Clinical trial NCT03278626
Conditions: Esophageal Squamous Cell Carcinoma
Keywords: Locally Advanced Esophageal Squamous Cell Carcinoma
Sponsor: NYU Langone Health
Start date: 2017-06-27; Completion date: 2021-05-31
Enrollment: 12 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
In this multi-institution phase I/II trial, the investigators have chosen paclitaxel and carboplatin using a schedule and doses identical to those used in the CROSS trial. Following a run-in with nivolumab alone at 240 mg IVPB every 2 weeks for 2 doses, nivolumab at 240 mg every 2 weeks will be added to paclitaxel and carboplatin, which will be dosed according to the standard of care established by the CROSS trial: paclitaxel 50 mg/m2 weekly for 6 weeks and carboplatin AUC 2 weekly for 6 weeks. Concurrent radiation will be administered with chemotherapy at 1.8 Gy/fraction × 28 fractions to a total dose of 50.4 Gy, the standard radiation dose administered in the United States for trimodality therapy that includes concurrent therapy with carboplatin and paclitaxel. A decrease in dose to 41.4 Gy per the protocol established by van Hagen, et al. will be permitted before discontinuing therapy due to unacceptable toxicity. While the CROSS study administered only 5 weekly doses of chemotherapy during the 5 weeks of radiation, the higher dose of 50.4 Gy (1.8 Gy/fraction ×28 fractions over 5½ weeks) utilized in this study permits for a sixth dose during the additional week of radiation.

Detailed description:

Arms: arm 1: 240 mg IVPB every 2 weeks for 2 doses, nivolumab at 240 mg every 2 weeks will be added to paclitaxel and carboplatin, which will be dosed according to the standard of care: paclitaxel 50 mg/m2 weekly for 6 weeks and carboplatin AUC 2 weekly for 6 weeks and radiation
Interventions: intervention 1: Nivolimumab+Carboplatin/paclitaxel+Radiation
Intervention descriptions: intervention 1: In the phase I portion of the study, up to six patients will be treated (radiation will be 50.4 Gy (1.8 Gy/fraction × 28 fractions)) and then observed for 28 days (following last day of treatment (Day 64)).

Protocol documents:
Prot_SAP_000.pdf: 
  
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as 
authorized in writing by the study sponsor 
 
 
A PHASE I/II OPEN LABEL MULTI-CENTER STUDY OF IMMUNE CHECKPOINT 
THERAPY WITH NIVOLUMAB FOR PATIENTS WITH LOCALLY ADVANCED 
ESOPHAGEAL SQUAMOUS CELL CARCINOMA  
 
Regulatory Sponsor: 
The Laura and Isaac Perlmutter Cancer Center 
NYU Langone Medical Center  
160 E 34th Street, New York, NY 10016 
(212) 731-5001 
 
Funding Sponsor: 
Bristol-Myers Squibb (BMS) 
Corporate Headquarters 
345 Park Avenue, New York, New York 10154 
Tel: (212) 546-4000 
Study Product: 
Nivolumab  
Overall PI/Co-Principal Investigator:          
 
Jennifer Wu, MD 
Dept. of Hematology and Medical Oncology 
Laura and Isaac Perlmutter Cancer Center 
     
New York University Langone Medical Center 
462 First Ave, Bellevue Hospital, BCD 556 
Telephone: 212-562-1135 
Co-Principal Investigator:                          
 
Geoffrey Y. Ku, MD  
Memorial Sloan Kettering Cancer Center 
300 East 66th Street, 1035, New York, NY 10065 
Telephone: (646) 888-4588 
Co-Principal Investigator Lawrence Leichman, MD 
Professor of Medicine 
Director, GI Oncology 
Moores Cancer Center 
UC San Diego Health - La Jolla 
Moores Cancer Center 
3855 Health Sciences Drive 
La Jolla, CA  92093 
Telephone: 858-822-6100 
 
Radiation Therapy  
Principal Investigator: 
Kevin Du, MD, PhD, MSCI 
Assistant Professor, Department of Radiation Oncology 
The Laura and Isaac Perlmutter Cancer Center 
NYU Langone Medical Center 
160 East 34th Street, New York, NY 10016 
Telephone: (212) 731-5003  
 
Surgical Coordinator 
Costas Bizekis, MD 
Assistant Professor of Cardiothoracic Surgery 
Director, Minimally Invasive Esophageal Surgery 
Minimally Invasive Lung and Esophageal Surgery 
Division of Thoracic Surgery 
Department of Cardiothoracic Surgery 
530 First Avenue, Suite 9V, New York, NY 10016 
Telephone: (212) 263-5969  
Clinical Research Protocol 


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Participating Sites: 
 
Memorial Sloan Kettering Cancer Center, Oregon Health 
& Science University, University of California San 
Diego,University of Southern California 
Coordinating Center: 
NYU Langone Health 
Perlmutter Cancer Center 
Clinical Trials Office 
PCC-QAU@nyumc.org 
 
NYU Protocol Number: 
 
s16-00971 
BMS Protocol Number: 
CA209-791 
ClinicalTrials.gov Number: 
NCT03278626 
IND Number: 
133388 
Date of Protocol Version: 
August 28, 2017 
December 21, 2017 
June 18, 2018 
August 22, 2018 
January 22, 2020 
 


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INVESTIGATOR SIGNATURE PAGE 
 
I have read this protocol, including all appendices, and I agree to conduct the study in 
compliance with all applicable regulations (including 21 CFR Part 312).  I will also make 
a reasonable effort to complete the study within the time designated.  I will provide all 
study personnel under my supervision copies of the protocol and access to all information 
provided by Bristol-Myers Squibb.  I will discuss this material with them to ensure that 
they are fully informed about the drug and the study. 
I am aware that, prior to the commencement of this study, the Institutional Review Board 
must approve this protocol and the informed consent document associated with the 
clinical facility where the study will be conducted.  I agree to make all reasonable efforts 
to adhere to the attached protocol.  I agree to provide all subjects with a signed and dated 
copy of their informed consent document, as required by FDA and ICH regulations.  I 
further agree to report to Bristol-Myers Squibb any adverse events in accordance with the 
terms of this protocol and FDA regulation 21 CFR 312.64.   
Nothing in this document is intended to limit the authority of a physician to provide 
emergency medical care under applicable regulations.  
 
 
 
 
Investigator Signature 
 
 Date of Signature 
(DD/MM/YYYY) 
__________________________________________________ 
Name of Investigator (please print) 
 
 


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TABLE OF CONTENTS 
 
INVESTIGATOR SIGNATURE PAGE .............................................................................. 2 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS............................................ 8 
SYNOPSIS........................................................................................................................ 12 
1.0 BACKGROUND AND RATIONALE.......................................................................... 20 
1.1 ESOPHAGEAL SQUAMOUS CELL CANCER (ESCC) .................................................. .20 
1.2 ESCC AND IMMUNOTHERAPY .................................................................................. 21 
1.3 NIVOLUMAB ............................................................................................................ 22 
1.3.1 Melanoma ....................................................................................................... 23 
1.3.2 Non-Small Cell Lung Cancer .......................................................................... 23 
1.3.3 Esophageal Cancer ........................................................................................ 24 
1.4 COMBINIING RADIATION THERAPY WITH PD-1 INHIBITION ......................................... 25 
1.5 NYU PRECLINICAL DATA FOR RADIATION AND PD-1 INHIBITION ............................... 25 
1.6 RATIONALE FOR COMBINING CHEMORADIATION WITH NIVOLUMAB ............................ 26 
1.7 RATIONALE FOR FLAT DOSING OF NIVOLUMAB......................................................... 26 
1.8 ADJUVANT NIVOLUMAB ........................................................................................... 27 
2.0 STUDY HYPOTHESIS AND OBJECTIVES ............................................................. 27 
2.1 HYPOTHESES .......................................................................................................... 27 
2.2 OBJECTIVES............................................................................................................ 28 
2.2.1 Phase I Objective............................................................................................ 28 
2.2.2 Phase II Objectives ......................................................................................... 28 
2.2.3 Exploratory Objectives.................................................................................... 28 
3.0 STUDY DESIGN ........................................................................................................ 30 
3.1 GENERAL DESIGN ................................................................................................... 30 
3.2 PRIMARY STUDY ENDPOINTS ................................................................................... 32 
3.3 SECONDARY STUDY ENDPOINTS .............................................................................. 32 
3.3.1 Immune Correlative Assays ............................................................................. 32 
   3.3.1.1 Sample Collection ...................................................................................... 32 
   3.3.1.2 Immunohistochemical Staining of Tumor Tissue ...................................... 32 
   3.3.1.3 Purpose of Immune Correlative Assays .................................................... 32 
   3.3.1.4 Subject Participation .................................................................................. 32 
   3.3.1.5 Rationale for Mandatory Correlative Study Specimen Collection ............ 32 
   3.3.1.6 Sample Labeling, Storage, and Handling ................................................. 32 
   3.3.1.7 Tumor Microarray (TMA) Immune Microenvironment Analysis ................ 32 
   3.3.1.8 Serum Cytokine Measurement .................................................................. 32 
   3.3.1.9 PBMC Phenotype Characterization .......................................................... 33 
   3.3.1.10 Serum Measurement of Antibody Responses to >8,000 Antigens  ....... 33 
   
4.0 
PATIENT SELECTION AND WITHDRAWAL ..................................................... 35 
4.1 INCLUSION CRITERIA ................................................................................................. 35 
4.2 EXCLUSION CRITERIA .............................................................................................. 35 


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4.3 PATIENT RECRUITMENT ........................................................................................... 36 
4.3.1 Informed Consent ............................................................................................ 37 
4.3.2 Documentation of Consent .............................................................................. 38 
4.3.3 Multi-Site Surveillance ..................................................................................... 38 
4.3.4 Patient Informed Consent at Additional Sites ................................................. 39 
4.4 REGISTRATION PROCEDURES .................................................................................. 39 
4.4.1 General Guidelines .......................................................................................... 39 
4.4.2 Patient Registration at Other Participating Institutions ................................... 40 
4.5 EARLY WITHDRAWAL OF SUBJECTS ........................................................................ 41 
4.5.1 When and How to Withdraw Subjects ............................................................. 41 
4.5.2  Data Collection and Follow-up for Withdrawn Subjects ................................ 42 
 
5.0 DESCRIPTION OF THERAPY .................................................................................. 42 
5.1 SYSTEMIC THERAPY: DESCRIPTION, PREPARATION, ADMINISTRATION AND TOXICITY 42 
5.1.1 Nivolumab  ...................................................................................................... 42 
 
5.1.1.1 Dose and Schedule ............................................................................ 42 
 
5.1.1.2 Nivolumab Description ....................................................................... 42 
 
5.1.1.3 Storage Requirements and Stability .................................................. 43 
 
5.1.1.4 Preparation ......................................................................................... 43 
 
5.1.1.5 Administration ..................................................................................... 43 
5.1.2 Carboplatin ..................................................................................................... 44 
 
5.1.2.1 Dose and Schedule ............................................................................ 44 
 
5.1.2.2 Carboplatin Description ...................................................................... 44 
 
5.1.2.3 Storage Requirements and Stability .................................................. 44 
 
5.1.2.4 Preparation ......................................................................................... 44 
 
5.1.2.5 Administration ..................................................................................... 45 
5.1.3 Paclitaxel  ........................................................................................................ 45 
 
5.1.3.1 Dose and Schedule ............................................................................ 45 
 
5.1.3.2 Paclitaxel Description ......................................................................... 45 
 
5.1.3.3 Storage Requirements and Stability .................................................. 45 
 
5.1.3.4 Preparation ......................................................................................... 45 
 
5.1.3.5 Administration ..................................................................................... 45 
5.2 RADIATION THERAPY……….…………………………………………………………..   46 
5.2.1 Technical Factors ........................................................................................... 46 
5.2.2 Required Benchmarks and Pre-Approval of 3D Treatment Plans ................ 46 
5.2.3 Protocol Treatment Volumes .......................................................................... 46 
5.2.4 Target Dose Constraints ................................................................................ 47 
5.2.5 Normal Dose Constraints ............................................................................... 47 
5.2.6 Treatment Planning ........................................................................................ 48 
5.2.7 Portal Film Review .......................................................................................... 49 
5.2.8 Definitions of Deviations in Protocol Performance ........................................ 49 
5.3 SURGERY: ESOPHAGCTOMY….………………………………………………………..   50 
5.3.1 Surgical Procedures ....................................................................................... 50 
 
6.0  Study Procedures .................................................................................................... 51 
   6.1 Study Visits .............................................................................................................. 51 


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SCHEDULE OF EVENTS/STUDY CALENDAR ............................................................. 52 
6.1.1 Screening ........................................................................................................ 53 
6.1.2 Pregnancy Precautions .................................................................................. 53 
6.1.3 Cycle 1 Day 1 ................................................................................................. 55 
6.1.4 Cycle 2 Day 1 (Day 15) .................................................................................. 55 
6.1.5 Cycle 2 Days 8-14 (Days 22-28)  ................................................................... 55 
6.1.6 Cycle 3 Day 1 (Day 29) .................................................................................. 55 
6.1.7 Cycle 3 Day 8 (Day 36) .................................................................................. 56 
6.1.8 Cycle 4 Day 1 (Day 43) .................................................................................. 56 
6.1.9 Cycle 4 Day 8 (Day 50) .................................................................................. 56 
6.1.10 Cycle 5 Day 1 (Day 57) .................................................................................. 57 
6.1.11 Cycle 5 Day 8 (Day 64) ................................................................................. 57 
6.1.12  After Completion of Radiation Therapy ........................................................ 57 
6.1.13 Cycles 6-11 .................................................................................................... 58 
6.1.14 End of Treatment and 30-Day Post Treatment Visits ................................... 58 
6.1.15 60-Day Post Treatment Visit.......................................................................... 58 
6.1.16 Follow-Up ....................................................................................................... 59 
6.2 PET/CT SCANS…………………………………………………………….…....……... 59 
6.2.1 PET/CT Imaging Interpretation ...................................................................... 59 
    6.3 ENDOSCOPY AND BIOPSY…...…...…………………………………………………… 59 
   
7.0 DOSE MODIFICATIONS AND MANAGEMENT OF TOXICITY .............................. 60 
7.1 GRADE 1 AND/OR GRADE 2 HEMATOLOGIC TOXICITIES ............................................ 62 
7.2 HEMATOLOGIC ADVERSE EVENTS ............................................................................ 62 
7.3 GRADE 1 HEPATIC TOXICITY .................................................................................... 63 
7.4 GRADE 2 HEPATIC TOXICITY .................................................................................... 63 
7.5 GRADE 3/4 HEPATIC TOXICITY ................................................................................. 64 
7.6 ALLERGIC REACTIONS ............................................................................................. 64 
7.7 GRADE 1 NEUROLOGIC TOXICITIES .......................................................................... 64 
7.8 GRADE 2 NEUROLOGIC TOXICITIES .......................................................................... 64 
7.9 GRADE 3/4 NEUROLOGIC TOXICITIES ....................................................................... 65 
7.10 GASTROINTESTINAL TOXICITIES ............................................................................... 65 
 
7.10.1 GRADE 1 AND 2 VOMITING  ........................................................................... 65 
 
7.10.2 GRADE 3/4 VOMITING  .................................................................................. 65 
 
7.10.3 GRADE 1 AND 2 DIARRHEA ........................................................................... 65 
 
7.10.4 GRADE 3/4 DIARRHEA  ................................................................................. 65 
 
7.10.5 GRADE 1 ESOPHAGITIS  ............................................................................... 65 
 
7.10.6 GRADE 2 ESOPHAGITIS  ............................................................................... 65 
 
7.10.7 GRADE 3/4 ESOPHAGITIS  ............................................................................ 66 
7.11 GRADE 1 PNEUMONITIS ........................................................................................... 66 
7.12 GRADE 2-4 PNEUMONITIS ........................................................................................ 66 
7.13 DOSE MODIFICATIONS FOR OTHER NON-HEMATOLOGIC TOXICITIES DURING COMBINED 
THERAPY ........................................................................................................................ 66 
7.14 NIVOLUMAB IMMUNE-MEDIATED TOXICITY ................................................................ 66 
 
7.14.1 IMMUNE-MEDIATED PNEUMONITIS  ................................................................ 66 
 
7.14.2 IMMUNE-MEDIATED COLITIS  ......................................................................... 67 


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7.14.3 IMMUNE-MEDIATED HEPATITIS  ..................................................................... 68 
 
7.14.4 IMMUNE-MEDIATED NEPHRITIS AND RENAL DYSFUNCTION  ............................ 68 
 
7.14.5 IMMUNE-MEDIATED NEUROPATHY  ................................................................ 69 
 
7.14.6 IMMUNE-MEDIATED ENDOCRINOPATHIES....................................................... 69 
7.15 GENERAL CRITERIA TO RESUME TREAMENT (DOSE RESUMPTION) WITH NIVOLUMAB 73 
8.0 CRITERIA FOR RESPONSSE AND PROGRESSION ...........................................  74 
8.1 CLINICAL RESPONSE ............................................................................................... 74 
8.2 PATHOLOGIC RESPONSE ......................................................................................... 74 
8.3 PROGRESSION OF DISEASE ..................................................................................... 74 
9.0 STATISTICAL PLAN ................................................................................................. 75 
10.0 SAFETY AND ADVERSE EVENTS ........................................................................ 76 
10.1 DEFINITIONS ............................................................................................................ 77 
10.2 OTHER SAFETY CONSIDERATIONS ........................................................................... 79 
10.3 RECORDING OF ADVERSE EVENTS ........................................................................... 81 
10.4 REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS ........... 81 
10.4.1 Investigator reporting:   notifying the study sponsor and Perlmutter Cancer 
Center Clinical Trials Office ...................................................................................... 81 
10.4.2 Investigator reporting: notifying the IRB ........................................................ 84 
10.4.3 Sponsor reporting: Notifying BMS ................................................................. 87 
10.4.4 Sponsor reporting: Notifying Participating Investigators ............................... 84 
10.5 STOPPING RULES .................................................................................................... 84 
10.6 MEDICAL MONITORING ............................................................................................ 84 
10.6.1 Data Monitoring Committee ........................................................................... 84 
11.0 DATA HANDLING AND RECORD KEEPING ........................................................ 86 
11.1 DATA COLLECTION .................................................................................................. 86 
11.2 CONFIDENTIALITY .................................................................................................... 86 
11.3 CONFIDENTIALITY AND HIPAA ................................................................................ 86 
11.4 SOURCE DOCUMENTS ............................................................................................. 87 
11.5 DATA AND SOURCE DOCUMENTATION ...................................................................... 87 
11.6 RECORDS RETENTION ............................................................................................. 87 
12.0 STUDY MONITORING, AUDITING, AND INSPECTING ....................................... 87 
12.1 STUDY MONITORING PLAN....................................................................................... 87 
12.2 AUDITING AND INSPECTING ...................................................................................... 88 
13.0 ETHICAL CONSIDERATIONS ................................................................................ 88 
14.0 STUDY FINANCES .................................................................................................. 88 
14.1 FUNDING SOURCE ................................................................................................... 88 
14.2 CONFLICT OF INTEREST ........................................................................................... 89 
15.0 PUBLICATION PLAN .............................................................................................. 89 
16.0 POTENTIAL RISKS AND POTENTAL BENEFITS OF STUDY TREATMENT. 89 
16.1 RISKS OF STUDY DRUGS ......................................................................................... 89 
16.1.1 Potential Nivolumab Toxicities ...................................................................... 89 


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16.1.2 Potential Carboplatin Toxicities ..................................................................... 96 
16.1.3 Potential Paclitaxel Toxicities ........................................................................ 98 
16.2 RISKS OF RADIATION THERAPY ............................................................................. 101 
16.3 RISKS OF BIOPSY .................................................................................................. 101 
16.4 RISKS OF SURGERY............................................................................................... 101 
16.5 OTHER RISKS OF STUDY PARTICIPATION ............................................................... 102 
16.5.1 Side Effects of Having Blood Taken ........................................................... 102 
16.5.2 Radiation Risks ............................................................................................ 102 
16.5.3 Electrocardiogram (ECG) Risks .................................................................. 102 
16.5.4 FDG-PET CT Scan Risks ............................................................................ 102 
16.5.5 Magnetic Resonance Imaging (MRI) Risks ................................................ 103 
16.5.6 Unforseeable Risks ..................................................................................... 104 
16.6 POTENTIAL BENEFITS ........................................................................................ 104 
17.0 REFERENCES ....................................................................................................... 105 
APPENDIX 
I: 
EASTERN 
COOPERATIVE 
ONCOLOGY 
GROUP 
(ECOG) 
PERFORMANCE STATUS SCALE .............................................................................. 108 
APPENDIX II: SAMPLE PREPARATIONS AND SHIPMENT INSTRUCTIONS ......... 109 
 
FIGURES 
Figure 1: Somatic Mutations Which Are Correlated With Sensitivity To Immunotherapy 
Are Highly Prevalent In Esophageal Cancer ................................................................... 22 
Figure 2: Role of the PD-1 Pathway in Suppressing Anti-Tumor Immunity.................... 23 
Figure 3: Waterfall Plot of Target Lesion Change Based on Investigator Assessment 
(N=64) as of May 17, 2005 .............................................................................................. 24 
Figure 4:  Change in Tumor Volume: ............................................................................... 26 
Figure 5: Change in Amount of CD8+ T Cells  ................................................................ 26 
Figure 6: Trial Schema: .................................................................................................... 29 
 
