discovery Rate 
FSH 
Follicle Stimulating Hormone 
GM-CSF 
Granulocyte-Macrophage Colony-Stimulating Factor 
GTV 
Gross Tumor Volume 
hCG 
Human Chorionic Gonadotropin 
HR 
Hazard Ratio 
HRT 
Hormone Replacement Therapy 
i.v. 
Intravenous 
IB 
Investigator Brochure 
IgG 
Immunoglobulin G 
IGRT 
Image Guided Radiation Therapy 
IHC 
Immunohistochemistry 
IMRT 
Intensity Modulated Radiation Therapy 
IP 
Investigational Product 
Ipi 
Ipilimumab 
IRB 
Institutional Review Board 
irBOR(R) 
Immune-Related Best Overall Response (Rate) 
irCR 
Immune-Related Complete Response 
irPD 
Immune-Related Progression of Disease 
irPFS 
Immune-Related Progression Free Survival 
irPR 
Immune-Related Partial Response 


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Abbreviation 
Term 
irRC 
Immune-Related Response Criteria 
irSD 
Immune-Related Stable Disease 
irSPD 
Immune-Related Sum of the Products of Diameters 
IT 
Immunotherapy 
mAb 
Monoclonal Antibody 
MDSC 
Myeloid-Derived Suppressor Cell 
MLC 
Multi-Leaf Collimator 
MRI 
Magnetic Resonance Imaging 
NK 
Natural Killer 
NSAID 
Non-Steroidal Anti-Inflammatory Drug 
NSCLC 
Non-Small Cell Lung Cancer 
OLP 
Overlapping Peptide 
PBMC 
Peripheral Blood Mononuclear Cell 
PD 
Progressive Disease 
PD1 
Programmed Death Receptor 1 
PFS 
Progression Free Survival 
PR 
Partial Response 
PS 
Performance Status 
PTV 
Planning Target Volume 
RCOIC 
Research Conflict of Interest Committee 
RECIST 
Response Evaluation Criteria In Solid Tumors 


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Abbreviation 
Term 
RT 
Radiotherapy or Radiation Therapy 
RT-Ipi 
Radiotherapy and Ipilimumab 
SAE 
Serious Adverse Event 
SD 
Standard Deviation 
sMICA 
Soluble MICA 
SPD 
Sum of the Products of Diameters 
TA 
Tumor Assessment 
TAA 
Tumor-Associated Antigen 
TCR 
T-Cell Receptor 
TIL 
Tumor Infiltrating Lymphocyte 
TNM Staging 
Tumor, Node and Metastasis Staging 
WOCBP 
Women of Child Bearing Potential 
 
 
 


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