TABLES 
Table 1: Screening Laboratory Values (Synopsis) .......................................................... 14 
Table 1: Screening Laboratory Values ............................................................................ 34 
Table 2: Product Description ............................................................................................ 42 
Table 3: Carboplatin Preparation ..................................................................................... 44 
Table 4: Schedule of Events/Study Calendar .................................................................. 52 
Table 5: Schedule of Events in Follow-Up ....................................................................... 59 
Table 6: Adverse Event Definitions .................................................................................. 60 
Table 7: Dose Modifications ............................................................................................. 62 
Table 8: Treatment Modification for Hematologic Toxicity .............................................. 63 


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Table 9: Appendix I ECOG Performance Status Scale ................................................. 108 
 
 


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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviation  Explanation  
% 
Percent 
◦C 
Degrees Celsius 
5-FU 
5-Fluorouracil 
ADL 
Activities of Daily Living 
AE 
Adverse Event 
AKR 
An esophageal squamous cell cancer line with cyclin-D1 overexpression and 
p53 deletion 
Alk Phos 
Alkaline Phosphatase, a non-specific metalloenzyme which hydrolyzes many 
types of phosphate esters, found in highest amounts in liver, bile ducts, and 
bone 
ALT/SGPT 
Alanine transaminase or alanine aminotransferase/serum glutamate-pyruvate 
transaminase, a transaminase enzyme found in plasma and various body 
tissues, but most common in the liver. 
ANC 
Absolute Neutrophil Count 
AP 
Anteroposterior  
AST/SGOT 
Aspartate transaminase or aspartate aminotransferase/Serum glutamic 
oxaloacetic transaminase, an enzyme that is normally present in liver and heart 
cells. 
AUC 
Area Under the Curve 
BMS 
Bristol-Myers Squibb 
BRAF 
A human gene that encodes the B-Raf protein, which is involved in directing cell 
growth.  
CBC 
Complete Blood Count 
Cc 
Cubic centimeter(s) 
cCR 
Clinical Complete Response 
CD279 
Programmed cell death protein 1 (PD-1), a cell surface receptor of the 
immunoglobulin superfamily and expressed on T cells and pro-B cells.  It binds 
two ligands: PD-L1 and PD-L2. 
CD3 
Cluster of Differentiation 3: a T-cell co-receptor that helps to activate the 
cytotoxic T-Cell. 
CD4 
Cluster of Differentiation 4: a glycoprotein found on the surface of immune cells 
such as T helper cells, monocytes, macrophages, and dendritic cells. 
CD8 
Cluster of Differentiation 8: a transmembrane glycoprotein that serves as a co-
receptor for the T cell receptor (TCR). Like the TCR, CD8 binds to a major 
histocompatibility complex (MHC) molecule, but is specific for the class I MHC 
protein. 
CFR 
Code of Federal Regulations 
cGy 
centi-Gray (see Gy below) 
CMP 
Complete Metabolic Panel 
CR 
Complete Response 
CrCl 
Creatinine Clearance 


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CRF 
Case Report Form 
CRO  
Clinical Research Organization 
CROSS 
ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study  
CT 
Computed Tomography 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTLA-4 
Cytotoxic T-lymphocyte associated antigen 4: a protein receptor that, functioning 
as an immune checkpoint, downregulates the immune system.  
CTV 
Clinical Target Volume 
DHEP 
di-2-ethylhexyl phthalate: A plastic form of polyvinyl chloride used to 
manufacture intravenous (IV) tubing and containers 
dL 
deciliter(s) 
DRR 
Digitally reconstructed radiographs 
DVH 
Dose volume histograms 
ECG 
Electrocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
ELISA 
Enzyme-Linked Immunosorbent Assay 
EOT 
End of Treatment Visit 
ESCC 
Esophageal Squamous Cell Carcinoma 
et al.  
et alia, a Latin phrase meaning "and others" 
etc. 
et cetera, used at the end of a list to indicate that further, similar items are 
included 
EUS 
Endoscopic Ultrasound 
FDA 
The US Food and Drug Administration  
FDG 
Fluorodeoxyglucose, a radiopharmaceutical used in the medical imaging 
modality positron emission tomography (PET) 
FOXP3 
Forkhead box P3, a protein involved in immune system responses and 
regulation of the development and function of regulatory T cells. 
FSH 
Follicle Stimulating Hormone 
G 
Gram(s) 
GTV 
Gross tumor volume 
Gy 
Gray: a derived unit of ionizing radiation dose in the International System of 
Units (SI). It is defined as the absorption of one joule of radiation energy per 
kilogram of matter. 
H1 Blocker 
Histamine 1 antagonist: a class of medications that block the action of histamine 
at the H1 receptor, helping to relieve allergic reactions 
H2 Blocker 
Histamine 2 antagonist: a class of medications that block the action of histamine 
at the histamine H2 receptors of the parietal cells in the stomach, decreasing 
production of stomach acid. 
Hb 
Hemoglobin 
HCG 
Human Chorionic Gonadotropin 
HBV 
Hepatitis B 
HCV 
Hepatitis C 
HIV 
Human Immunodeficiency Virus 


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HRT 
Hormone Replacement Therapy 
i.e. 
id est, a Latin phrase meaning “that is” 
IC50 
The concentration of an inhibitor required to reduce the rate of an enzymatic 
reaction by 50%. It is a measure of how effective a drug is. 
ICH 
The International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
ICOS 
Inducible T Cell Co-stimulator 
ICRU 
International Commission on Radiation Units & Measurements 
IFNγ 
Interferon Gamma 
IgG4 
Immunoglobulin G4 
IL-13 
Interleukin 13 
IL-1β 
Interleukin 1 Beta 
IMF  
Immune Monitoring Facility 
IMRT 
Intensity-Modulated Radiation Therapy  
IU 
International Units 
IUD  
Intrauterine Device 
IUS 
Intrauterine hormone releasing System 
IV 
Intravenous 
IVPB 
Intravenous piggy-back 
KD 
Dissociation Constant 
Kg 
kilogram(s) 
Ki-67 
A protein that is a cellular marker for proliferation.  
L 
Liter 
LAC 
Los Angeles County 
LAG-3 
Lymphocyte-activation gene 3 protein: a cell surface molecule with diverse 
biologic effects on T cell function. It is an immune checkpoint receptor. 
M 
Meter(s) 
MAGE-A3 
Melanoma-associated antigen 3. The presence of the antigen on tumor cells has 
been associated with worse prognosis. 
mcL or µL 
Microliter(s) 
Mg 
Milligram(s) 
Min 
Minute(s) 
mL 
Milliliter(s) 
Mm 
Millimeter(s) 
MRI 
Magnetic Resonance Imaging 
MSKCC 
Memorial Sloan Kettering Cancer Center 
MV 
millivolt  
NCI 
National Cancer Institute 
nmol/L 
Nano molar (10-9 molar) 
NY-ESO-1 
A cancer-testis antigen found in various tumors; may serve as a marker for 
metastasis 
NYU  
New York University 


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O2 Sat. 
Oxygen Saturation 
OS 
Overall Survival 
PA 
Posteroanterior 
PBMCs 
Peripheral Blood Mononuclear Cells 
pCR 
Pathological Complete Response 
PD-1 
Programmed Death-1 
PD-L1/2 
Programmed Death Ligand ½ 
PET 
Positron Emission Tomography 
PFS 
Progression-Free Survival 
PI 
Principal Investigator 
Plt 
Platelets 
PVC  
Polyvinylchloride 
PO 
Per os, referring to the oral administration of medications 
PTV 
Planning target volume  
PVC 
Polyvinylchloride 
Q 
Every 
ROI 
Regions of Interest 
RPC 
Radiological Physics Center 
RT 
Radiation Therapy  
RTOG 
Radiation Therapy Oncology Group 
SAE 
Serious Adverse Event 
SUVmax 
Maximum PET/CT Standardized Uptake Value  
Th1 
Type 1 T Helper Cells 
Th2 
Type 2 T Helper Cells 
TIM-3 
T-cell immunoglobulin and mucin-domain containing-3: a protein that in humans 
is encoded by the HAVCR2 gene. It is an immune checkpoint, Th1-specific cell 
surface protein that regulates macrophage activation. 
TMA 
Tumor Microarray 
TNFα 
Tumor Necrosis Factor Alpha 
TPN 
Total Parenteral Nutrition 
Treg 
Regulatory T Cell 
Tx. 
Treatment 
ULN 
Upper Limit of Normal 
USC 
University of Southern California 
US 
United States 
USP 
United States Pharmacopeia 
UT 
Unacceptable Toxicity 
Vs 
Versus 
WOCBP 
Women of Child-Bearing Potential 
Wt 
Wild Type 
3D 
3-dimensional 
4DCT 
4-dimentional CT  


Nivolumab in ESCC 
 
Page 14 
Version: 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as authorized 
in writing by the study sponsor 
SYNOPSIS 
Study Title 
A Phase I/II Open Label Multi-Center Study of Immune Checkpoint Therapy with 
Nivolumab in Patients with Locally Advanced Esophageal Squamous Cell 
Carcinoma (ESCC) 
Short Title 
Nivolumab in ESCC 
Study Sponsor 
New York University (NYU)  
Funding Sponsor 
Bristol-Myers Squibb (BMS) 
NYU Protocol 
Number 
s16-00971 
BMS Protocol 
Number 
CA209-791 
Phase 
I/II 
Study Type 
Multi-Center, Single-arm, Open Label Study  
Study Duration 
1.5 - 2 years 
Study Center(s) 
1. NYU: Laura and Isaac Perlmutter Cancer Center and Bellevue Hospital 
2. Memorial Sloan Kettering Cancer Center (MSKCC) 
3. University of Southern California (USC): Norris Cancer Center and Los 
Angeles County (LAC) + USC Medical Center 
4. Oregon Health Sciences University Knight Cancer Institute 
5. University of San Diego: Moores Cancer Center 
Objectives 
Phase I Objective 
1. Assess the safety of induction nivolumab followed by chemoradiation with 
nivolumab followed by surgery when necessary and adjuvant nivolumab 
for patients with locally advanced squamous cell cancer of the esophagus 
 
Phase II Objectives 
1. Estimate the clinical complete response (cCR) + pathological complete 
response (pCR) rate of induction nivolumab followed by chemoradiation 
with nivolumab.  
2. Describe Progression-Free Survival (PFS) and Overall Survival (OS) with 
nivolumab and chemoradiation, followed by adjuvant nivolumab 
3. Describe the major toxicities encountered with this treatment 
 
  
Exploratory Objectives 
1. Assess whether PET/CT clinical response to nivolumab can predict the 
following outcomes: CR, PFS and OS 
2. Assess the association between the outcomes CR, PFS and OS and 
immune correlative assays 


ESCC Nivolumab  
 
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Number of Patients 
50-56 
Diagnosis 
Histologically or cytologically confirmed treatment-naïve T3-T4NanyM0 or T1-
2N+ squamous cell carcinoma of the esophagus 
Inclusion Criteria 
Inclusion Criteria 
1. Histologically or cytologically confirmed, treatment-naive esophageal 
squamous cell carcinoma  
2. Previously obtained archival tumor tissue, or tissue obtained by 
endoscopically-guided core biopsy at screening 
3. TanyN1-3 or T3-4N0 as determined by EUS or PET/CT. All palpable or 
PET/CT visible lymph nodes outside the usual surgical field must be 
biopsy-proven negative for cancer.  
4. All patients must have locoregional staging determined by endoscopic 
ultrasound (EUS) if technically feasible. Endoscopy reports or subsequent 
GI clinic note should clearly state both the T and N stage.  
5. All patients must have initial PET/CT scans to document no evidence of 
metastatic or unresectable squamous cell cancer  
6. All patients with tumors involving the thoracic esophagus must undergo 
bronchoscopy to document the absence of a fistula 
7. No known contraindication to the use of taxanes or platinum compounds.  
8. No history of severe hypersensitivity reaction to Cremophor® EL.  
9. Patients who are ≥ 18 years old are eligible for this study. No specific 
gender distribution, nor specific racial or ethnic origins are necessary for 
enrollment in this study.  
10. Eastern Cooperative Oncology Group (ECOG) Performance Status 0-1 
11. A patient must be capable of giving informed consent or have an 
acceptable surrogate capable of giving consent on the subject’s behalf  
12. Deemed a suitable candidate for esophagectomy by the treating surgeon 
13. Deemed a suitable candidate for radiation therapy by the treating 
radiation oncologist.  
14. Patient must be non-pregnant and non-nursing. Women of child bearing 
potential (WOCBP) must have a negative serum or urine pregnancy test 
(minimum sensitivity 25 IU/L or equivalent units of HCG) within 72 hours 
prior to C1D1.   
15. Screening Laboratory Values must meet the following criteria and should be 
obtained within 14 days prior to C1D1 (see Table 1 below) 
16. All patients have to agree to participate in the correlative study of sample 
collection for immune correlative assays in order to participate in the main 
study. However, if the sample cannot be obtained due to feasibility issues, 
the patient will be allowed to continue on treatment 


ESCC Nivolumab  
 
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Table 1. Screening Laboratory Values 
Test 
Acceptable Result 
WBC 
≥ 2000/µL 
Neutrophils 
≥ 1500/µL 
Platelets 
≥ 100,000 /µL 
Hemoglobin 
> 9.0 g/dL 
Serum Creatinine 
≤ 1.5 x ULN  OR 
Creatinine Clearance (CrCl)* 
≥ 40 mL/min  
AST 
≤ 3 x ULN 
ALT 
≤ 3 x ULN 
Total Bilirubin** 
≤ 1.5 x ULN   
 
 
Oxygen Saturation (O2 Sat.) 
≥92% on ambient air 
Hepatitis B status 
HBV Surface Antigen  
Negative 
HBV Surface Antibody  
Positive or Negative 
HBV Core Antibody 
Positive or Negative***  
HBV Viral Load  
Negative  
Hepatitis C status 
Anti-HCV Total Antibody  
Negative 
HCV RNA analysis 
Negative 
HIV status 
Rapid HIV 1/2 Antibodies 
Negative  
*Creatinine Clearance Calculated using the Cockcroft-Gault formula 
 
Female CrCl = (140- age in years) x weight in kg x 0.85  
72 x serum creatinine in mg/dL  
 
Male CrCl = (140- age in years) x weight in kg x 1.00  
72 x serum creatinine in mg/dL  
 


ESCC Nivolumab  
 
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**Total Bilirubin ≤ 1.5 x ULN, except subjects with Gilbert Syndrome, who can have 
total bilirubin < 3.0 mg/dL 
 
*** Subjects whose HBV core antibody is positive must have a negative HBV viral 
load measurement 
 
Exclusion Criteria 
Exclusion Criteria 
1. T1-2N0 as determined by EUS or PET/CT. 
2. Pregnant or lactating women 
3. Active or prior documented autoimmune or inflammatory disorders 
including but not limited to diabetes mellitus Type 1, inflammatory bowel 
disease; 
systemic 
lupus 
erythematosus; 
Wegener 
syndrome 
[granulomatosis with polyangiitis]; myasthenia gravis; Graves’ disease; 
rheumatoid arthritis, hypophysitis, uveitis) within the past 3 years prior to 
the start of treatment. The following are exceptions to this criterion: 
3a.Subjects with vitiligo or alopecia 
       3b.Subjects with hypothyroidism (e.g., following Hashimoto syndrome)   
             stable on hormone replacement or psoriasis not requiring systemic  
             treatment 
4. History of idiopathic pulmonary fibrosis, organizing pneumonia, drug-
induced pneumonitis, idiopathic pneumonitis, or evidence of active 
pneumonitis on screening chest Computed Tomography (CT) scan 
5. The use of immunosuppressive medication within 28 days prior to the first 
dose of nivolumab.  The following are exceptions to this criterion: 
          5a.  Intranasal, topical, inhaled corticosteroids or local steroid injections  
                 (e.g. intra-articular injection) 
            5b. Systemic corticosteroids at physiologic doses ≤10 mg/day of  
                  prednisone or equivalent 
           5c. Steroids as premedication for hypersensitivity reactions (e.g. CT    
                scan premedication 
 
6. Positive test for Human Immunodeficiency Virus (HIV) 
7. Prior treatment with any immunotherapy 
8. Any other factors, including psychiatric or social, that in the opinion of the 
treating physician makes the patient an inappropriate candidate for a study. 
9. Patients are excluded if they have active brain metastases or 
leptomeningeal metastases. Subjects with brain metastases are eligible if 
metastases have been treated and there is no magnetic resonance imaging 
(MRI) evidence of progression for [lowest minimum is 4 weeks or more]  
after treatment is complete and within 28 days prior to the first dose of 
nivolumab administration. There must also be no requirement for 
immunosuppressive doses of systemic corticosteroids (> 10 mg/day 


ESCC Nivolumab  
 
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prednisone equivalents) for at least 2 weeks prior to study drug 
administration. 
10. Patients should be excluded if they have an active, known or suspected 
autoimmune disease. Subjects are permitted to enroll if they have vitiligo, 
residual hypothyroidism due to autoimmune condition only requiring 
hormone replacement, psoriasis not requiring systemic treatment, or 
conditions not expected to recur in the absence of an external trigger 
11. Patients should be excluded if they have a condition requiring systemic 
treatment with either corticosteroids (> 10 mg daily prednisone equivalents) 
or other immunosuppressive medications within 14 days of study drug 
administration. Inhaled or topical steroids and adrenal replacement doses 
< 10 mg daily prednisone equivalents are permitted in the absence of active 
autoimmune disease. 
12. As there is potential for hepatic toxicity with nivolumab or nivolumab  non-
drugs with a predisposition to hepatoxicity should be used with caution in 
patients treated with nivolumab-containing regimen. 
Patients with a history of allergy to the study drug components are 
excluded. 
Study Product, 
Dose, Route, 
Regimen 
Nivolumab  240 mg (flat dose) IV administered every 2 weeks   
Duration of 
administration 
2 cycles pre-chemotherapy and radiotherapy (1 Cycle = 14 Days) 
3 cycles concurrently with chemotherapy and radiotherapy 
6 cycles post-chemotherapy, radiotherapy, and surgery as applicable 
Endpoints 
Phase I Primary Endpoint: 
Unacceptable Toxicity (defined in a later section) at 28 days after last dose of 
carboplatin and paclitaxel on day 64. 
 
 
 
Phase II Endpoints: 
1. Primary endpoint 
2. Clinical complete response (cCR) by endoscopic and PET/CT 
evaluation or pathologic complete response (pCR) for those undergoing 
surgery 
2.Secondary endpoints 
3. Median overall survival (OS) using Kaplan Meier curves 
OS is defined as time from treatment to death from any cause. 


ESCC Nivolumab  
 
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4. Median progression free survival (PFS) using Kaplan Meier curves. 
PFS is defined as time from treatment to disease recurrence after all 
therapy is complete  or death from any cause 
 
3. Exploratory Endpoints: 
Immune correlative assays 
 
Patients will have the following samples collected: 
• Paraffin embedded blocks from the primary tumor (at baseline, 
following induction nivolumab and at surgery, if available). 
• Whole blood will be collected at the following time-points for all 
patients: 
pre-induction 
nivolumab, 
post-nivolumab/pre-
chemoradiation and post-chemoradiation/pre-surgery. Whole blood 
will be processed into peripheral blood mononuclear cells (PBMCs), 
serum and plasma on the day of collection and stored at -70°C for 
future analysis. 
• Whole blood will be collected at the following time points for patients 
who receive adjuvant nivolumab: pre-1st, 2nd and 4th dose. 
 
Research Analyses  
The following analyses will be performed on these samples: 
Immunohistochemical staining of tumor tissue 
Archived tumor tissue will be stained with an antibody against PD-L1 to 
characterize the PD-L1 status of the tumor cells. The antibody and scoring 
system will be determined at a later date. 
 
Tumor microarray (TMA) immune microenvironment analysis 
     Our laboratory collaborator at MSKCC, Dr. Prasad Adusumilli, has extensive 
experience in investigating the immune microenvironment in tumors from >2,000 
patients with lung adenocarcinomas, squamous cell carcinomas and 
neuroendocrine cancers. In addition, he is the principal investigator of a National 
Cancer Institute R21-funded prospective clinical trial in defining mesothelin, a 
cancer-associated antigen as a marker for esophageal cancer therapy response.  
     His laboratory will construct a TMA from each tumor that will comprise ≥4 
tumor cores from the most inflammatory region of the tumor as seen on H&E, ≥4 
peritumoral stromal cores, along with normal tissue. Tissue immune markers 
staining will be graded according to the intensity and/or distribution of staining. 
Grading intensity will be categorized as follows: 0 (staining absent); 1 (weak 
expression); 2 (moderate expression); and 3 (strong expression). The 
distribution of staining will be graded as follows: 0 (staining absent); 1 (1% to 
50%); and 2 (51% to 100%). The sum of the stain intensity and the distribution 
grade will be used to determine the total score, ranging from 0 to 5. Markers that 
will be analyzed include immune cell surface markers (CD3, CD4, CD8, 
CD45RO, FOXP3) and chemokines/cytokines (CCR7, CXCL12, CXCR4 and IL-
7R).  


ESCC Nivolumab  
 
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Serum cytokine measurement 
Cytokine profiles provide information about the status of immune activation and 
whether there is predominance of a Th1 or Th2 response. Th1 responses are 
associated with cytotoxic T cell responses and effective anti-tumor immunity, 
while Th2 responses are regarded as being anti-inflammatory and counteract 
Th1 responses. Cytokines can be measured using multiplexed ELISA kits, which 
can detect IL-1β, -2, -4, -6, -8, -10, -12p70, IL-13, tumor necrosis factor-α, 
interferon (IFN-γ) and others. These assays will be performed in the Immune 
Monitoring Facility (IMF) at MSKCC. 
 
PBMC phenotype characterization 
Multiparameter flow cytometry will be used to characterize the PBMC phenotype 
at various time points. Based on the time-intensive nature of these analyses, 
they may be restricted to patients with extreme outlier responses, e.g. complete 
vs. minimal pathologic response or rapid recurrence following surgery. The panel 
will include CD3, CD4, CD8, FOXP3, Ki67, ICOS, PD-1, LAG-3, TIM-3 and 
CTLA-4. Testing will be performed by the MSKCC Immune monitoring Facility 
(IMF) using this “T cell activation/exhaustion panel,” which has previously been 
validated in other studies of anti-PD-1 and anti-PD-L1 antibodies performed at 
MSKCC. 
 
Serum measurement of antibody responses to >8,000 antigens 
The analysis of antibody responses offers additional insight into the 
immunomodulatory properties of nivolumab. These assays will be performed by 
the IMF. Because of the cost of the array, such analyses may again be restricted 
to patients with unusual/extreme responses. 
Commercially available protein microarrays (Invitrogen) now allow for concurrent 
serologic screening for antibody responses to >8,000 antigens with a single 
serum sample on an unprecedented scale (termed seromics). Matched baseline 
and post-therapy sera would be assayed on one array. 
 
Statistical 
Methodology 
     This is a single-arm phase I/II study of nivolumab combined with 
carboplatin/paclitaxel and radiation for patients with locally advanced squamous 
cell carcinoma the esophagus. In the phase III CROSS study, pre-operative 
carboplatin/paclitaxel and radiation was associated with a grade 3/4 toxicity rate 
of 20% (7% hematologic and 13% non-hematologic grade 3-4 toxicities). The 
discontinuation rate for nivolumab as a single agent due to any toxicity has been 
reported to be approximate 9% {BMS, #81}. The hypothesis is that the addition 
of nivolumab to carboplatin/paclitaxel and radiation will not increase the 
aggregate grade 3/4 toxicity rate beyond 30%. 
 
     In the phase I portion of the study, up to six patients will be treated (radiation 
will be 50.4 Gy (1.8 Gy/fraction × 28 fractions)) and then observed for 28 days 


ESCC Nivolumab  
 
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(following last day of treatment (Day 64)). If there are 1 or less unacceptable 
toxicities (1/6 is less than 30%), the current regimen will be used in the phase II 
portion of the study. If there are 2 or more unacceptable toxicities (2/6 is more 
than 30%), the radiation will be reduced to 41.4 Gy (1.8 Gy/fraction × 23 
fractions). Up to six additional patients will be treated at the reduced radiation 
regimen and then observed for 28 days (following last day of treatment (Day 
64)). If there are 1 or less unacceptable toxicities, radiation of 41.4 Gy will be 
used in the phase II portion of the study. If there are 2 or more unacceptable 
toxicities, the trial will be discontinued. 
 
     Unacceptable Toxicity (UT) is defined here as: 
• Recurrent grade 3 or 4 hematologic toxicity (despite 1 prior dose reduction 
in chemotherapy) 
• Any toxicity that results in a >2-week delay in chemoradiation 
 
If the regimen is found to be tolerable, the phase II portion of the study will be 
executed. An optimal two-stage design will be implemented. With an overall 
sample size of 44 patients, there is 80% power (actual power is 80%) to test the 
null hypothesis of clinical complete response (cCR) rate + pathologic complete 
response (pCR) rate ≤ 35%, versus the alternative hypothesis of cCR+pCR ≥ 
55%, with significance level of 5% (actual significance level is 4.5%). In the first 
stage, 18 patients will be treated with the combination therapy.  If there are 7 or 
fewer cCR+pCRs the trial will be terminated. If there are 8 or more cPR+pCRs, 
the trial will continue with the subsequent enrollment of 26 additional patients in 
phase 2. If the total cPR+pCRs out of 44 patients is 20 or less, the combination 
therapy will be rejected. 
 
     cCR will be evaluated by endoscopic evaluation and CT/PET scan evaluation 
at the completion of radiation with concurrent nivolumab + carboplatin and 
radiation and pCR will be evaluated post-surgery. The trial will continue accruing 
patients in the second stage, while the 14 patients in the first stage are being 
evaluated for cCR or pCR. In an event that the interim analysis deems the 
combination therapy futile, accrual to the second stage will cease.   
 
 
 
1.0 BACKGROUND AND RATIONALE 
 
1.1 Esophageal Squamous Cell Cancer (ESCC) 
In 2016, there will be an estimated 16,980 cases of esophageal cancer and 15,590 death 
as a result of the disease in the United States [1]. However, worldwide, there will be an 
estimated 455,800 cases over 400,000 deaths [2]. Despite advances in the multimodality 
care in esophageal cancers, in particular the combination of chemotherapy, radiation 


ESCC Nivolumab  
 
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therapy and surgery, the generally observed 5-year overall survival rate remains only 15-
34%.  
The two major histologies of esophageal cancer, adenocarcinoma and squamous cell 
carcinoma (ESCC), have distinct epidemiologic and etiologic characteristics.  These entities 
also have distinct precursor lesions and distinct molecular properties. Indeed, there are 
enough differences in these histologies to suggest exploitable differences in future 
therapeutic approaches [3]. 
Worldwide, over 80 percent of the esophageal cancers are squamous histology [4]. In the 
past three decades, Western societies have seen the incidence of ESCC decline and the 
incidence of adenocarcinomas markedly increase.  This has led to a proportional under-
representation of ESCC patients included in US clinical trials. Indeed, recent US, NCI- 
sponsored clinical trials have focused only on adenocarcinomas. This has led to the 
observation that ESCC has become an understudied orphan disease [5]. 
For patients with either ESCC or adenocarcinoma of the esophagus, multiple randomized 
controlled studies and meta-analyses have conclusively demonstrated a survival benefit for 
those patients receiving neoadjuvant chemoradiation [6]. A new standard-of-care was 
established by van Hagen, et al., who performed the seminal Dutch CROSS trial, in which 
patients with esophageal adenocarcinomas and ESCC were treated with weekly carboplatin 
AUC 2 and paclitaxel 50 mg/m2, administered concurrently with 41.4 Gy external radiation 
prior to surgery, versus surgery alone [7]. The combined modality arm was markedly 
superior to surgery alone.  Although patients with either histology benefitted from combined 
modality treatment, patients with ESCC tumors (about 23% of the total) had a statistical 
benefit far greater than those with adenocarcinomas [7]. Specifically, ESCC patients treated 
with chemoradiation and surgery had a 49% pathologic complete response (pCR) rate and 
a median overall survival (OS) of 82 months [8]. It should be noted that these data (pCR 
rate and OS) are far superior to what has been the overall experience of those who routinely 
treat ESCC of the esophagus. 
In the CROSS Trial, the investigators reported on “any” adverse event and grade ≥ 3 
adverse events.  Of the 171 patients who received carboplatin and paclitaxel with radiation, 
30 (18%) developed diarrhea; two patients (1%) developed grade ≥ 3 diarrhea. Twenty-five 
patients (15%) developed some grade of neurotoxicity; no patient developed grade ≥ 3 
neurotoxicity.  Sixteen patients (9%) developed neutropenia; four patients developed grade 
≥ 3 neutropenia.  Ninety-two patients (54%) developed thrombocytopenia; one patient (15) 
had grade ≥ 3 thrombocytopenia.  In their manuscripts describing the CROSS trial [7, 8], 
there were no reports of renal and/or hepatic dysfunction.   
For patients receiving neoadjuvant combined modality therapy, survival is generally thought 
to be dependent on response, as those with complete pathologic response (pCR) or near 
pCR have the best chance of long-term survival [9]. In particular, in ESCC patients who have 
co-morbidities associated with alcohol and tobacco use, surgery carries with it a higher rate 
of post-operative mortality following neoadjuvant chemoradiation secondary to increased 
risks of cardiopulmonary complications [10]. Therefore, many clinicians opt to avoid surgery 
in such patients.  Indeed, long-term survival data from RTOG 85-01 in which patients with 
esophageal ESCC were definitively treated with chemotherapy and radiation without surgery 
indicates that 27% of patients were alive without cancer 10 years after treatment [11]. 


ESCC Nivolumab  
 
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In an effort to definitively address the issue regarding the need for an operation for ESCC 
patients, two randomized European trials compared definitive chemoradiation vs. 
chemoradiation followed by surgery in ESCC patients [12, 13]. Taken together, both studies 
suggest that local control is improved by subsequent surgery but that there is no clear 
improvement in survival for patients who respond to chemoradiation. This has led many 
investigators to the conclusion that those patients with clinical CR to definitive 
chemoradiotherapy (endoscopic clearance of the tumor and 18F-fludeoxyglucose (FDG)-
PET scan resolution of all FDG-avid areas) can safely forego surgery.  
 
1.2 ESCC and Immunotherapy  
Programmed cell death protein 1, also known as PD-1, is a protein transmembrane receptor 
expressed on activated lymphocytes, including tumor infiltrating lymphocytes that acts to 
shut down T cell responses in order to prevent unchecked inflammation.  Thus, PD-1 
functions as an immune checkpoint inhibitor.  When PD-1 binds with its ligands, 
programmed cell death 1 ligand (PD-L1) or programmed cell death ligand 2 (PD-L2), effector 
T cells become inactive. Investigators have found that tumors with relatively high levels of 
PD-L1 have a poorer prognosis than those with relatively lower levels [14]. Another measure 
for the potential effectiveness for immune checkpoint inhibitors is the number of mutations 
found in a tumor. As noted by Alexandrov et al., squamous cell tumors of the esophagus 
have a relatively high number of somatic mutations (Figure 1) [15].  
 
 Figure 1. 
Alexandrov, et al. [15] 


ESCC Nivolumab  
 
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1.3 Nivolumab 
Nivolumab, a 146–kilodalton molecule is a fully human immunoglobulin G4 (IgG4) antibody 
with high affinity for the human programmed death-1 receptor (PD-1 or CD279). Nivolumab 
binds to PD-1 and blocks the interaction with its ligands (PD-L1 or PD-L2), thereby liberating 
T cells from suppression mediated by PD-1 signaling. Nivolumab is a genetically engineered 
monoclonal antibody with minimal cellular and complement-mediated cytolytic function by 
virtue of its IgG4 isotype. Preclinical models demonstrated that incubation with nivolumab 
augmented T-cell expansion and enhanced cytokine production and cytolytic function [16].  
 
Nivolumab is administered intravenously every 2 weeks, and steady-state concentrations 
are reached by 12 weeks at a dose of 3 mg/kg. The serum half-life was estimated at 12 days 
for the lower-dosage cohorts (0.3-, 1- or 3-mg/kg dose) and at 20 days for the highest-
dosage cohort (10 mg/kg). The mean volume of distribution at steady state was 8 L and the 
mean clearance was 9.5 mL/hour. The area under the curve and maximum concentrations 
were directly related to the dose level indicating that the pharmacokinetic properties 
remained linear across the dose ranges [17].  
 
Blocking immune checkpoints that function as negative regulators of the immune system, is 
an approach that has proven to be most effective against solid tumors with relatively high 
mutational burdens such as melanoma [18], squamous cell lung cancers [19], and a subset 
of colon tumors (microsatellite instability-high tumors with a very high mutation burden) [20].  
Squamous cell esophageal cancers, epidemiologically associated with cigarette smoking, 
have a high prevalence of somatic mutations, which may correlate with increased sensitivity 
to immune checkpoint inhibitors (Figure 2) [15, 21].  
 
Nivolumab has been well-studied in solid tumors, demonstrating efficacy in melanoma, 
squamous cell and adenocarcinomas of the lung, and squamous tumors of the head and 
neck.  Nivolumab is administered intravenously every 2 weeks and steady-state 
concentrations are reached by 12 weeks at a dose of 3 mg/kg [17, 22]. We will document 
the smoking status of patients of all patients registered for this protocol.  
 


ESCC Nivolumab  
 
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1.3.1 Melanoma   
A phase 3 trial for patients with BRAFwt metastatic melanoma tested nivolumab at 3 mg/kg 
against dacarbazine at 1000 mg/m2 + a nivolumab-matched placebo.  The investigators 
reported that nivolumab-treated patients had a superior overall response rate of (40% vs. 
13.9%), superior progression free survival (5.1 months vs. 2.2 months) and a higher 
percentage of those alive after one year (72.1% vs. 42.1%).  Toxicities, generally non-
cumulative occurred mostly in the first 6 months of therapy included pneumonitis, low-grade 
fatigue, diarrhea, pruritus, nausea and decreased appetite.  Grade 3 or 4 adverse advents 
occurred in 11.7% of patients treated with nivolumab and 17.6% of those treated with 
dacarbazine [23].  
 
1.3.2 Non-Small Cell Lung Cancers 
Two phase III non-small-cell lung cancer trials tested nivolumab 3 mg/kg against docetaxel 
75 mg/m2 for patients with squamous cell lung cancers and those with non-squamous cell 
lung cancers. In each trial, entry criteria included patients for whom initial platinum-based 
doublet therapy had failed.  In each trial, the primary endpoint was overall survival.  Both 
trials demonstrated superior survival for the nivolumab-treated patients.  In the non-
squamous cell trial, the median overall survival for the nivolumab-treated patients was 12.2 
versus 9.4 months for the docetaxel-treated patients (p=0.002) [24]. The median overall 
survival for squamous cell lung cancer patients receiving nivolumab as second line therapy 
was 9.2 months versus 7.3 months for those receiving docetaxel (p=0.001) [25]. Grade 3 
or4 or toxicities for patients who received nivolumab were 10% and 7% for non-squamous-
cell and squamous-cell lung cancers.  
 
1.3.3 Esophageal Cancer 
Figure 2. 


ESCC Nivolumab  
 
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Evidence for the benefit of nivolumab for ESCC comes from the results of a phase II trial 
reported as an abstract at the 2015 European Cancer Conference. Japanese investigators 
evaluated nivolumab in 65 patients with esophageal cancer who had up to 4 previous 
treatments. Although the trial allowed patients with adenocarcinoma or mixed adeno-
squamous cell tumors to be treated, all 65 patients entered into this trial has squamous-cell 
histology. Two-thirds of patients had received 3 prior chemotherapy regimens.  Fifty-four 
men and 11 women with a median age of 62 years were treated in this trial. One complete 
response and 12 partial responses total were found by the investigators (total response rate 
20.4%) and one complete response and 10 partial responses were coded by central review 
(17.2%). Figure 3 is a waterfall plot of the target-lesion change as presented by Ura, et al. 
[26]. 
 
 
 
  
 
 
 
 
1.4 Combining Radiation Therapy with PD-1 Inhibition 
Traditionally, radiation therapy has been used in cancer therapy as a means of controlling 
local disease. However, recent investigations have demonstrated that radiation to a specific 
tumor may prompt the release of tumor-associated antigens that prime the adaptive immune 
system [27, 28].  It is now postulated that the ‘vaccine effect’ of radiation is responsible for 
the abscopal effect whereby radiation to one tumor may induce a response in an area that 
was not irradiated. As a corollary, radiation may have the effect of turning an 
immunotherapy-insensitive tumor into one that is sensitive to radiation [29].  By releasing 


ESCC Nivolumab  
 
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tumor-associated antigens, radiation has been described as inducing a vaccine-like effect 
by priming the adaptive immune system [27, 30]. 
  
An abscopal response was observed in a patient with advanced melanoma previously 
treated with ipilimumab, an antibody against CTLA-4, who subsequently received palliative 
radiation to a painful metastatic site [31]. This patient’s tumor expressed NY-ESO-1, an 
antigen expressed only in normal testicular germ cells and placenta and in 30-40% of 
advanced melanomas [31]. Significant regression was observed in tumors outside the 
radiation field [31]. Immune analyses revealed an increase in NY-ESO-1-specific antibody 
responses and in the proportion of NY-ESO-1-specific CD4+ T cells that expressed inducible 
co-stimulator (ICOS), a marker of T cell activation [31]. A second patient with melanoma 
treated with ipilimumab also experienced a similar abscopal response following radiation, 
with a corresponding increase in the antibody response against the cancer-testis antigen 
MAGE-A3 [32].  In addition to stimulating immune responses, the combination of 
radiotherapy and immunotherapy may also serve to reinvigorate pre-existing tumor-specific 
CD8+ T-cell populations [33].  
 
 
1.5 NYU Preclinical Data for Radiation and PD-1 Inhibition 
To examine the role of PD-1 in the radiation response of esophageal squamous cell 
carcinomas, investigators at the NYU Perlmutter Cancer Center used the AKR esophageal 
squamous cell cancer cell line in a mouse allograft model. The AKR mouse esophageal 
squamous cell cancer cell line is derived from the ED-L2-cyclin D1;p53−/− mouse model. 
Irradiation of AKR flank tumors demonstrated tumor reduction but also an upregulation in 
PD-1 expression, reflecting T-cell exhaustion. The addition of anti-PD-1 antibody to radiation 
leads to improved tumor reduction and increases in CD8+ effector T-cells and less 
exhaustion of PD-1+ T-cells. This pre-clinical data, summarized in figures 4 and 5 below, 
add to our enthusiasm in combining the PD-1 inhibitor nivolumab, radiation therapy and 
chemotherapy in a clinical trial for patients with squamous cell carcinomas of the esophagus 
[34].  
 
 
 
 
 
 
 
 
 
 
 
Change in Tumor Volume 
Change in Amount of CD8+ T Cells 


ESCC Nivolumab  
 
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                       Figure 4                                                                  Figure 5 
 
 
The investigators who designed this trial hypothesize that the combination of immune 
checkpoint blockade with radiation will exploit the abscopal effect.    
 
 
1.6 Rationale for Combining Chemoradiation with Nivolumab 
Although the potential synergy between radiation and PD-1 blockade has been 
demonstrated (see above), radiation by itself has not had an impact on survival for patients 
with ESCC. However, the curative benefit for combining external beam radiation therapy 
with chemotherapy for patients with ESCC has been clearly demonstrated [7]. Regardless, 
only a minority of patients treated obtain a pCR.  Yet, even those who do achieve a pCR or 
near pCR have a distant recurrence rate close to 40% [35]. This is ample reason to 
investigate methods for producing a higher cure rate for the majority of patients with ESCC.  
 
1.7 Rationale for Flat Dosing of NIVOLUMAB 
Nivolumab monotherapy has been extensively studied in a number of tumor types including 
non-small cell lung cancer (NSCLC), melanoma, renal cell carcinoma (RCC), and colorectal 
cancer (CRC) with body weight normalized dosing (mg/kg). Nivolumab pharmacokinetics 
(PK) and exposures of subjects in these studies have been characterized by population 
pharmacokinetic (PPK) analysis of data collected in these studies, together with PK data 
from several Phase 1, 2, and 3 clinical studies of nivolumab monotherapy in solid tumors. 
PPK analyses have shown that the PK of nivolumab are linear, with dose proportional 
exposures over a dose range of 0.1 mg/kg to 10 mg/kg, and are similar across tumor types. 
Nivolumab clearance and volume of distribution were found to increase with increasing body 
weight, but the increase was less than proportional, indicating that a mg/kg dose represents 
an over-adjustment for the effect of body weight on nivolumab PK. Given the relationship 
between nivolumab PK and body weight, a flat dose is expected to lead to lower exposures 
in heavier patients, relative to the exposures in lighter patients.  
 
Using the PPK model, nivolumab steady-state trough, peak and time-averaged 
concentration (Cminss, Cmaxss, and Cavgss, respectively) were predicted for a flat 


ESCC Nivolumab  
 
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nivolumab dose of 240 mg Q2W and compared to those following administration of 3 mg/kg 
Q2W in NSCLC, melanoma, and RCC subjects. A dose of 240 mg nivolumab is identical to 
a dose of 3 mg/kg for subjects weighing ~ 80 kg, which is the approximate median body 
weight of subjects in the Phase 2 and 3 BMS clinical studies of nivolumab monotherapy. 
From the simulations, the geometric mean values of Cminss, Cmaxss, and Cavgss with flat 
dosing are slightly (< 15%) higher than that produced by a 3 mg/kg dose, and the coefficient 
of variation (cv%) in these measures of exposure are only slightly (< 10%) greater than that 
of 3 mg/kg dosing. Given the similarity of nivolumab PK across tumor types and the similar 
exposures predicted following administration of a 240 mg flat dose compared to 3 mg/kg, it 
is expected that the safety and efficacy profile of nivolumab following a flat dose will be 
similar to that of 3 mg/kg nivolumab dose.  
 
1.8 Adjuvant Nivolumab 
 
 
In general, postoperative cytotoxic therapy following intensive chemo-radiation with 
or without surgery for patients with esophageal cancer has not been successful.  Frequently, 
patient performance status declines following neoadjuvant therapy and surgery.  This makes 
cytotoxic therapy quite difficult, if not impossible, for the majority of patients with esophageal 
cancer.  The concept that continued stimulation of the immune system could be a successful 
method to wipe out microscopic cancer cells is being examined in a BMS trial for esophageal 
cancer patients that receive only chemotherapy and radiation prior to surgery.  Thus, in this 
pilot trial, testing the toxicity of immunotherapy in the initial multi-modality therapy for 
squamous cell cancer of the esophagus, we will test whether continued treatment with 
nivolumab after definitive therapy with nivolumab and chemoradiation is well tolerated.  
Indeed, for most patients that have no or minimal toxicity to their first doses of nivolumab, 
continued use has generally been very well tolerated.    
 
 
2.  Study Hypotheses and Objectives 
 
2.1 Hypotheses 
This protocol will be testing the following hypotheses: 
 
 
1) Nivolumab as induction single-agent therapy followed by nivolumab combined with 
chemoradiation is safe and feasible. (Phase I) 
 
2) Nivolumab as induction single-agent therapy followed by nivolumab combined with 
chemoradiation will increase cCR + pCR rate beyond 55%. (Phase II) 
 
3) Assessment of induction nivolumab by PET/CT and/or correlative analyses of tumor 
tissue and peripheral blood may identify biomarkers that correlate with outcomes. 
(Phase II) 
 


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2.2 Objectives  
2.2.1 Phase I Objective 
1. Assess the safety of induction nivolumab followed by chemoradiation with nivolumab 
and adjuvant nivolumab for patients with locally advanced squamous cell cancer of 
the esophagus 
  
2.2.2 Phase II Objectives 
 
2.2.2.1 
Primary Objective 
1.  Estimate the cCR + pCR rate of induction nivolumab followed by chemoradiation with 
nivolumab.  
2.2.2.2 
Secondary Objectives 
1. Describe the PFS and OS of nivolumab and chemoradiation, followed by adjuvant 
nivolumab 
2. Describe the major toxicities encountered in this treatment 
2.2.2.3 
Exploratory Objectives 
      1. Assess whether PET/CT clinical response to nivolumab can predict the following 
outcomes: CR, PFS, and OS 
2. Assess the association between the outcomes CR, PFS, and OS and immune 
correlative assays. 
 
 
3. Study Design 
 
3.1 General Design 
In this multi-institution phase I/II trial, the investigators have chosen paclitaxel and 
carboplatin using a schedule and doses identical to those used in the CROSS trial.   
Following a run-in with nivolumab alone at 240 mg IVPB every 2 weeks for 2 doses, 
nivolumab at 240 mg every 2 weeks will be added to paclitaxel and carboplatin, which 
will be dosed according to the standard of care established by the CROSS trial: paclitaxel 
50 mg/m2 weekly for 6 weeks and carboplatin AUC 2 weekly for 6 weeks [7].  Concurrent 
radiation will be administered with chemotherapy at 1.8 Gy/fraction × 28 fractions to a 
total dose of 50.4 Gy, the standard radiation dose administered in the United States for 
trimodality therapy that includes concurrent therapy with carboplatin and paclitaxel [36, 
37]. A decrease in dose to 41.4 Gy per the protocol established by van Hagen, et al. will 
be permitted before discontinuing therapy due to unacceptable toxicity [7].  While the 
CROSS study administered only 5 weekly doses of chemotherapy during the 5 weeks of 
radiation, the higher dose of 50.4 Gy (1.8 Gy/fraction ×28 fractions over 5½ weeks) 
utilized in this study permits for a sixth dose during the additional week of radiation. 
      Figure 6. Trial Schema 
 
 
 
  


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Footnotes 
*****: Day 22-28 upper endoscopy with core biopsy is optional 
*****: For those with clinical response, patients should go directly to nivo x6, but patients can be offered 
esophagectomies after discussion with the treating physician 
 
Single-arm phase I/II open label multi-center study  
 
Phase I:  Up to 12 patients 
6 patients treated and observed for 28 days after last day of treatment (Day 64) 
• ≤ 1 unacceptable toxicity (UT): use current regimen for Phase II 
• ≥ 2 UT: reduce total RT dose to 41.4 Gy and treat 6 additional patients, then 
observe for 28 days after Day 64   
• ≤ 1 UT: use reduced RT for Phase II 
• ≥ 2 UT: discontinue trial  
 
Phase II: 44 patients 
Stage I: 18 patients treated  
• ≤ 7 CRs (either pCR or cCR): discontinue trial as combination therapy deemed 
futile 
• ≥ 8 CRs (either pCR or cCR): continue on to Stage II. 
Stage II: 26 additional patients treated  
• ≤ 20 cCR + pCR out of all 44 patients: combination therapy rejected 


ESCC Nivolumab  
 
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• ≥ 21 cCR + pCR out of all 44 patients: combination therapy should be studied 
further.   
 
• Accrual to Stage II will continue while the 18 patients in Stage I are evaluated 
for cCR and pCR.  
 
• Accrual to Stage II will stop if Stage I analysis deems combination futile 
 
 
Unacceptable toxicity (UT) is defined here as:  
• Recurrent grade 3 or 4 hematologic toxicity (despite 1 prior dose reduction in 
chemotherapy) 
• Any toxicity related to chemotherapy, radiotherapy, or treatment with 
nivolumab that results in a >2-week delay in chemoradiation 
 
See section 7.0 for the definition of toxicities and steps in dose reduction on an individual 
patient level.  
 
3.2 Primary Study Endpoints 
Phase I: Unacceptable toxicity at 28 days after last dose of carboplatin and paclitaxel (day 
64). The primary endpoints of this phase are primary safety endpoints.  
 
Phase II: cCR by endoscopic + PET/CT evaluation, pCR for patients undergoing surgery,  
 
3.3  Secondary Study Endpoints 
3.3.1 median OS (Kaplan Meier) + median PFS (Kaplan Meier) 
3.3.2 Immune Correlative Assays   
3.3.2.1 
Sample Collection 
The following samples will be collected: 
• Paraffin embedded blocks from primary tumor (at baseline; after induction 
nivolumab(optional); and at surgery, if applicable) 
• Whole blood will be collected at the following time points for all patients: pre-induction 
nivolumab, post-nivolumab/pre-chemoRT and post-chemoRT/pre-surgery. Whole 
blood will be processed into peripheral blood mononuclear cells (PBMCs), serum, 
and plasma on the day of collection and stored at -70°C for future analysis 
• Whole blood will be collected at the following time-points for patients who receive 
adjuvant nivolumab: pre-1st, 2nd and 4th dose 
These assays that will be performed may include but are not limited to the assays 
discussed below.  No genetic testing will be performed. 
 
3.3.2.2 
Immunohistochemical Staining of Tumor Tissue 


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Archived tumor tissue will be stained with an antibody against PD-L1 to characterize the PD-
L1 status of the tumor cells. The antibody and scoring system will be determined at a later 
date. 
 
3.3.2.3 
Purpose of Immune Correlative Assays 
Immune correlative assays will be conducted as part of this study in order to investigate 
changes that occur in cell surface markers, cytokine profiles, and PBMC phenotype before 
and after treatment with nivolumab, chemoradiation, and surgery (if applicable).  Such 
information would lead to a better understanding of the effect of immunocheckpoint 
intervention on the subjects’ esophageal squamous cell carcinoma.  This information will not 
be of benefit to participating patients, but may influence future treatments with 
immunocheckpoint inhibitors in combination with chemoraditation therapy.   
 
3.3.2.4 
Subject Participation 
Sample collection for the immune correlative assays described is mandatory for participation 
in this study. Sample collection is mandatory to report on one of the primary endpoints of 
the study. The study of this correlative information is essential for understanding the efficacy 
of immunotherapy and radiation therapy in this disease treatment application. If subjects do 
not agree to participate in this correlative study, they may not participate in the main study.  
If subjects decide not to participate, this will not affect the care the patients receive, and it 
will not result in any loss of benefits to which patients are otherwise entitled. Participating 
study subjects will be told of any significant new findings that may develop during the course 
of the research using their specimens and associated health information that may influence 
their willingness to continue to participate. 
 
3.3.2.5 
Rationale For Mandatory Correlative Study Specimen Collection 
We hypothesize that these immune assays (CD3, CD4, CD8, CD45RO, FOXP3) and 
chemokines/cytokines (CCR7, CXCL12, CXCR4, and cytokine profiles) will statistically 
correlate with response and/or resistance to the protocol therapy. 
 
3.3.2.6 
Sample Labeling, Storage, and Handling  
If a patient does give his/her permission (consent) to participate in this study, his/her 
samples will be kept for analysis indefinitely. This permission will never expire unless the 
subject withdraws it. The patient may withdraw (take back) his/her permission to use and 
share his/her specimens and health information at any time, without penalty. If the subject 
withdraws his/her consent, any unused specimens that have not been provided to 
researchers will be destroyed. If the subject withdraws his/her permission, we will not be 
able to take back information that has already been used or shared with others. To formally 
withdraw consent and/or revoke authorization, we ask that the subject contact Dr. Jennifer 
Wu in writing, and tell him of their wish to withdraw permission for specimens for research 
and/or authorization.  
 
Only approved study personnel at NYU, MSKCC, and the study sub-sites will have access 
to the samples. Samples will be stored in a secure locked room at the laboratory at MSKCC:   
Geoffrey Y. Ku, MD  


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Immune Monitoring Facility, Memorial Sloan Kettering Cancer Center 
Zuckerman Research Center, 15th floor 
417 East 68th Street 
New York, NY 10065 
Telephone: (646) 888-4588 
Only authorized personnel will have access to them. Samples will only be studied for 
purposes relating to cancer and this study. The subject’s name and personal information will 
not appear on the specimens. Samples will be labeled with a code (the subject’s clinical 
study identification number) that can be linked to him/her only by the study doctor. 
Researchers who perform tests on these samples will only see the code, but will not see 
any personal information that specifically identifies the subject. Although complete privacy 
cannot be guaranteed, the study team will make every effort to protect subject identity and 
health information.  The log to personal health information (PHI) will be maintained at each 
individual study site, only by authorized study personnel.  Information will be stored in a 
secure locked room and in a secure password-protected database.             
Any results from the research testing performed in this study will not be shared with the 
subjects, thereby greatly reducing the possibility of psychological or social risks that could 
arise from knowledge of this information, such as risk to the subject’s employability or 
insurability, or the risk of discrimination. 
 
For samples collected at NYU, the Center for Biospecimen Research and Development will 
ship processed samples (see Appendix II for shipment preparation) to MSKCC in batches.  
These batched samples will be labeled with a code (the subject’s clinical study identification 
number) that can be linked to him/her only by the study doctor.  Researchers who perform 
tests on these samples will only see the code, but will not see any personal information that 
specifically identifies the subject. Although complete privacy cannot be guaranteed, the 
study team will make every effort to protect subject identity and health information.  The log 
to personal health information (PHI) will be maintained at each individual study site, only by 
authorized study personnel.  Information will be stored in a secure locked room and in a 
secure password-protected database. 
 
3.3.2.7 
Tumor Microarray (TMA) Immune Microenvironment Analysis 
The laboratory of our collaborator at MSKCC, Dr. Prasad Adusumilli, will construct a TMA 
from each tumor that will comprise ≥4 tumor cores from the most inflammatory region of the 
tumor as seen on H&E, ≥4 peritumoral stromal cores, along with normal tissue. Tissue 
immune markers staining will be graded according to the intensity and/or distribution of 
staining. Grading intensity will be categorized as follows: 0 (staining absent); 1 (weak 
expression); 2 (moderate expression); and 3 (strong expression). The distribution of staining 
will be graded as follows: 0 (staining absent); 1 (1% to 50%); and 2 (51% to 100%). The 
sum of the stain intensity and the distribution grade will be used to determine the total score, 
ranging from 0 to 5. 
 
Markers that will be analyzed include immune cell surface markers (CD3, CD4, CD8, 
CD45RO, FOXP3) and chemokines/cytokines (CCR7, CXCL12, CXCR4 and IL-7R).  
 


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3.3.2.8 
Serum Cytokine Measurement 
Cytokine profiles provide information about the status of immune activation and whether 
there is predominance of a Th1 or Th2 response. Th1 responses are associated with 
cytotoxic T cell responses and effective anti-tumor immunity, while Th2 responses are 
regarded as being anti-inflammatory and counteract Th1 responses. Cytokines can be 
measured using multiplexed ELISA kits, which can detect IL-1β, -2, -4, -6, -8, -10, -12p70, 
IL-13, tumor necrosis factor-α, interferon (IFN)-γ and others. These assays will be performed 
in the Immune Monitoring Facility (IMF) at MSKCC. 
 
3.3.2.9 
PBMC Phenotype Characterization 
Multiparameter flow cytometry will be used to characterize the PBMC phenotype at various 
time-points. Based on the time-intensive nature of these analyses, they may be restricted to 
patients with extreme outlier responses, e.g. complete vs. minimal pathologic response or 
rapid recurrence following surgery. The panel will include CD3, CD4, CD8, FoxP3, Ki67, 
ICOS, PD-1, LAG-3, TIM-3 and CTLA-4. Testing will be performed by the IMF using this “T 
cell activation/exhaustion panel”, which has previously been validated in other studies of 
anti-PD-1 and anti-PD-L1 antibodies performed at MSKCC. 
 
3.3.2.10 Serum Measurement of Antibody Responses to >8,000 Antigens 
The analysis of antibody responses offers additional insight into the immunomodulatory 
properties of nivolumab. These assays will be performed by the IMF. Because of the cost of 
the array, such analyses may again be restricted to patients with unusual/extreme 
responses. 
 
Commercially available protein microarrays (Invitrogen) now allow for concurrent serologic 
screening for antibody responses to >8,000 antigens with a single serum sample on an 
unprecedented scale (termed seromics). Matched baseline and post-therapy sera would be 
assayed on one array.  
 
4.0  Patient Selection and Withdrawal 
4.1 Inclusion Criteria 
1. Histologically or cytologically confirmed, treatment-naive esophageal squamous cell 
carcinoma  
2. Previously obtained archival tumor tissue, or tissue obtained by endoscopically-
guided core biopsy at screening 
3. TanyN1-3 or T3-4 N0as determined by EUS or PET/CT. All palpable or CT/PET visible 
lymph nodes outside the usual surgical field must be biopsy-proven negative for 
cancer.  
4. All patients must have locoregional staging determined by endoscopic ultrasound 
(EUS) if technically feasible. Endoscopy reports or subsequent GI clinic note should 
clearly state both the T and N stage.  


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5. All patients must have initial PET/CT scans to document no evidence of metastatic 
or unresectable squamous cell cancer  
6. All patients with tumors involving the thoracic esophagus must undergo 
bronchoscopy to document the absence of a fistula No known contraindication to the 
use of taxanes or platinum compounds.  
7. No history of severe hypersensitivity reaction to Cremophor® EL.  
8. Patients who are ≥ 18 years old are eligible for this study. Neither specific gender 
distribution, nor specific racial or ethnic origins are necessary for enrollment in this 
study.  
9. Eastern Cooperative Oncology Group (ECOG) Performance Status 0-1 
10. A patient must be capable of giving informed consent or have an acceptable 
surrogate capable of giving consent on the subject’s behalf  
11. Deemed a suitable candidate for esophagectomy by the treating surgeon as 
documented in a pre-operative assessment visit per standard practice at each 
participating institution.  
12. Deemed a suitable candidate for radiation therapy by the treating radiation oncologist 
as documented in a standard pretreatment visit per standard practice at each 
participating institution.  
13. Patient must be non-pregnant and non-nursing. Women of child bearing potential 
(WOCBP) must have a negative serum or urine pregnancy test (minimum sensitivity 
25 IU/L or equivalent units of HCG) within 72 hours prior to C1D1.   
14. Screening Laboratory Values must meet the following criteria and should be obtained 
within 14 days prior to C1D1 (see Table 1 below) 
15. Patients with a positive Hepatitis B viral load are allowed on the study as long as 
patients are getting active treatment for hepatitis B on or prior to the first dose of 
treatment on this trial and continue throughout this trial.  
16. All patients have to agree to participate in the correlative study of sample collection 
for immune correlative assays in order to participate in the main study. However, if 
the sample cannot be obtained due to feasibility issues, the patient will be allowed to 
continue on treatment 
 
Table 1. Screening Laboratory Values 
Test 
Acceptable Result 
WBC 
≥ 2000/µL 
Neutrophils 
≥ 1500/µL 
Platelets 
≥ 100,000 4/µL 
Hemoglobin 
> 9.0 g/dL 
Serum Creatinine 
≤ 1.5 x ULN  OR 


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Creatinine Clearance (CrCl)* 
≥ 40 mL/min 
AST 
≤ 3 x ULN 
ALT 
≤ 3 x ULN 
Total Bilirubin** 
≤ 1.5 x ULN   
 
 
Oxygen Saturation (O2 Sat.) 
≥92% on ambient air 
 
 
HIV status 
Rapid  HIV 1/2 Antibodies 
Negative  
*Creatinine Clearance Calculated using the Cockcroft-Gault formula 
 
Female CrCl = (140- age in years) x weight in kg x 0.85 
72 x serum creatinine in mg/dL 
 
Male CrCl = (140- age in years) x weight in kg x 1.00 
72 x serum creatinine in mg/dL 
 
**Total Bilirubin ≤ 1.5 x ULN, except subjects with Gilbert Syndrome, who 
can have total bilirubin < 3.0 mg/dL 
*** Subjects whose HBV core antibody is positive must have a negative 
HBV viral load measurement 
 
4.2  Exclusion Criteria 
1. T1-2 N0 as determined by EUS and PET/CT. 
2. Pregnant or lactating women 
3. Active or prior documented autoimmune or inflammatory disorders including but not 
limited to inflammatory bowel disease; systemic lupus erythematosus; type I diabetes 
mellitus; Wegener syndrome [granulomatosis with polyangiitis]; myasthenia gravis; 
Graves’ disease; rheumatoid arthritis, hypophysitis, uveitis) within the past 3 years 
prior to the start of treatment. The following are exceptions to this criterion: 
3a)  Subjects with vitiligo or alopecia 
3b) Subjects with hypothyroidism (e.g., following Hashimoto syndrome) stable 
on hormone replacement or psoriasis not requiring systemic treatment 
4. History of idiopathic pulmonary fibrosis, organizing pneumonia, drug-induced 
pneumonitis, idiopathic pneumonitis, or evidence of active pneumonitis on screening 
chest Computed Tomography (CT) scan 


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5. The use of immunosuppressive medication within 28 days prior to the first dose of 
nivolumab.  The following are exceptions to this criterion: 
5a) Intranasal, topical, inhaled corticosteroids or local steroid injections (e.g. 
intra-articular injection) 
5b) Systemic corticosteroids at physiologic doses ≤10 mg/day of prednisone 
or equivalent 
5c) Steroids as premedication for hypersensitivity reactions (e.g. CT scan 
premedication 
 
6. Positive test for Human Immunodeficiency Virus (HIV) or known acquired 
immunodeficiency syndrome (AIDS) 
7. Prior treatment with any immunotherapy 
8. Any other factors, including psychiatric or social, that in the opinion of the treating 
physician makes the patient an inappropriate candidate for a study. 
9. Patients are excluded if they have active brain metastases or leptomeningeal 
metastases. Subjects with brain metastases are eligible if metastases have been 
treated and there is no magnetic resonance imaging (MRI) evidence of progression 
for [lowest minimum is 4 weeks or more]  after treatment is complete and within 28 
days prior to the first dose of nivolumab administration. There must also be no 
requirement for immunosuppressive doses of systemic corticosteroids (> 10 mg/day 
prednisone equivalents) for at least 2 weeks prior to study drug administration. 
10. Patients should be excluded if they have an active, known or suspected autoimmune 
disease. Subjects are permitted to enroll if they have vitiligo,  residual hypothyroidism 
due to autoimmune condition only requiring hormone replacement, psoriasis not 
requiring systemic treatment, or conditions not expected to recur in the absence of an 
external trigger 
11. Patients should be excluded if they have a condition requiring systemic treatment with 
either corticosteroids (> 10 
mg daily prednisone equivalents) or other 
immunosuppressive medications within 14 days of study drug administration. Inhaled 
or topical steroids and adrenal replacement doses < 10 mg daily prednisone 
equivalents are permitted in the absence of active autoimmune disease. 
12. As there is potential for hepatic toxicity with nivolumab or nivolumab non-drugs with a 
predisposition to hepatoxicity should be used with caution in patients treated with 
nivolumab-containing regimen. 
 
13. Patients with a history of allergy to the study drug components are excluded. 
 
4.3 Patient Recruitment  
Patients will be recruited from the investigators’ clinical practices in Medical, Surgical and 
Radiation Oncology at the Perlmutter Cancer Center at NYU, Bellevue Hospital Center, 
Memorial Sloan-Kettering Cancer Center (MSKCC), USC-Norris Cancer Center, LAC-USC 
Medical Center, and Oregon Health Sciences University (OHSU) Knight Cancer Institute.  


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Prior to study entry, a patient’s eligibility must be approved in writing (e-mail is allowed) by 
the NYU Clinical Trials Office study coordinator.   
 
Target enrollment for this study is 50-56 patients.  Patients will be recruited from physicians 
at the NYU Langone Perlmutter Cancer Center.  Consenting, screening, and treatment will 
take place at the NYULMC PCC under the supervision of the Overall PI.  Prospective 
subjects will receive detailed information regarding this study; its investigational nature, 
required study procedures, alternative treatments, risks and potential benefits of the study.  
They will also receive the informed consent document to read.  All questions are answered 
by the PI and qualified research personnel.   
 
 
The Principal Investigator will: 
1. Obtain signed and dated informed consent from the potential subject before any 
study specific procedures are performed. 
2. Determine patient eligibility See Section 4.1  and 4.2 
3. Submit registration to NYU Langone Perlmutter Cancer Center CTO 
4. Receive registration confirmation from NYU Perlmutter Cancer Center CTO, 
including a unique study identification number assigned to the patient  that will 
be distributed to the study team upon registration of the patient. 
Recruitment and consenting will take place in a private area such as an exam room to 
protect the patient’s privacy.  The informed consent process and documentation follows the 
established procedures of the NYULMC Perlmutter Cancer Center Clinical Trials Office. 
 
4.3.1 Informed Consent 
Consent will be obtained only by a participating investigator who has completed requisite 
training for human subject research and has been instructed by the Principal Investigator 
about the patients and address any questions or concerns prior to obtaining written informed 
consent for participation and HIPAA authorization. 
 
Patients will be given adequate time to read the consent form.  They will be given time to 
ask questions about the study in private exam rooms.  Questions will be answered by a 
participating physician, or qualified research study team member all of whom have 
completed requisite training for human subject research.  Investigators will review the 
informed consent form with patients and address any questions or concerns prior to 
obtaining written informed consent for participation.  Investigators will stress that 
participation in the study is completely voluntary and will not affect the care patients receive 
or result in any loss of benefits to which patients are otherwise entitled. 
 
The Investigator must explain to each subject the nature of the study, its purpose, the 
procedures involved, the expected duration, the potential risks and benefits involved and 
any discomfort it may entail.  This informed consent should be given by means of standard 


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written statement, written in non-technical language.  No patient can enter the study before 
his/her informed consent has been obtained. 
 
The informed consent form is considered to be part of the protocol, and must be submitted 
by the investigator with it for IRB approval. 
 
All patients will be required to sign a written informed consent prior to being registered on 
this study.  Every effort will be made to answer questions raised by patients and their families 
or advocates regarding the protocol and alternative therapies prior to asking a patient to sign 
the consent form.   
 
For non-English speaking patients, institutional translation services will be utilized. For these 
patients the consent letter and all other information will be administered orally and a witness, 
not related to the research project, will be present while the oral presentation is given. A 
short form will be utilized for the subject to sign in his/her name and the translator and/or 
witness must sign the short form. The translator will also sign the main consent form. 
 
For patients who cannot read. A witness, not related to the research study will be present. 
The consent will be read to the patient. The patient will also be allowed to ask any questions 
s/he may have. The investigator will ask the patient questions to ensure s/he understands 
the study. If the investigator determines the subject understands the study, the patient will 
mark an X where his/her name would go and the witness will sign the consent form. 
 
4.3.2 Documentation of Consent 
The Principal Investigator or IRB approved sub-investigator will be responsible for 
documentation in the medical record that consent has been obtained from all participants. 
A signed copy of the consent form will be given to each participant. Original consent forms 
will be stored in the subject’s medical chart. 
 
4.3.3 Multi-Site Surveillance 
As the lead investigator in a multi-site trial, the Overall Principal Investigator is responsible 
for organizing and conducting monthly teleconferences with all participating sites.  The PI 
will also be responsible for including data from all of the participating sites within the overall 
trial’s quarterly Data and Safety Monitoring report to the DSMC to include minutes from 
monthly PI teleconferences.  Each participating site will be responsible for submitting the 
results and recommendations from the DSMC’s quarterly review to their IRB of record at the 
time of continuing review.  Additionally, the NYULMC PCC Clinical Trial Office, Quality 
Assurance Unit will provide monitoring every 4-6 weeks to ensure completeness, accuracy, 
and consistency of the data. 
4.3.4 Patient Informed Consent at Additional Sites 
The Principal Investigator (PI) at each participating site will identify the physician members 
of the study team who will be obtaining consent and signing the consent form for therapeutic 


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protocols. It is NYULMC policy that Nurses and Fellows cannot obtain consent to greater 
than minimal risk trials, unless Fellows are listed as co-investigators.  
 
The Investigator must ensure that each participant, or his/her legally acceptable 
representative, is fully informed about the nature and objectives of the study and possible 
risks associated with participation. All participants must be provided a consent form 
describing this study and providing sufficient information for participants to make an 
informed decision about their participation in this study. The formal consent of a participant, 
using the IRB approved consent form, must be obtained before the participant is involved in 
any study-related procedure. The consent form must be signed and dated by the participant 
or the participant’s legally authorized representative (if applicable), and by the person 
obtaining the consent. The participant must be given a copy of the signed and dated consent 
document. The original signed copy of the consent document must be retained in the 
medical record or research file. 
 
All parties will ensure protection of participant personal data and will not include participant 
names on any sponsor forms, reports, publications, or in any other disclosures, except 
where required by laws.  In case of data transfer, NYULMC Perlmutter Cancer Center (PCC) 
will maintain high standards of confidentiality and protection of participant personal data. 
 
The informed consent form must be in compliance with ICH/GCP, local regulatory 
requirements, and legal requirements. 
 
The informed consent form used in this study, and any changes made during the course of 
the study, must be prospectively approved by both the IRB and NYULMC before use. 
 
4.4 Registration Procedures 
4.4.1 General Guidelines 
Each patient must sign and date an informed consent form before undergoing any study 
specific procedure unless a procedure is being performed as part of the patient’s standard 
of care. 
Enrollment in the study requires that all inclusion and exclusion criteria have been met.  
Enrollment occurs upon confirmation of registration from the NYULMC PCC Clinical Trials 
Office.  The following materials must be submitted to the Research Coordinator for subject 
registration: 
1.  Complete signed and dated informed consent form 
2. Complete signed and dated eligibility checklist 
3. All supporting documentation verifying each criterion has been met 
 
Registration will occur within 48 hours of research coordinator receipt of all of the above 
documents.  A written confirmation of enrollment including a unique study identification 
number assigned by the research coordinator will be disbursed to the study team upon 
registration. 
 


ESCC Nivolumab  
 
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Once eligibility is verified, a unique patient study number will be issued within 24 hours of 
receiving all required registration material.  The patient will not be identified by name.  This 
is the point, at which, the patient is considered accrued on study.   
 
4.4.2 Patient Registration at Other Participating Institutions 
The Principal Investigator (PI) at each participating site will identify the physician members 
of the study team who will be obtaining consent and signing the consent form for therapeutic 
protocols. It is NYULMC policy that Nurses and Fellows cannot obtain consent to greater 
than minimal risk trials.  
 
 
Enrollment at addition sites can begin once each site’s IRB has approved this 
protocol, a copy of each 
site’s IRB approval, Citi training certificates, Medical 
Licenses and signed CVs are provided to NYU Langone Health Perlmutter Cancer 
Center (PCC) Clinical Trials Office. Once, all required documents are provided to 
NYU Clinical Trials Office an activation notification will be sent to the PI and 
research coordinator of that site. Central registration for this study will take place at 
NYU Langone Health PCC Quality Assurance Unit (PCC-QAU@nyumc.org). 
 
Each patient must sign and date an informed consent form before undergoing 
any study specific procedures unless a procedure is being performed as part of 
the patient’s standard of care. Once a patient has signed consent, each site must 
notify the NYU Langone Health PCC Quality Assurance Unit and forward a copy of 
the signed consent to NYU Langone Health PCC Clinical Trials Office within 24 
hours. 
 
Enrollment in the study requires that all inclusion and exclusion criteria have been 
met. Enrollment occurs upon confirmation of registration from the NYU Langone 
Health PCC Clinical Trials Office. The following materials must be submitted to the 
Quality Assurance Unit at NYU Langone Health via email (PCC-QAU@nyumc.org): 
 
1. Complete signed and dated informed consent form 
2. Complete signed and dated informed consent checklist 
3. Complete signed and dated eligibility checklist 
4. All supporting documentation verifying each criterion has been met. 
 
Registration will occur once the Senior Research Nurse for Quality Assurance 
conducts a central review of the submitted materials. Once eligibility is verified, a 
unique subject study number will be issued within 48 hours of receiving all required 
registration material. This number is unique to the participant and must be written on 
all data and correspondence for the participant. The NYU Langone Health PCC CTO 
will return a signed eligibility confirmation worksheet email with the subject’s unique 
study number. 


ESCC Nivolumab  
 
Page 43 
 
 
 
The subject will not be identified by name. This is the point, at which, the patient is 
considered accrued on study. Protocol treatment should begin within  designated 
timeframe; issues  that would cause treatment delays should be discussed with the 
overall PI, Dr. Wu. Pretreatment evaluation will therefore be dictated by standard clinical 
practice.  Except in very unusual circumstances, each participating institution will order the 
study drug directly from the supplier.  All screen failures/ineligible subjects, as well as 
subject’s who withdraw consent prior to initiation of protocol therapy must be 
submitted to the CTO in a manner analogous to the procedures noted above. 
Applicable 
source 
documentation will be required within the corresponding 
submissions. 
 
 
Each site is responsible for reporting all unexpected problems involving risks to participants 
or others to NYULMC PCC Clinical Trials Office and to their IRB as per site institutional 
policy. 
 
Each site is responsible for reporting all unexpected problems involving risks to 
participants or others to NYU Langone PCC Clinical Trials Office and to their IRB as 
per site institutional policy. 
 
Please email all SAEs to NYUPCCsafetyreports@nyumc.org, PCC Assigned 
Medical Monitor, Dr. Wu, and the NYU Langone Health CTO regulatory specialist. 
 
 
4.5  Early Withdrawal of Subjects 
4.5.1 When and How to Withdraw Subjects 
A subject may withdraw consent and leave the trial at any time.   
 
A subject who withdraws consent prior to receiving the combination of chemotherapy, 
immunotherapy and radiation may be replaced in the phase I portion of the trial.   
 
A subject has the right to voluntarily discontinue study treatment or withdraw from the study 
at any time, for any reason, and without repercussion.  The investigator and sponsor have 
the right to discontinue a patient from study treatment or withdraw a patient from the study 
at any time. 
 
Reasons for subject withdrawal from the study may include, but are not limited to: 
 
• Subject withdrawal of consent at any time. 
• Disease progression 
• Intolerable toxicity (If applicable) 


ESCC Nivolumab  
 
Page 44 
 
 
• Any medical condition that the investigator or sponsor determines may 
jeopardize the patient’s safety if s/he continues in the study or continues 
treatment with study drug. 
• The investigator or sponsor determines it is in the best interest of the subject. 
• Failure of the subject to adhere to protocol procedure requirements 
• Pregnancy  
• Study termination by Sponsor 
 
4.5.2 Data Collection and Follow-up for Withdrawn Subjects 
Subjects who withdraw consent following treatment with chemotherapy, immunotherapy and 
radiation will be followed for toxicity and survival.  Such subjects will not be replaced. 
 
The follow-up will depend on the staging of the subject’s disease at the time he/she is 
withdrawn from the study.  Subjects will be seen in the outpatient clinic at a minimum of 
every 3 months, for two years, or until death. 
 
 
 
5.0 Description of Therapy   
 
5.1 Systemic Therapy: Description, Preparation, Administration, and Toxicity 
 
Table 2. Product Description  
Product Description 
and Dosage Form 
Potency 
Primary 
Packaging 
(Volume)/ 
Label Type 
Secondary Packaging 
(Quantity) / Label Type 
Appearance 
Storage Conditions     
(per label) 
BMS-936558-01 
(nivolumab) 
Solution for Injection 
100mg 
(10 mg/mL) 
10m per vial/ 
Open-label 
5 or 10 vials per 
carton/Open-label 
Clear to opalescent 
colorless to pale yellow 
liquid. May contain particles 
2 to 8ºC. Protect from 
light and freezing 
Carboplatin  
Solution for Injection 
450 mg/vial 
(10 mg/mL) 
45 mL per vial/ 
Open-label 
4 vials per 
carton/Open-label 
Clear, colorless or slightly 
yellow solution 
Store at or below 25ºC. 
Protect from light. 
Paclitaxel  
Solution for Injection  
100 mg/vial 
(6 mg/mL) 
16.7 mL vial/ 
Open-label 
4 vials per carton/ 
Open-label 
Clear colorless or slightly 
yellow viscous solution 
Store at 15ºC-30ºC. 
Protect from light 
 
 
5.1.1 Nivolumab   
5.1.1.1 
Dose and Schedule 
Nivolumab 240 mg (flat dose) will be administered as an intravenous infusion on 
days 1 and 15 as a single agent.  On Days 29, 43 and 57 nivolumab will be 
administered concurrently with chemotherapy and radiation.   
 
For patients determined to have a complete clinical response continue nivolumab 
240 mg (flat dose) q 2 weeks x 6 within two weeks of response determination 
 
For patients undergoing surgery begin nivolumab 240 mg (flat dose)  q 2 weeks x 6, 
within 12   weeks following esophagectomy  


ESCC Nivolumab  
 
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5.1.1.2 
Nivolumab Description 
Nivolumab is  a  sterile,  preservative-free,  non-pyrogenic,  clear  to  opalescent,  
colorless  to  pale-yellow liquid that may contain light (few) particles. Nivolumab 
injection for intravenous infusion is supplied in single-use vials.  Each mL  of  
nivolumab  solution  contains  nivolumab  10  mg, mannitol (30 mg), pentetic acid 
(0.008 mg), polysorbate 80 (0.2 mg), sodium chloride (2.92 mg), sodium citrate 
dihydrate (5.88 mg), and Water for Injection, USP. The solution may contain 
hydrochloric acid and/or sodium hydroxide to adjust pH to 6. 
 
5.1.1.3 
Storage Requirements and Stability  
• The product does not contain a preservative.  
• Protect from light by storing in the original package until time of use. Do not 
freeze or shake.  
• After preparation, store the infusion either:  
• At room temperature  for  no  more  than  4  hours  from  the  time  of  
preparation.  This includes room temperature  storage  of  the  infusion  in  
the  IV  container  and  time  for administration of the infusion, or  
• Under refrigeration at 2°C to 8°C (36°F-46°F) for no more than 24 hours 
from the time of infusion preparation.  
• If stored in a glass front refrigerator, vials should be stored in the carton. 
Recommended safety measures for preparation and handling of nivolumab 
include laboratory coats and gloves. 
• For additional details on prepared drug storage and use time of nivolumab 
under room temperature/light and refrigeration, please refer to the BMS-
936558 (nivolumab) Investigator Brochure section for “Recommended 
Storage and Use Conditions”  
 
5.1.1.4 
Preparation  
• Nivolumab will be supplied in single-use injection vials at concentrations of 
40 mg/4 mL (10 mg/mL) and 100 mg/10 mL (10 mg/mL).  
• 240 mg IV diluted with either 0.9% Sodium Chloride Injection, USP or 5% 
Dextrose Injection, USP, to prepare an infusion with a final concentration 
ranging from 1 mg/mL to 10 mg/L, to be infused over 30 minutes 
 
• Nivolumab  is available as follows:  
  
Carton Contents   
 
 
NDC  
      40 mg/4 mL single-use vial   
0003-3772-11  
  
100 mg/10 mL single-use vial   
0003-3774-12  
 
5.1.1.5 
Administration  
• Administer the infusion over 30 minutes through an intravenous line 
containing a sterile, non-pyrogenic, low protein binding in-line filter (pore size 
of 0.2 micrometer to 1.2 micrometer). Fewer infusion reactions have been 
observed in clinical trials when decreasing nivolumab infusion time from 60 


ESCC Nivolumab  
 
Page 46 
 
 
minutes to 30 minutes. It is not to be administered as IV push or bolus 
injection.  
• Do not coadminister other drugs through the same intravenous line. 
• Flush the intravenous line at end of infusion. Nivolumab can be infused 
undiluted (10 mg/mL) or diluted with 0.9% Sodium Chloride Injection, USP 
or 5% Dextrose Injection, USP to protein concentrations as low as 1 mg/mL. 
Care must be taken to assure sterility of the prepared solution as the product 
does not contain any antimicrobial preservative or bacteriostatic agent 
• Subjects may be dosed no less than 12 days from the previous dose of drug. 
There are no premedications recommended for nivolumab on the first cycle. 
• The dosing calculations should be based on the actual body weight at 
baseline. If the subject’s weight on the day of dosing differs by > 10% from 
the weight used to calculate the original dose, the dose must be recalculated. 
All doses should be rounded to the nearest milligram. There will be no dose 
modifications allowed. 
• Subjects should be carefully monitored for infusion reactions during 
nivolumab administration. If an acute infusion reaction is noted, subjects 
should be managed according to Protocol Section 7.4. 
 
5.1.2 Carboplatin  
 
5.1.2.1 
Dose and Schedule 
Carboplatin will be administered days 29, 36, 43, 50, 57 and 64 at AUC 2 q weeks 
as an IV infusion. 
 
5.1.2.2 
Carboplatin Description 
Carboplatin is commercially available as a sterile lyophilized powder in single-
dose vials containing 50 mg, 150 mg, and 450 mg of carboplatin. Each vial 
contains equal parts by weight of carboplatin and mannitol. It is also available as 
an aqueous solution in multidose vials containing 50 mg, 150 mg or 600 mg, at a 
concentration of 10 mg/mL, and as a preservative- free 10 mg/mL solution 
containing 50 mg, 150 mg, or 450 mg.  
 
5.1.2.3 
Storage Requirements and Stability  
Unopened vials of carboplatin powder or solution are stable for the life indicated 
on the package when stored at controlled room temperature and protected from 
light. Reconstituted solutions are reported to be stable for at least five days at 
room temperature, but if no preservative is employed, it is recommended that 
carboplatin solutions be discarded eight hours after reconstitution. The multidose 
vials of carboplatin aqueous solution are reported to maintain microbial and 
chemical stability at room temperature for up to 14 days following multiple needle 
entries.  
 
5.1.2.4 
Preparation  


ESCC Nivolumab  
 
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Reconstitute  
carboplatin powder with sterile water for injection, USP, 5 % 
dextrose in water, or 0.9% sodium chloride injection, USP, according to the 
following schedule:  
 
Table 3. Carboplatin Preparation 
 
Vial Strength 
Diluent Volume 
50 mg 
5 mL 
150 mg 
15 mL 
450 mg 
45 mL 
 
 
5.1.2.5 
Administration  
Carboplatin will be administered intravenously (IV) over 30 minutes. 
  
Note: Aluminum reacts with carboplatin causing precipitate formation and loss of 
potency: therefore, needles or intravenous sets containing aluminum parts that 
may come in contact with the drug must not be used for the preparation or 
administration of carboplatin.  
 
 
5.1.3 Paclitaxel  
 
5.1.3.1 
Dose and Schedule  
Paclitaxel will be administered on days 29, 36, 43, 50, 57 and 64 at 50 mg/m2 as 
an IV infusion. 
 
5.1.3.2 
Paclitaxel Description 
Paclitaxel is commercially available in a concentration of 6 mg/mL in 5 mL, 16.7 
mL, 25 mL and 50 mL multidose vials. Each mL of solution also contains 527 mg 
of polyoxyethylated castor oil and dehydrated alcohol, USP. Please refer to the 
FDA-approved package insert for complete product information.  
 
5.1.3.3 
Storage Requirements and Stability  
Intact vials should be stored at controlled room temperature (20° - 25°C; 68° - 
77°F) in the original package to protect from light, and remain stable until the 
expiration date on the label. Refrigeration does not adversely affect stability. Upon 
refrigeration components in the paclitaxel vial may precipitate, but will re-dissolve 
upon reaching room temperature with little or no agitation. Diluted 0.3 – 1.2 mg/mL 
solutions are stable for up to 27 hours at room temperature under normal room 
lighting. Although solutions may be chemically stable for longer periods in some 
situations, precipitation may occur unpredictably. The mechanism of this 
precipitation has not been determined.  
 
5.1.3.4 
Preparation  


ESCC Nivolumab  
 
Page 48 
 
 
Paclitaxel must be diluted prior to administration with 0.9% sodium chloride 
Injection, USP; 5% Dextrose Injection, USP; 5% Dextrose and 0.9% Sodium 
Chloride Injection, USP; or 5% Dextrose in Ringer’s Injection to a final 
concentration of 0.3 to 1.2 mg/mL. Paclitaxel should be prepared and stored in 
glass, polypropylene, or polyolefin containers due to leaching of DEHP [di-
(2ethylhexyl)phthalate] plasticizer from polyvinyl chloride (PVC) containers. Non-
PVC containing tubing and connectors should also be used. Paclitaxel should be 
administered through an in-line < 0.22 micron filter. 
 
5.1.3.5 
Administration  
In this study, during induction therapy, paclitaxel is administered intravenously 
over 2 hours on days 1 and 8 of each 21-day cycle of therapy. During combined 
therapy, paclitaxel is administered intravenously, over 2 hours weekly for 5 weeks.  
 
 
5.2 Radiation Therapy  
Radiation therapy will be started on the first day of combined chemoradiation, Day 29. 
The total dose of RT will be 50.4 Gy in 1.8 Gy fractions x 28 fractions. Patients can 
undergo simulation for radiotherapy planning prior to the second PET scan since the 
treatment volumes are based on pre-chemotherapy tumor involvement. The simulation 
should be performed at least 2 weeks prior to the start date for radiotherapy so that the 
treatment plan can undergo QA without delaying the start date of the radiotherapy.  
 
5.2.1 Technical Factors  
Linear accelerators with a minimum energy of 6-16 MV will be used. A multiple field 
3-D conformal technique or IMRT technique will be used. All fields will be treated 
each day. The patient will be treated in the supine position. Radiation will be delivered 
5 days/week, once per day.  
 
5.2.2 Required Benchmarks and Pre-approval of 3D Treatment Plans  
CT-based conformal planning is required on this study. In accordance with current 
guidelines for use of IMRT in clinical trials (see www.irocri.qarc.org), IMRT may be 
used. 
 
5.2.3 Protocol Treatment Volumes  
The nomenclature and definitions of ICRU Reports 50 and 62 shall be followed in this 
study.  
 
A volumetric treatment planning CT study will be required for this study. Each patient 
will be positioned in an individualized immobilization device in the treatment position 
on a flat table. Contiguous CT slices, 3-5 mm thickness of the regions harboring gross 
tumor and grossly enlarged nodes and 8-10 mm thickness of the remaining regions, 
are to be obtained starting from the level of the cricoid cartilage and extending 
inferiorly through the liver. A measurement scale for the CT image shall be included.  
 


ESCC Nivolumab  
 
Page 49 
 
 
Gross Tumor Volume (GTV): The GTV is based on the pre-chemotherapy extent of 
disease using the initial PET/CT scan, endoscopy report, and CT scan. The entire 
esophageal wall, including any disease that has extended through the wall should be 
contoured as the GTV as well as any PET/CT-avid or enlarged lymph nodes.  
 
Clinical Target Volume (CTV): The intent of pre-operative treatment is to include the 
tumor bed plus the nodal groups at risk (whether clinically positive or negative). The 
clinical target volume (CTV) should encompass the peri-esophageal lymph nodes, 
mediastinal lymph nodes for mid- and upper- thoracic esophageal tumors, and the 
submucosal spread longitudinally along the esophagus. This is generally a 3-4 cm 
expansion on the GTV superiorly and inferiorly and 1.0 cm expansion radially. For 
distal esophageal tumors and GE junction tumors, the CTV should include the celiac 
lymph nodes. For tumors above the carina, the supraclavicular lymph nodes should 
be included in the CTV. Due to the variable margin expansion models used by 
different contouring and treatment planning systems, the radial expansion may be 
larger than 1 cm on each slice. The treating physician should modify the margins to 
minimize overlap with normal adjacent structures such as the heart, lungs, or liver.  
 
Planning Target Volume (PTV): The PTV is established by expanding the CTV by 0.5 
cm in all directions. This will result in a margin of up to 5 cm superior and inferior and 
approximately 1.0-2 cm radially to the extent of tumor (GTV). For distal esophageal 
and GE junction tumors where motion management is not being used, the superior-
inferior expansion can be 0.7-1.0 cm to account for the respiratory motion.  
 
Internal Target Volume (ITV): The ITV may be utilized with four-dimensional CT 
simulation. The ITV volume shall be contoured per the treating Radiation Oncologists 
standard practice. This is described in “Motion Management” section 5.2.26.   
 
5.2.4 Target Dose Constraints  
Dose Prescription  
The prescribed dose to the PTV is 5040 cGy delivered in 180 cGy/day over 28 
fractions.  
 
Dose Uniformity  
The dose to 99% of the PTV must be at least 93% of the prescribed dose, and no 
more than 2cc within the PTV may receive a dose greater than 120% of the 
prescribed dose.  
 
Tissue Heterogeneity  
Calculation shall take into account the effects of tissue heterogeneities. Planning 
must be performed using an approved dose calculation algorithm. Approved 
algorithms include: convolution superposition, collapsed cone convolution, and 
Monte Carlo.  
 
5.2.5 Normal Tissue Dose Constraints  


ESCC Nivolumab  
 
Page 50 
 
 
The normal structures to be contoured will depend on the level of the esophagus 
involved, but can include left and right lungs, heart, esophagus, brachial plexus, left 
and right kidneys, liver, stomach, small intestine, and spinal canal. The dose to 
normal tissues must be kept within the parameters described below.  
 
1. Lungs  
1. V20Gy ≤ 25% 
2. and V30Gy ≤ 15% 
3. and V40Gy ≤ 10% 
4. V10Gy ≤ 40% 
2. Cord 
1. Max ≤ 4500 cGy 
3. Bowel 
1. Max bowel dose < Max PTV dose 
2. and D05 ≤ 4500 cGy 
4. Heart 
1. V30Gy ≤ 30% (closer to 20% preferred) 
2. Mean < 3000 cGy 
5. Left kidney, Right kidney (evaluate each one separately): 
1. No more than 33% of the volume can receive 1800 cGy 
6. Liver 
1. V20Gy ≤ 30% 
2. V30Gy ≤ 20% 
3. Mean < 2500 cGy 
7. Stomach 
1. Mean < 3000 cGy (if not within PTV) 
2. Max dose <54 Gy 
 
5.2.6 Treatment Planning  
Simulation: Patients will be positioned supine with arms above the head in a mold for 
immobilization. A CT simulation will be performed using oral and/or IV contrast, when 
possible, using ≤3 mm slice thickness. In patients for whom treatment will be 
delivered using respiratory gating or tracking, the planning CT scan should be 
performed with the patient in a breath-hold in end-expiration.  
 
Motion Management: For distal esophageal and GE junction tumors, respiratory 
motion can be significant, requiring an assessment of the degree of tumor motion at 
the time of simulation. Gold fiducial markers will be placed prior to simulation in 
patients for whom treatment will be delivered using respiratory gating or tracking to 
aid the visualization of the tumor motion during treatment. To determine the extent of 
respiratory motion, a respiratory correlated 4DCT scan will be obtained at the time of 
simulation: this scan will be performed throughout the breathing cycle (i.e., 4-
dimensional CT) so that separate CT data sets associated with each phase of 
respiration can later be reconstructed. Treatment delivery can be done using the 
motion management technique available at the institution and can include treatment 


ESCC Nivolumab  
 
Page 51 
 
 
during free-breathing as long as an internal target volume (ITV) has been designed 
based on the motion of the tumor on the 4DCT.  
 
Beam Arrangements:  
1. 3D Conformal Beam Arrangements  
Beam arrangement selection for 3D conformal treatment will vary based on the 
shape, size, and location of the CTV and the resulting PTV in relation to normal 
organs. The most common arrangement is an AP/PA with Right and Left Lateral 
beams.  
 
2. IMRT - Beam Arrangement  
A five-field beam arrangement is preferred to minimize the low dose distributed to the 
lungs. Suggested beam arrangements are:  
 
a. For distal esophagus the following beam arrangement is useful for minimizing dose 
to the heart and lungs:  
LPO (155), LAO(70-80), AP(0), RAO(280-290), RPO(205)  
Note that the range of gantry angles for the LAO and RAO fields is due to the fact 
that one needs to find the best compromise between the amount of heart and lung in 
the field.  
 
b. For GE-junction esophagus, the following beam arrangement may be substituted 
if it is better for minimizing dose to the kidney. All beams are 15/16 MV:  
PA (180o), close to LL (90o+/-10o), LAO (30-35o), RAO (325-330o), close to RL 
(270o+/-10o)  
 
c. VMAT or RapidArc-like delivery approaches are acceptable 
 
These recommended beam arrangements may be changed to one more fitting for 
the patient’s particular anatomy.  
 
Field verification: As a minimum requirement, institutions are required to obtain 
verification images at the start of treatment and each week thereafter. Prior to the 
first treatment images that verify the position of the isocenter placement must be 
obtained. For 3D-CRT this imaging can include individual portal views. Weekly 
imaging can consist of portal views for 3D-CRT and isocenter verification images. For 
IMRT orthogonal images, verifying isocenter position are required. More frequent 
(daily) imaging is allowed, particularly for patients treated with motion management 
techniques and/or arc-based treatment techniques, but is not required.  
 
5.2.7 Portal Film Review  
First day port films or portal images of each field must be obtained and kept by the 
treating institution. Weekly (at least 48 hours apart) verification films or images of 
orthogonal views (anterior to posterior and lateral projection) must be reviewed by 
the treating physician. The required accuracy of patient positioning and the use of 


ESCC Nivolumab  
 
Page 52 
 
 
multi-leaf collimator apertures suggest the daily use of on-line imaging may be 
desirable. If on-line daily imaging is used, this must be documented.  
 
5.2.8 Definitions of Deviations in Protocol Performance  
 
Prescription Dose  
• No Deviation: ≥ 99% of the PTV receives ≥ 93% of the prescribed dose, and a 
contiguous volume of no more than 2cc inside PTV exceeds 20% of the 
prescribed dose.  
• Minor Deviation: Between 95% and 99% of the PTV receives 93% of the 
prescribed dose, or the dose to a volume of 2cc within the PTV exceeds the 
prescribed dose by 20- 25%.  
• Major Deviation The dose to 1 cc of tissue outside the PTV exceeds 120% of the 
prescribed dose, or less than 95% of the PTV receives 93% of the prescribed 
dose, or the dose to a volume of 2cc within the PTV exceeds 125% of the 
prescribed dose.  
 
Volume  
• Minor Deviation: Margins less than specified, or field(s) 1-3 cm greater than 
specified.  
• Major Deviation: Fields transect tumor or specified target volume(s), or 
fields are more than 3 cm greater than specified.  
• Critical Organ  
• Major Deviation: The maximum dose to the spinal cord exceeds 4500cGy; the 
heart mean dose exceeds 3000cGy; the lung V20 exceeds 30% or the V10 
exceeds 50%.  
• Minor Deviation: The lung V20 exceeds 20% or the V10 exceeds 40%.  
 
Treatment Interruption  
• Minor Deviation: Treatment interruptions between five and nine normally 
scheduled treatment days. 
• Major Deviations: Treatment interruptions totaling more than nine normal 
scheduled treatment days.  
 
 
5.3 Surgery: Esophagectomy 
 
Patients who do not achieve a complete clinical response after study therapy will undergo 
esophagectomy followed by nivolumab 240 mg every two weeks for 6 weeks.  Patients 
who achieve a complete clinical response after study therapy will go on to receive 
nivolumab 240 mg every two weeks for 6 weeks and will not undergo surgery. At the 
discretion of the treating physician and based on patient preference, patients who 
achieve a clinical complete response may still choose to undergo surgery.  
 
5.3.1 Surgical Procedures 
 


ESCC Nivolumab  
 
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Surgical options (Types of Esophagectomies) 
1. Ivor Lewis Esophagectomy 
a. Laparotomy with gastric mobilization. Feeding jejunostomy. Gastric 
emptying procedure at discretion of surgeon. 
b. Thoracotomy with esophageal mobilization and resection. 
Esophagogastric anastomosis at discretion of the surgeon. 
2. Three Incision Esophagectomy 
a. Right thoracotomy with esophageal mobilization 
b. Laparotomy with gastric mobilization. Feeding jejunostomy. Gastric 
emptying procedure at discretion of surgeon. 
c. Left neck incision. Esophagogastric anastomosis at discretion of the 
surgeon. 
3. Transhiatal Esophagectomy 
a. Laparotomy with gastric mobilization. Feeding jejunostomy. Gastric 
emptying procedure at discretion of surgeon. 
b. Transhiatal esophageal mobilization 
c. Left neck incision. Esophagogastric anastomosis at discretion of the 
surgeon. 
4. Minimally Invasive Versions 
a. Minimally invasive versions of above procedures, which may include 
thoracoscopy, laparoscopy, robotics. 
 
 
6.0 Study Procedures 
6.1  Study Visits


Nivolumab in ESCC 
 
Page 54 
Version: 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as authorized in writing by the study sponsor 
TABLE 4: SCHEDULE OF EVENTS / STUDY CALENDAR 
Activity 
Screenin
g 
C1 
(D
1) 
C2
D1 
(D1
5) 
C2 
W2/ 
(D22-
28) 
C3 
D1     
(D2
9) 
C3  
D8 
(D3
6) 
C4   
D1  
(D4
3) 
C4 
D8 
(D5
0) 
C5
D1 
(D5
7) 
C5
D8 
(D6
4) 
5-8 
W 
Post 
RT 
C
6  
C
7 
C
8 
C
9 
C1
0 
C1
1 
EO
T 
30D 
Post 
Tx. 
60D 
Post 
Tx. 
Follo
w-
up@ 
EOS 
Enrollment 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopy* 
X 
 
 
X1 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X 
 
Tumor core 
biopsy**** 
X 
 
 
X1 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
PET/CT scan** 
X 
 
 
X 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
Disease staging 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECG 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vital Signs 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Physical exam 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
CBC 
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
CMP  
X 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
TSH  
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
fT4 
X 
X 
X 
 
X 
 
X 
 
X 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
fT3 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
 
 
 
 
 
 
X 
X 
X 
 
 
Amylase 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lipase 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cortisol 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious 
disease screen 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Β-HCG - serum 
(pregnancy test) 
X 
X 
X 
 
X 
 
X 
 
X 
 
 
X 
X 
X 
X 
X 
X 
 
X 
X 
 
 
HIV testing 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hepatitis panel 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Correlative 
studies 
X 
 
 
X 
 
 
 
 
 
 
X 
X 
X 
 
X 
 
 
 
 
 
 
 
Nivolumab             
 
X 
X 
 
X 
 
X 
 
X 
 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
Carboplatin        
 
 
 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Paclitaxel              
 
 
 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Radiation 
therapy*** 
 
 
 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 


ESCC Nivolumab  
 
Page 55 
 
 
AEs 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Concurrent 
medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
Esophagectomy#    
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Extent of disease 
evaluation 
 
 
 
X 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
X 
X^ 
 
Off treatment 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
Protocol 
deviation 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Survival status 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
X 
X 
X 
X 
Off study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
* Endoscopic ultrasound will be performed if technically feasible. Bronchoscopy will be performed for tumors involving the cervical or thoracic esophagus only at screening to rule out fistula. 
** For those with allergy to CT IV contrast, PET alone, with MRI of abdomen and non-contrast CT of chest, is acceptable. Procedures done on C2W2 can be done beyond Day 28, as long as it is prior 
to C3D1. It can be done at time of surgery if endoscopy during 5-8 week post RT is not feasible. 
*** Radiation Therapy (RT) will be administered at 1.8 Gy/fraction, Monday through Friday, × 28 fractions, on Days 29-66. 
****Optional at C2W2(D22-28) 
# If  no complete clinical response; for subjects with a complete clinical response, Esophagectomy can be offered at the discretion of the treating physician. 
@ Every 3 months up to 2 years, then every 6 months until 5 years after the start of therapy; 11 clinic follow-up visits in all 
^ Every 6 months up to 2 years, then annually until 5 years after the start of therapy; 5 follow-up scans in all 
1 Procedure can occur after 28 days, but must be prior to C3D1 drug administration 


Nivolumab in ESCC 
 
Page 56 
Version: 
CONFIDENTIAL 
This material is the property of the NYU School of Medicine and Langone Medical Center.  Do not disclose or use except as authorized in 
writing by the study sponsor 
6.1.1 Screening 
The following will be performed during the Screening period (28 days prior to study 
enrollment): 
 
• Informed Consent 
• Physical Examination 
• Vital signs 
• Electrocardiogram (ECG) 
• Complete Blood Count (CBC) with Differential 
• Complete Metabolic Panel (CMP) with liver function tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Amylase 
• Lipase 
• Cortisol 
• Hepatitis Panel  
o Hepatitis B Surface Antigen, Antibodies, and Core Antibody 
o Anti-Hepatitis C Total Antibody 
• HIV Testing 
o Rapid HIV 1/2 Antibodies 
• Upper Endoscopy 
o Endoscopic ultrasound will be performed if technically feasible 
o Bronchoscopy will be performed for tumors involving the cervical or thoracic 
esophagus only at screening to rule out fistula.  
• Tumor Core Biopsy 
• Correlative Studies 
• PET/CT Scan   
o For those with allergy to CT IV contrast: PET alone is acceptable with MRI of 
abdomen and non-contrast CT of chest.  
• Serum Β-HCG for WOCBP 
 
6.1.2 Pregnancy Precautions 
Pregnancy Test: WOCBP prior to dosing nivolumab.  
A serum or urine pregnancy testing is required within 24 hrs. of study enrollment, then 
prior to day 1 of each cycle. After discontinuation from nivolumab, these should be 
repeated at approximately 30 days and approximately 60 days [or more frequently if 
required by local standard]. 
Women of childbearing potential (WOCBP) must have a negative serum or urine 
pregnancy test (minimum sensitivity 25 IU/L or equivalent units of HCG) within 24 
hours prior to the start of study drug and prior to day 1 of each cycle. 
Women must not be breastfeeding.  


ESCC Nivolumab  
 
Page 57 
 
 
WOCBP must agree to follow instructions for method(s) of contraception for the 
duration of treatment with study drug Nivolumab plus 5 months post-treatment 
completion  
Men who are sexually active with WOCBP must agree to follow instructions for 
method(s) of contraception for the duration of treatment with study drug(s) nivolumab 
plus 7 months post-treatment completion. In addition, male subjects must be willing to 
refrain from sperm donation during this time.  
Azoospermic men are exempt from contraceptive requirements. WOCBP who are 
continuously not heterosexually active are also exempt from contraceptive 
requirements, and still must undergo pregnancy testing as described in this section.  
Investigators shall counsel WOCBP, and men who are sexually active with WOCBP, 
on the importance of pregnancy prevention and the implications of an unexpected 
pregnancy. Investigators shall advise on the use of highly effective methods of 
contraception, which have a failure rate of < 1% when used consistently and correctly.  
HIGHLY EFFECTIVE METHODS OF CONTRACEPTION  
Highly effective methods of contraception have a failure rate of < 1% when used 
consistently and correctly. WOCBP and female partners of male subjects, who are 
WOCBP, are expected to use one of the highly effective methods of contraception 
listed below. Male subjects must inform their female partners who are WOCBP of the 
contraceptive requirements of the protocol and are expected to adhere to using 
contraception with their partner. Acceptable contraception methods of include:  
▪ Progestogen: hormonal contraception associated with inhibition of ovulation 
▪ Hormonal methods of contraception including oral contraceptive pills 
containing combined estrogen + progesterone 
▪ Vaginal Ring 
▪ Injectables  
▪ Implants 
▪ Intrauterine Devices (IUDs) such as Mirena®  
▪ Non-hormonal IUDs, such as ParaGard ® 
▪ Bilateral Tubal Occlusion  
▪ Vasectomised partner with documented azoospermia 90 days after procedure.  
A Vasectomised partner is a highly effective birth control method provided that partner is 
the sole sexual partner of the WOCBP trial participant and that the vasectomised partner 
has received medical assessment of the surgical success. 
▪ Intrauterine Hormone-Releasing System (IUS). 
▪ Complete Abstinence  


ESCC Nivolumab  
 
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Complete Abstinence is defined as the complete avoidance of heterosexual intercourse. 
Complete abstinence is an acceptable form of contraception for all study drugs and must 
be used throughout the duration of the study treatment (plus 5 half-lives of the 
investigational drug plus 30 days).  
It is not necessary to use any other method of contraception when complete abstinence 
is elected. Subjects who choose complete abstinence must continue to have pregnancy 
tests. Acceptable alternate methods of highly effective contraception must be discussed 
in the event that the subject chooses to forego complete abstinence. The reliability of 
sexual abstinence needs to be evaluated in relation to the duration of the clinical trial and 
the preferred and usual lifestyle of the subject.  
 
6.1.3 Cycle 1 Day 1 
The following will be performed at the Cycle 1 Day 1 Visit: 
 
• Physical Examination 
• Administration of Nivolumab 240 mg IV (q 2 weeks) 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Serum Β-HCG for WOCBP 
 
 
 
6.1.4 Cycle 2 Day 1 (Day 15) 
The following will be performed at the Cycle 2 Day 1 Visit: 
 
• Physical Examination 
• Administration of Nivolumab 240 mg IV (q 2 weeks) 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Serum Β-HCG for WOCBP 
 
 
Patients for whom nivolumab is not being held due to toxicity may begin Cycle 2  Day 1 on 
days 14-16 after Cycle 1 Day 1 without incurring a protocol deviation.   
  
6.1.5 Cycle 2 Days 8-14 (Days 22 – 28) 
The following will be performed during Cycle 2 between Days 8 and 14 (between Days 22 
and 28): 
 
• Upper Endoscopy (optional) 
• Tumor Core Biopsy (optional) 


ESCC Nivolumab  
 
Page 59 
 
 
• PET/CT scan 
• Correlative studies  
• Endoscopy and tumor biopsy collections may occur after day 28, but must be done 
prior to Day1 of Cycle 3 administration. 
 
 
6.1.6 Cycle 3 Day 1 (Day 29) 
The following will be performed at Cycle 3 Day 1 (Day 29) (± 2 Days up to 14 days max)  
 
• Physical Examination 
• Administration of Nivolumab 240 mg (flat dose) IV(q 2 weeks) 
• Administration of Carboplatin AUC 2 (weekly) 
• Administration of Paclitaxel 50 mg/m2 (weekly) 
• Radiation Therapy commences (1.8 Gy/fraction Monday through Friday × 28 
fractions) 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Serum Β-HCG for WOCBP 
 
 
 
6.1.7 Cycle 3 Day 8 (Day 36) 
The following will be performed at Cycle 3 Day 8 (Day 36) (± 1 Day): 
 
• Physical Examination 
• Administration of Carboplatin AUC 2 (weekly) 
• Administration of Paclitaxel 50 mg/m2 (weekly) 
• Radiation Therapy 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
 
 
6.1.8 Cycle 4 Day 1 (Day 43)  
The following will be performed at Cycle 4 Day 1 (Day 43) (± 1 Day): 
 
• Physical Examination 
• Administration of Nivolumab 240 mg (flat dose)  IV (q 2 weeks) 
• Administration of Carboplatin AUC 2 (weekly) 
• Administration of Paclitaxel 50 mg/m2 (weekly) 
• Radiation Therapy 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Serum Β-HCG for WOCBP 


ESCC Nivolumab  
 
Page 60 
 
 
 
 
6.1.9 Cycle 4 Day 8 (Day 50) 
The following will be performed at Cycle 4 (Day 50) (± 1 Day): 
 
• Physical Examination 
• Administration of Carboplatin AUC 2 (weekly) 
• Administration of Paclitaxel 50 mg/m2 (weekly) 
• Radiation Therapy 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
 
 
6.1.10 Cycle 5 Day 1 (Day 57)  
The following will be performed at Cycle 5 Day 1 (Day 57) (± 1 Day): 
 
• Physical Examination 
• Administration of Nivolumab 240  mg (flat dose) IV (q 2 weeks) 
• Administration of Carboplatin AUC 2 (weekly) 
• Administration of Paclitaxel 50 mg/m2 (weekly) 
• Radiation Therapy 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Serum Β-HCG for WOCBP 
 
 
6.1.11 Cycle 5 Day 8 (Day 64) 
The following will be performed at Cycle 5 (Day 64) (± 1 Day). 
 
• Physical Examination 
• Administration of Carboplatin AUC 2 (weekly) 
• Administration of Paclitaxel 50 mg/m2 (weekly) 
• Radiation Therapy 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
 
Radiation Therapy (RT) will be administered at 1.8 Gy/fraction, Monday through 
Friday × 28 fractions, on Days 29-66. 
 
 
6.1.12 After Completion of Radiation Therapy  
The following will be performed 5-8 weeks after completion of radiation therapy: 
 
• Physical Examination 


ESCC Nivolumab  
 
Page 61 
 
 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Upper endoscopy 
• Tumor Core Biopsy 
• Correlative Studies 
• PET/CT scan & Disease Assessment 
• Surgical Consult for esophagectomy, to be performed in 5-8 weeks post-
chemoradiation (for patients who do not achieve a CR or who elect to undergo 
surgery) 
o Delay beyond 8 weeks is reasonable if the patient has not yet recovered from 
chemoradiation and should be discussed with the study Principal Investigator. 
 
Patients who do not achieve a radiographic/clinical complete response (CR) should undergo 
surgery. 
 
Patients who achieve a clinical CR are not required to undergo surgery but, based on a 
discussion with their treating physician, can still undergo esophagectomy. 
 
Patients who achieve a CR and who do not undergo surgery must initiate adjuvant nivolumab 
within 2 weeks of determination of their CR status and within 8 weeks of completing 
chemoradiation.   Patients who do undergo surgery must initiate adjuvant nivolumab within 
12 weeks of their surgery date. 
 
 
6.1.13 Cycles 6-11 
The following will be performed on Day 1 of Cycles 6-11: 
 
• Physical Examination 
• Administration of Nivolumab 240 mg (flat dose) mg/kg IV 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Serum Β-HCG for WOCBP 
• Correlative studies will be done prior to treatment on Day 1 of Cycles 6, 7, and 9. 
 
 
6.1.14 End of Treatment and 30-Day Post Treatment Visits 
The following will be performed at the End of Treatment (EOT) and 30-Day Post 
Treatment Visits: 
 
• Physical Examination 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 


ESCC Nivolumab  
 
Page 62 
 
 
• Serum B-HCG for WOCBP 
 
The End of Treatment Visit is defined as the last day of protocol therapy.  The 30- and 60-
Day Post Treatment Visits will take place approximately 30 and 60 days after the last day of 
protocol therapy, respectively.  
 
6.1.15 60-Day Post Treatment Visit 
The following will be performed at the 60-Day Post Treatment Visit: 
 
• Physical Examination 
• Complete Blood Count with Differential 
• Complete Metabolic Panel with Liver Function Tests 
• Thyroid Function Tests (TSH, fT4, fT3) 
• Upper endoscopy (for patients who have not undergone surgery; it is optional for 
patients who have undergone esophagectomy) 
• Serum Β-HCG for WOCBP 
 
6.1.16 Follow-up 
Evaluations during post-treatment surveillance are summarized as follows: 
 
Table 5. SCHEDULE OF EVENTS IN FOLLOW-UP 
Clinic Visits 
Visits every 3 months ±1 month until 2 years after the start 
of therapy, then every 6 months ±1 month weeks for 3 years 
until 5 years after the start of therapy 
CBC and standard comprehensive panel at each visit 
CT or MRI of 
chest/abdomen 
Every 6 months ±1 month for 2 years, then annually ±1 
month for 3 years until 5 years after the start of therapy 
Endoscopy 
As clinically indicated (annually is recommended) 
 
 
6.2 PET/CT Scans 
 
6.2.1 PET/CT Imaging Interpretation  
Baseline PET/CT Scan Interpretation  
The baseline PET/CT scans will be interpreted by an experienced nuclear medicine physician 
at each participating site who will be responsible for image interpretation and clinical reporting 
for the local site. The images will be interpreted together with pertinent clinical findings and 
findings of other imaging modalities such as barium esophagogram, EUS, endoscopy and 
standard (i.e., contrast-enhanced) CT or MRI. Interpreting the PET/CT scans in this fashion 
mimics the usual clinical situation, in which this information is incorporated into the 
interpretation, especially in the case of an equivocal scan finding that may be easily explained 


ESCC Nivolumab  
 
Page 63 
 
 
by the CT/MRI scan result (e.g., anatomic variation of the bowel or bladder) or clinical 
information (e.g., increased uptake at a site of recent surgery or biopsy). 
 
6.3 Endoscopy and Biopsy 
Endoscopy with tumor core biopsy will be assessed at screening, after 2 weeks of therapy 
with nivolumab (optional), and 6-8 weeks after completion of radiation therapy. 
 
 
 
 
7.0  Dose Modifications and Management of Toxicity 
 
Table 6. Adverse Event Definitions 
 
Common Terminology for Adverse Events   
Condition 
Grade 
 
1 
2 
3 
4 
Hematologic 
Neutropenia 
<1999-1500/mm3 
(<1.99-1.5 x 10e9 
/L)  
 
<1500-1000/mm3 
(<1.5-1.0 x 10e9 /L)  
 
<1000 - 500/mm3 
(<1.0-0.5 x 10e9 /L)   
 
 <500/mm3 
(<0.5 x 10e9 /L)  
 
Anemia 
<LLN -10 g/dL 
(males) 
<LLN-10 
g/dL 
(females) 
<10.0-8.0 g/dL (males 
and females) 
<8.0-7.0 g/dL (males 
and females) 
<7.0 g/dL (males and 
females)* 
Thrombocytopenia 
  <75,000/mm3 
  (<75.0 x 10e9 /L)  
 
<75,000 - 50,000/mm3  
(<75.0 - 50.0 x 10e9 /L)  
 
<50,000 - 25,000/mm3  
(<50,000-25.0x10e9 
/L)  
 
<25,000/mm3 
(<25.0 x 10e9 /L)  
 
Pulmonary 
Pneumonitis 
Asymptomatic; 
clinical 
or 
diagnostic 
observations only; 
intervention 
not 
indicated  
 
Symptomatic; medical 
intervention indicated; 
limiting instrumental 
ADL 
Severe symptoms; 
limiting self-care ADL; 
oxygen indicated  
 
Life-threatening 
respiratory 
compromise; urgent 
intervention 
indicated (e.g., 
tracheotomy or 
intubation)  
 
Gastrointestinal 
Vomiting 
1-2 episodes 
(separated by 5 
minutes) in 24 
hours 
3-5 episodes 
(separated by 5 
minutes) in 24 hours 
≥ 6 episodes 
(separated by 5 
minutes) in 24 hours 
Life-threatening 
consequences; 
urgent intervention 
indicated 
Colitis  
Asymptomatic; 
clinical or 
diagnostic 
observations only; 
intervention not 
indicated  
Abdominal pain; 
mucus or blood in 
stool  
 
Severe abdominal 
pain; change in bowel 
habits; medical 
intervention indicated; 
peritoneal signs  
Life-threatening 
consequences; 
urgent intervention 
indicated  
 
Diarrhea 
Increase of <4 
stools per day over 
baseline; mild 
increase in ostomy 
Increase of 4 - 6 
stools per day over 
baseline; moderate 
increase in ostomy 
Increase of >=7 stools 
per day over baseline; 
incontinence; 
hospitalization 
Life-threatening 
consequences; 
urgent intervention 
indicated  


ESCC Nivolumab  
 
Page 64 
 
 
output compared to 
baseline  
 
output compared to 
baseline  
 
indicated; severe 
increase in ostomy 
output compared to 
baseline; limiting self-
care ADL  
 
 
Esophagitis  
Asymptomatic; 
clinical or 
diagnostic 
observations only; 
intervention not 
indicated  
 
Symptomatic; altered 
eating/swallowing; oral 
supplements indicated  
 
Severely altered 
eating/swallowing; 
tube feeding, TPN or 
hospitalization 
indicated  
 
Life-threatening 
consequences; 
urgent operative 
intervention 
indicated  
 
Dysphagia/ 
odynophagia 
Symptomatic, able 
to eat regular diet  
Symptomatic and 
altered 
eating/swallowing  
Severely altered 
eating/swallowing; 
tube feeding or TPN 
or hospitalization 
indicated  
Life-threatening 
consequences; 
urgent intervention 
indicated  
 
Hepatitis  
Asymptomatic, 
treatment not 
indicated  
AST, ALT,  
Alk Phos:  
1.25-2.5 x ULN 
Bilirubin:  
>1.0-1.5 ULN 
 
AST, ALT, Alk Phos:  
>2.5-5.0 x ULN 
Bilirubin:  
>1.5-2.5 x ULN 
Symptomatic liver 
dysfunction; fibrosis 
by biopsy; 
compensated 
cirrhosis; reactivation 
of chronic hepatitis  
AST, ALT, Alk Phos:  
>5.0-10 x ULN 
Bilirubin:  
> 2.5-5 x ULN 
 
Decompensated 
liver function (e.g., 
ascites, 
coagulopathy, 
encephalopathy, 
coma)  
AST, ALT, Alk 
Phos:  
>10 x ULN 
Bilirubin:  
>5 x ULN 
 
Renal 
Creatinine 
elevation 
>1-1.5 x baseline 
>ULN - 1.5 x ULN  
 
>1.5 - 3.0 x baseline  
>1.5 - 3.0 x ULN  
 
>3.0 baseline 
>3.0 - 6.0 x ULN 
>6.0 x ULN  
 
Neurologic 
Peripheral 
sensory 
neuropathy 
Asymptomatic; loss 
of deep tendon 
reflexes or 
paresthesia  
 
Moderate symptoms; 
limiting instrumental 
ADL  
 
Severe symptoms; 
limiting self-care ADL  
 
Life-threatening 
consequences; 
urgent intervention 
indicated  
 
Endocrine 
Hyperthyroidism 
Asymptomatic; 
clinical or 
diagnostic 
observations only; 
Intervention 
generally not 
indicated  
 
Symptomatic: thyroid 
suppression therapy 
indicated; limiting 
instrumental ADL 
Severe symptoms; 
limiting self care ADL; 
hospitalization 
indicated 
Life-threatening 
consequences; 
urgent intervention 
indicated  
Hypothyroidism  
Asymptomatic; 
clinical or 
diagnostic 
observations only; 
intervention not 
indicated 
Symptomatic: thyroid 
replacement indicated; 
limiting instrumental 
ADL 
Severe symptoms; 
limiting self care ADL; 
hospitalization 
indicated 
Life-threatening 
consequences; 
urgent intervention 
indicated 
Adrenal 
insufficiency 
Asymptomatic; 
clinical or 
diagnostic 
observations only; 
intervention not 
indicated 
Moderate symptoms; 
medical intervention 
indicated 
Severe symptoms; 
hospitalization 
indicated 
Life-threatening 
consequences; 
urgent intervention 
indicated  


ESCC Nivolumab  
 
Page 65 
 
 
Other endocrine 
disorders  
Asymptomatic or 
mild symptoms; 
clinical or 
diagnostic 
observations only; 
intervention not 
indicated 
Moderate; minimal, 
local or noninvasive 
intervention indicated; 
limiting age-
appropriate 
instrumental ADL 
Severe or medically 
significant but not 
immediately life-
threatening; 
hospitalization or 
prolongation of 
existing hospitalization 
indicated; disabling; 
limiting self care ADL 
Life-threatening 
consequences; 
urgent intervention 
indicated  
General 
Allergic reaction  
 
Transient flushing 
or rash, drug fever 
<38 degrees C 
(<100.4 degrees 
F); intervention not 
indicated  
 
Intervention or 
infusion interruption 
indicated; responds 
promptly to 
symptomatic 
treatment (e.g., 
antihistamines, 
NSAIDS, narcotics); 
prophylactic 
medications indicated 
for <=24 hours 
 
Prolonged (e.g., not 
rapidly responsive to 
symptomatic 
medication and/or 
brief interruption of 
infusion); recurrence 
of symptoms following 
initial improvement; 
hospitalization 
indicated for clinical 
sequelae (e.g., renal 
impairment, 
pulmonary infiltrates)  
 
Life-threatening 
consequences; 
urgent intervention 
indicated  
 
For grading of all other toxicities, please refer to Common Terminology Criteria for Adverse Events (CTCAE) Version 
4.03 [38] 
*There are no CTCAE criteria for grade 4 anemia.   
 
 
 
Table 7. Dose Modifications* 
Chemotherapy 
Drug  
Starting Dose  
Dose Modification 
 
 
Level -1 
Level -2 
Paclitaxel 
50 mg/m2IV 
37.5 mg/m2 
25 mg/m2 
 
Carboplatin 
AUC = 2 IV 
AUC = 1.5 
AUC = 1 
 
Immunotherapy 
Nivolumab  
240 mg IV flat dose No dose adjustments. See management of 
toxicities below   
 
Radiation 
 
Starting Dose 
Dose Modification 
 
50.4 Gy (28 fractions)** 
41.4 Gy (23 fractions)*** 
*There are no dose reductions beyond level -2. Patients who require a dose reduction beyond dose 
level -2 should discontinue protocol therapy. Patients should also be taken off-study if they 
develop unacceptable toxicity.  **Standard radiation dose administered in the United States for 
trimodality therapy that includes concurrent therapy with carboplatin and paclitaxel [36, 37] 
***Per the protocol established by the CROSS regimen [7] Radiation dose level reduction will be 
done on a study level. 
 
 
 
  
7.1 Grade 1 and/or Grade 2 Hematologic Toxicities 


ESCC Nivolumab  
 
Page 66 
 
 
• No delay in dosing of systemic agents or radiation therapy. 
 
  
7.2 Hematologic Adverse Events 
The dose of paclitaxel, carboplatin, and radiation will be modified according to blood counts 
on the day of treatment as shown in the table below. Dose reductions of paclitaxel and 
carboplatin are permanent. 
 
 
 
 
 
 
 
Table 8. Treatment Modification for Hematologic Toxicity    
 
 
For absolute neutrophil count less than 1000/mm3, must use filgrastim 300 mcg 
subcutaneously (for patients < 70 kg) or 480 mcg (for patients > 70 kg) for one day and up 
to three consecutive days.   
 
Missing doses of carboplatin and paclitaxel will not be made up.  
 
Missing doses of radiation therapy will be made up.  
 
 
7.3 Grade 1 Hepatic Toxicity  
• No change in dosing of systemic therapy for grade 1 bilirubin elevation 
Treatment Day Blood Counts 
Dosage 
ANC 
Platelet Count 
> 1,000/mm3 or  
(>1.0 x 109/L) 
AND 
> 75,000/mm3 or  
> 75,000 x 109/L 
Full         dosage         paclitaxel, carboplatin, and 
nivolumab. 
500-999/mm3 
OR 
50,000-75,000/mm3  No change in n i v o l u m a b  d o s e .  
C o n t i n u e  r a d i a t i o n  w i t h o u t  
c ha ng e in  do se  o r sc hed u le.  
Hold carboplatin and paclitaxel. Recheck CBC 
weekly. When ANC > 1,000 and Plt > 75,000, 
resume paclitaxel and carboplatin at level -1. If 
grade III hematologic toxicity persists after 
decreasing to dose level -1, hold for one week and 
restart at dose level -2. For persistent grade III 
hematologic toxicity after treating at level 2, 
discontinue chemotherapy: patient is off-study. 
< 500/mm3 
OR 
< 50,000/mm3mcL 
Hold RT, carboplatin, paclitaxel, and nivolumab. 
Recheck CBC weekly. When ANC > 500 and Plt 
>50,000 resume XRT, full-dose nivolumab.  
When ANC >1,000 and Plt >75,000 resume 
paclitaxel and carboplatin and reduce at dose 
level -2.  For persistent grade III hematologic 
toxicity after treating at level 2, discontinue 
chemotherapy: patient is off-study. 
 


ESCC Nivolumab  
 
Page 67 
 
 
• No change in dosing of systemic therapy for grade 1 AST/ALT elevation 
• No change in dosing or delay in therapy of nivolumab  
 
7.4 Grade 2 Hepatic Toxicity  
 
▪ For grade 2 total bilirubin elevation OR grade 2 AST/ALT elevation, do not delay 
systemic therapy but decrease paclitaxel dose to level -1  
▪ If grade 2 total bilirubin elevation OR grade 2 AST/ALT elevation persists despite 
1 dose reduction in paclitaxel, decrease paclitaxel to dose level -2.  
▪ No change in carboplatin or nivolumab dose.  
 
▪ For grade 2 total bilirubin elevation AND grade 2 AST/ALT elevation, decrease 
paclitaxel to dose level -2  
▪ No change in carboplatin or nivolumab dose or treatment schedule   
 
7.5 Grade 3/4 Hepatic Toxicity  
▪ For grade 3 hepatic toxicity discontinue paclitaxel, carboplatin and nivolumab.  
Begin steroids as per section 7.13.  
▪ When bilirubin and AST/ALT return to grade 2 resume paclitaxel at Dose -1.  
Resume carboplatin and previous dose and resume nivolumab if reduction from 
grade 3 to grade 2 occurs within two weeks.  
▪ See section 7.13 for changes in nivolumab administration.  
 
7.6 Allergic Reactions  
Paclitaxel premedication:  
▪ Diphenhydramine (or equivalent) and ranitidine (or equivalent) are given according to 
institutional procedures. Patients should receive dexamethasone 10 mg intravenously 
immediately prior to receiving paclitaxel. The dexamethasone premedication dose can 
be tapered to 0 (zero) if no hypersensitivity reactions occur by the 4th dose of 
paclitaxel. If patients develop a hypersensitivity reaction despite this pre-medication 
schedule, other schedules (e.g. dexamethasone 20 mg immediately prior to 
chemotherapy or the night before and morning of chemotherapy) can be considered 
after discussion with the Principal Investigator.  
 
▪ For grade 1 or grade 2 allergic reactions during any drug administration: stop 
infusion. Administer H1 and/or H2 blockers, and/or steroids according to institutional 
policy. Restart the infusion when symptoms resolve and pretreat before all subsequent 
doses. Treat according to institutional policy.  
 
▪ For grade 3 or 4 allergic reactions or anaphylaxis during any drug 
administration, stop infusion and discontinue treatment completely. Patients should 
be taken off protocol. 
 
 
7.7 Grade 1 Neurologic Toxicities  
• For grade 1 peripheral sensory neuropathy that is not limiting activity of daily living, no 
change in dosing for systemic therapies or radiation therapy.  


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• No change in nivolumab dosing or treatment schedule  
 
 
7.8 Grade 2 Neurologic Toxicities  
▪ Delay all systemic therapy until toxicity resolves to ≤ grade 1 
▪ Resume paclitaxel at dose level -1 and resume carboplatin at the previous dose 
level 
▪ If recurrent grade 2 toxicity develops, decrease paclitaxel dose to level -2 and 
decrease carboplatin dose to level -1 
▪ Continue radiation therapy 
▪ See section 7.13 for changes in nivolumab administration 
 
 
 
 
7.9 Grade 3/4 Neurologic Toxicities  
▪ Discontinue all systemic therapy and take patient off study. 
 
 
7.10 
Gastrointestinal Toxicities  
7.10.1 Grade 1 and 2 Vomiting 
▪ Treat patient symptomatically with antiemetic therapy without holding or 
changing doses of systemic therapy or radiation.  
7.10.2 Grade 3/4 Vomiting  
▪ Hold radiation and systemic therapy until vomiting improves to ≤grade 2 
▪ Decrease carboplatin and paclitaxel doses to level -1 
▪ If recurrent toxicity develops, decrease carboplatin and paclitaxel doses to 
level -2 
▪ No change in nivolumab dose.  
 
7.10.3 Grade 1/2 Diarrhea  
▪ No changes in carboplatin and paclitaxel dosing.  Rule out C. difficile.  If C. 
difficile ele is ruled out, treat symptomatically with anti-diarrheals (see section 
7.13 for changes in nivolumab administration). 
  
7.10.4 Grade 3/4 Diarrhea  
▪ Hold carboplatin, paclitaxel, and radiation therapy until diarrhea improves to 
grade ≤2.  
▪ Resume treatment with carboplatin at full-dose and reduce paclitaxel dose to 
level -1.  
▪ If recurrent toxicity develops, decrease paclitaxel dose to level -2.  
▪ See section 7.13 for changes in nivolumab administration. 
 
7.10.5 Grade 1 Esophagitis  
▪ No change in chemotherapy dose or schedule 
▪ No change in radiation dose or schedule  


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▪ No change in nivolumab dosing or treatment schedule 
 
7.10.6 Grade 2 Esophagitis  
▪ No change in chemotherapy, radiation therapy, or nivolumab dosing or 
treatment schedules  
It is suggested that patients be advised to begin:  
▪ Soft diet, high-calorie with oral nutritional supplements 
▪ Oral analgesics such as hydrocodone with acetaminophen, liquid 
morphine, prolonged action opiates as necessary  
▪ Outpatient IV fluids at the discretion of the investigator 
▪ Continue chemoradiation at stated dosages and schedule 
 
 
 
7.10.7 Grade 3/4 Esophagitis  
▪ Discontinue all therapy until improvement to ≤ grade 2 
▪ Hospitalization or daily outpatient IV hydration and IV pain control is 
recommended 
▪ Total parenteral nutrition or feeding tube at the discretion of the investigator. 
Decrease carboplatin and paclitaxel dose to level -1 
▪ If recurrent toxicity develops, decrease carboplatin and paclitaxel dose to level 
-2  
▪ No change in nivolumab dose or treatment schedule  
 
7.11 Grade 1 Pneumonitis 
• No change in systemic therapy; no change in radiation therapy.  
 
7.12 Grade 2-4 Pneumonitis  
• Hold chemotherapy and radiation until symptoms improve to ≤ grade 2 
• Resume chemotherapy paclitaxel and carboplatin and radiation without dose 
reduction. 
• See section 7.13 for changes in nivolumab administration. 
 
7.13 Dose Modifications for Other Non-hematologic Toxicities During Combined 
Therapy  
 
For other grade 3 or 4 non-hematologic toxicities (excluding suboptimally controlled nausea 
or vomiting, and fatigue) related to treatment, hold carboplatin and paclitaxel until toxicity 
improves to ≤ grade 2. Then resume with one dose level reduction in carboplatin/paclitaxel. 
If treatment is held for >2 weeks, this is considered unacceptable toxicity and treatment 
should be discontinued.  The patient will be followed off-protocol.  
 
 
7.14 Nivolumab Immune-Mediated Toxicity 
 
7.14.1 Immune-Mediated Pneumonitis 


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• Patients will be monitored weekly for symptoms and signs of immune-mediated 
pneumonitis 
• For patients with new-onset symptoms of shortness of breath, cough or hemoptysis,  
a non-contrast chest CT is required at the time of symptoms or signs.  
• For treatment days 1-28 (nivolumab induction) 
 
▪ Grade 1 
• No delay or change in schedule or dose 
 
▪ Grade 2   
• Hold nivolumab 
• Administer corticosteroids at a dose of 1-2 mg/kg/day prednisone 
equivalents. Upon improvement to grade 1, begin a corticosteroid taper 
over 1 month   
• Upon resolution of pneumonitis, continue nivolumab at the same dose 
and schedule if resolution occurs within two weeks of holding nivolumab 
 
▪ Grade 3 or 4 
• Permanently discontinue nivolumab for grade 3 or grade 4 pneumonitis 
• Administer corticosteroids at a dose of 1-2 mg/kg/day prednisone 
equivalents. Upon improvement to grade 1, begin corticosteroid taper 
over one month 
 
• For days 29-64 (combination chemoradiotherapy and immunotherapy):  
▪ For patients with new-onset symptoms of shortness of breath, cough or 
hemoptysis, a non-contrast chest CT is required at the time of symptoms or 
signs.  
 
▪ Grade 2-4 
• For grade 2 pneumonitis, Hold nivolumab.  
• Administer corticosteroids at a dose of 1-2 mg/kg/day prednisone 
equivalents. Upon improvement to grade 1restart nivolumab and begin 
a corticosteroid taper over 1 month 
 
• For grade 3 or 4 pneumonitis, permanently discontinue nivolumab 
• Administer corticosteroids at a dose of 1-2 mg/kg/day prednisone 
equivalents.  Upon improvement to grade 1, begin corticosteroid taper 
over one month.   
 
7.14.2 Immune-Mediated Colitis 
▪ Patients will be monitored weekly for symptoms and signs of immune-mediated 
colitis 
 
o Grade 1  
 
▪ No change in dose or schedule 
 


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o Grade 2  
▪ Delay nivolumab until colonoscopy is performed to confirm 
immune-colitis.  If immune-colitis is diagnosed, administer 
corticosteroids at a dose of 0.5-1 mg/kg/day prednisone 
equivalents followed by a corticosteroid taper over 1 month. 
▪ For grade 2 colitis of more than 5 days duration, if worsening or 
no improvement occurs despite initiation of corticosteroids, 
increase corticosteroid dose to 1-2 mg/kg/day prednisone 
equivalents. Other immunosuppressants, e.g. infliximab, should 
also be considered 
▪ Upon improvement of diarrhea to grade 1 or less, initiate 
corticosteroid taper over 1 month and resume nivolumab without 
a change in dose or schedule.   
 
o Grade 3 and 4 
 
▪ Permanently discontinue nivolumab for ≥grade 3 colitis or for 
recurrent colitis upon restarting nivolumab.  For grade 3 colitis 
that recovers to grade 1 or less by day 28, can remain on 
treatment 
 
 
7.14.3 Immune-Mediated Hepatitis  
▪ Evaluation of serum liver function studies will be performed weekly while the patient 
is on therapy.  
 
o Grade 1 
▪ Continue nivolumab 
▪ Repeat liver function tests, including AST, ALT, and bilirubin prior to 
the next cycle of treatment  
 
o Grade 2 
▪ Delay nivolumab 
▪ Administer corticosteroids at a dose of 1 mg/kg/day prednisone 
equivalents  
▪ Upon resolution of bilirubin, AST, and ALT to grade ≤ 1, taper 
corticosteroids over 1 month 
▪ Resume therapy with nivolumab only upon resolution of bilirubin, AST, 
and ALT to grade ≤ 1. 
 
o Grade 3-4 
 
▪ Permanently discontinue nivolumab  
▪ Begin therapy with prednisone 1-2 mg/kg 
▪ Also begin therapy with mycophenolate mofetil 500-1000mg q12h 


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▪ If refractory and/or rapid clinical deterioration, the patient should be 
hospitalized with consideration of adding antithymocyte globulin 1.5 
mg/kg for 2 consecutive days  
 
7.14.4 Immune-Mediated Nephritis and Renal Dysfunction 
▪ PD-1 inhibitors may cause acute interstitial nephritis (AIN). Although evaluation of 
serum renal function studies will be performed weekly while patients are receiving 
therapy, those developing grade 2 creatinine elevation will have a delay in 
nivolumab therapy if their urine shows evidence of AIN or immune-mediated 
nephritis with elevated white cells, white cell casts, and, in some cases, 
eosinophilia without bacteria.   
 
• Grade 2-4 elevation of serum creatinine 
▪ Delay nivolumab for grade 2 or grade 3 serum creatinine elevation, and 
administer corticosteroids at a dose of 0.5-1 mg/kg/day prednisone 
equivalents if U/A shows evidence of AIN or immune-mediated nephritis 
with elevated white cells, white cell casts, and, in some cases, 
eosinophilia without bacteria.   
 
▪ If no improvement or worsening of the creatinine level occurs,  increase 
dose of corticosteroids to 1-2 mg/kg/day prednisone equivalents and 
permanently discontinue nivolumab 
▪ Upon improvement to grade 1 or less, initiate corticosteroid taper and 
continue to taper  over  at  least  1  month 
▪ Drug-related elevation in creatinine must have resolved to baseline 
before treatment with nivolumab is resumed. 
 
 
7.14.5 Immune-Mediated Neuropathy  
▪ 
Evaluation of peripheral neuropathy will be performed weekly during protocol 
therapy by history and physical examinations.   
o 
Delay nivolumab for grade 2 neuropathy or any symptom that may be 
related to Guillain-Barre Syndrome. 
o 
For grade ≥ 2 neuropathy, administer corticosteroids at a dose  of  1  to  
2  mg/kg/day  prednisone  equivalents  
▪ For Guillan Barre Syndrome symptoms, the first line of therapy 
should be immune globulin administration.  
o 
Upon improvement to grade 1 or less, initiate corticosteroid taper and 
continue to taper over at least 1 month.  
o 
Upon improvement in neurotoxicity to grade ≤1, resume nivolumab. The 
decision to reinitiate nivolumab at the next scheduled treatment date 
will be based upon treating physician’s clinical judgment. 
 
7.14.6 Immune-Mediated Endocrinopathies  
▪ 
Hypothyroidism and Hyperthyroidism 


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▪ Thyroid function will be monitored at baseline and every two weeks while 
the patient is on therapy; these studies will be measured every four 
weeks while the patient is being followed off active therapy 
 
• Grade 1 
▪ If TSH < 0.5 x lower limit of normal or TSH > 2 x ULN or 
consistently out of range in 2 subsequent measurements, 
check free thyroxine (fT4) at subsequent cycles 
▪ Continue nivolumab 
 
• Grade 2 
 
▪ Hypothyroidism 
▪ If TSH > 2 x upper limit of normal and the patient is 
symptomatic, initiate thyroid replacement therapy 
▪ Continue nivolumab 
 
▪ Hyperthyroidism 
▪ If TSH < 0.5 x lower limit of normal and the patient 
is asymptomatic, initiate thyroid suppression 
therapy 
▪ Continue nivolumab 
 
• Grade 3 
▪ If TSH < 0.5 x lower limit of normal or TSH > 2 x ULN and 
the patient is severely symptomatic (limiting activities of 
daily living): 
▪ Delay nivolumab 
▪ Initiate prednisone at 1 mg/kg/day  
▪ Initiate 
thyroid 
replacement 
therapy 
(hypothyroidism) or thyroid suppression therapy 
(hyperthyroidism) 
▪ Administer corticosteroids at a dose of 1 mg/kg/day 
prednisone equivalents  
▪ Upon improvement to grade 1 or less, initiate 
corticosteroid taper and continue to taper over at 
least 1 month.  
▪ Upon improvement in thyroid function to grade ≤1, 
resume nivolumab 
 
o Hypophysitis 
▪ For symptoms including significant headache, visual impairment, 
nausea, vomiting, anorexia, fatigue, weakness, fever, lethargy, 
hypotension, 
hypoglycemia, 
hyponatremia, 
eosinophilia: 
check 
adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone 
(TSH), free thyroxine (fT4), follicle-stimulating hormone (FSH), 


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luteinizing hormone (LH), insulin-like growth factor 1 (IGF-1), prolactin, 
plasma cortisol, ADH (antidiuretic hormone), testosterone/estradiol. 
Also perform pituitary MRI. 
 
• ≤ Grade 1: Asymptomatic TSH elevation 
▪ Hold nivolumab pending evaluation, Endocrinology 
consultation 
▪ Resume nivolumab after completion of the consultation  
 
• Grade 2-3 
▪ For abnormal lab and/or pituitary MRI results and 
significant symptoms limiting activities of daily living  
▪ Delay nivolumab 
▪ Endocrinology consultation 
▪ Administer corticosteroids at a dose of 1 mg/kg/day 
prednisone equivalents  
• Also initiate appropriate hormone therapy  
▪ Upon resolution of symptoms, initiate corticosteroid 
taper and continue to taper over at least 1 month 
▪ Resume nivolumab 
▪ Patients with adrenal insufficiency may need to 
continue 
steroids 
with 
a 
mineralocorticoid 
component 
If no abnormal lab or pituitary MRI results but symptoms 
persist, repeat labs in 1 week or MRI in 1 month 
 
• Grade 4 
▪ For life-threatening symptoms and abnormal lab and/or 
pituitary MRI results 
▪ Permanently discontinue nivolumab  
▪ Endocrinology consultation 
▪ Administer corticosteroids at a dose of 1 mg/kg/day 
prednisone equivalents  
▪ Also initiate appropriate hormone therapy  
 
 
o Adrenal insufficiency  
 
• ≤ Grade 1 
• Hold nivolumab pending evaluation, Endocrinology consultation 
• Resume nivolumab at the same dose level once the consultation 
has been completed 
 
▪ Grade 2 
 
• Delay nivolumab 


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• Initiate appropriate hormone replacement therapy (may require 
steroids with mineralocorticoid component)  
• Upon resolution of symptoms and lab abnormalities to grade 1 or 
less, resume nivolumab 
 
▪ Grade 3-4 
• For suspicion of adrenal crisis, including severe dehydration, 
hypotension, shock out of proportion to current illness 
▪ Discontinue nivolumab  
▪ Rule out sepsis 
▪ Administer stress-dose IV steroids with mineralocorticoid 
activity 
▪ IV fluids 
▪ Endocrinology consultation 
 
 
Endocrine Hypophysitis     
Adrenal Insufficiency 
Management/Next Dose for Nivolumab + 
Ipilimumab  
≤ Grade 1 
Asymptomatic TSH elevation. *Hold pending 
evaluation, endocrine consult  
Grade 2 
Hold until patients are on a stable replacement 
hormone regimen. If treated with steroids patients 
must remain stable after completion of any doses 
greater 
than 
replacement 
dose. 
Resume 
nivolumab at same dose level.  
Grade 3 
Off study treatment  
Grade 4 
Off study treatment 
Note all patients with symptomatic pituitary enlargement, exclusive of hormone 
deficiency, but including severe headache or enlarged pituitary on MRI should be 
considered grade 3 events. Isolated thyroid or testosterone deficiency may be 
treated as grade 2 if there are no other associated deficiencies and adrenal 
function is monitored.  
Please evaluate pituitary function before beginning steroid therapy or replacement 
therapy of any kind.  
*Note patients with thyroiditis may be retreated on replacement therapy. Patients 
must be evaluated to rule out pituitary disease prior to initiating thyroid 
replacement.  
Recommended management: See Endocrine Management Algorithm below 
 
 


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7.15 
General Criteria to Resume Treatment (Dose Resumption) with 
Nivolumab 
Subjects may resume treatment with nivolumab when the drug-related AE(s) resolve to 
Grade ≤1 or baseline value, with the following exceptions: 
• Subjects may resume treatment in the presence of grade 2 fatigue  
• Subjects who have experienced a Grade 3 drug-related skin AE may resume 
treatment in the presence of grade 2 skin toxicity  
• Subjects with baseline grade 1 AST/ALT or total bilirubin who require dose delays for 
reasons other than a 2-grade shift in AST/ALT or total bilirubin may resume treatment 
in the presence of grade 2 AST/ALT OR total bilirubin 
• Nivolumab-related grade 2 pulmonary toxicity or grade 2 diarrhea or colitis must 
have resolved to baseline before treatment is resumed 
If treatment is interrupted for >4 consecutive weeks, patient’s protocol treatment will be 
discontinued with the exception of the following outlined below (pg.102): 


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• 
 
 Any dosing interruption lasting > 6 weeks with the following exceptions: 
• 
Dosing delays or interruptions to allow for prolonged steroid tapers to manage drug-
related adverse events are allowed. Prior to re-initiating treatment in a subject with 
a dosing interruption lasting > 6 weeks, the Investigator must be consulted. Tumor 
assessments should continue as per protocol even if dosing is interrupted or delayed 
• 
Dosing interruptions or delays lasting > 6 weeks that occur for non-drug-related 
reasons may be allowed if approved by the Investigator. Prior to re-initiating 
treatment in a subject with a dosing interruption lasting > 6 weeks, the Investigator 
must be consulted. Tumor assessments should continue as per protocol even if 
dosing is interrupted 
 
 
8.0 Criteria for Response and Progression 
 
8.1 Clinical Response 
All eligible patients who have received therapy on this study will be considered evaluable. 
Patients who discontinue study therapy because of progressive disease or serious drug-
related adverse events are also considered evaluable for efficacy. Patients removed from the 
study prior to treatment will not be evaluable. 
 
The assessment of clinical response is based on clinical staging of the patient five to eight 
weeks following the completion of radiation by PET/CT scan, upper GI endoscopy, and 
histopathologic evaluation of tumor at the time of endoscopic evaluation. 
To be coded as a complete clinical response the following must occur: 
1. A resolution of PET SUV evaluation to the lower value between SUV ≤75% of pre-
treatment value or SUV ≤2.  
2. No visible tumor by CT scan (Esophageal wall thickening does not indicate residual 
cancer).  
3. No visible tumor at the time of endoscopy 
4. No viable tumor at biopsy of the esophageal mucosa where tumor had previously been 
appreciated.  
 
NB: Those patients achieving a complete clinical response will be allowed to 
forego surgery in a decision that will be made by the patient and his/her oncology 
team. Those patients achieving a complete clinical response who do not undergo 
surgery will be treated with adjuvant nivolumab as outlined in the protocol.  
 
 
NB: Those patients who do not achieve a complete clinical response will be 
referred for esophagectomy and lymph node dissection.  The procedure of choice will 
be left to the surgical team.  Upon recovery from esophagectomy and nodal dissection 
patient will be placed on adjuvant nivolumab as outlined in the protocol.  
 
8.2 Pathologic Response  


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Pathologic response will be based on anatomic pathologic evaluation of the biopsy or 
surgical specimen and be reported as complete pathologic response if all evidence of tumor 
is gone from the primary esophageal cancer and lymph nodes.  Pathologic response will be 
categorized as either complete (T0N0M0) or near complete Tis/T1N0M0 or not complete T2-
T4NanyMany 
 
8.3 Progression of Disease  
Distant metastatic disease on CT or PET/CT imaging or evidence of locally recurrent disease 
or progressive disease documented by endoscopy, CT or PET/CT imaging. Progression of 
disease on PET/CT scan alone (new sites of metastatic disease) prior to surgery should be 
corroborated by biopsy whenever possible.  
 
Patients who undergo an operation for following neoadjuvant combined modality therapy and 
are found to have an R1 or R2 resection will be declared as having progressive disease at 
that time.   
 
9.0 Statistical Plan 
This is a single-arm phase I/II study of nivolumab combined with carboplatin/paclitaxel and 
radiation for patients with locally advanced squamous cell carcinoma the esophagus. 
In the phase III CROSS study, pre-operative carboplatin/paclitaxel and radiation was 
associated with a grade 3/4 toxicity rate of 20% (7% hematologic and 13% non-hematologic 
grade 3-4 toxicities). The discontinuation rate for nivolumab as a single agent due to any 
toxicity has been reported to be approximate 9% {BMS, #81}.  The hypothesis is that the 
addition of nivolumab to carboplatin/paclitaxel and radiation will not increase the aggregate 
grade 3/4 toxicity rate beyond 30%. 
 
     In the phase I portion of the study, up to six patients will be treated (radiation will be 50.4 
Gy (1.8 Gy/fraction × 28 fractions)) and then observed for 28 days (following last day of 
treatment (Day 64)). If there are 1 or less unacceptable toxicities (1/6 is less than 30%), the 
current regimen will be used in the phase II portion of the study. If there are 2 or more 
unacceptable toxicities (2/6 is more than 30%), the radiation will be reduced to 41.4 Gy (1.8 
Gy/fraction × 23 fractions). Up to six additional patients will be treated at the reduced radiation 
regimen and then observed for 28 days (following last day of treatment (Day 64)). If there are 
1 or less unacceptable toxicities, radiation of 41.4 Gy will be used in the phase II portion of 
the study. If there are 2 or more unacceptable toxicities, the trial will be discontinued. 
   
Unacceptable Toxicity (UT) is defined here as: 
 
• Recurrent grade 3 or 4 hematologic toxicity (despite 1 prior dose reduction in 
chemotherapy) 
• Any toxicity that results in a >2-week delay in chemoradiation 
  
If the regimen is found to be tolerable, the phase II portion of the study will be executed. An 
optimal two-stage design will be implemented. With an overall sample size of 44 patients, 


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there is 80% power (actual power is 80%) to test the null hypothesis of clinical complete 
response (cCR) rate + pathologic complete response (pCR) rate ≤ 35%, versus the 
alternative hypothesis of cCR+pCR ≥ 55%, with significance level of 5% (actual significance 
level is 4.5%). In the first stage, 18 patients will be treated with the combination therapy.  If 
there are 7 or fewer cCR+pCRs the trial will be terminated. If there are 8 or more cPR+pCRs, 
the trial will continue with the subsequent enrollment of 26 additional patients in phase 2. If 
the total cPR+pCRs out of 44 patients is 20 or less, the combination therapy will be rejected 
[39] 
 
  
cCR will be evaluated by endoscopic evaluation and CT/PET scan evaluation at the 
completion of radiation with concurrent nivolumab + carboplatin and radiation and pCR will 
be evaluated post-surgery. The trial will continue accruing patients in the second stage, while 
the 18 patients in the first stage are being evaluated for cCR or pCR. In an event that the 
interim analysis deems the combination therapy futile, accrual to the second stage will cease.   
 
The median overall survival (OS) will be described using Kaplan Meier curves. OS is defined 
as the time from treatment to death from any cause. The median progression-free survival 
(PFS) will be described using Kaplan Meier curves. PFS is defined as time from treatment to 
disease progression or death from any cause.  
 
Regression models will be used to assess whether the PET/CT clinical response to 
nivolumab can predict the outcomes pCR, PFS, and OS.  
 
 
10.0 
Safety and Adverse Events 
10.1 
Definitions 
 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency (i.e. not described in study-related 
documents such as the IRB-approved protocol or consent form, the investigators 
brochure, etc.) 
• Related or possibly related to participation in the research (i.e. possibly related means 
there is a reasonable possibility that the incident experience, or outcome may have 
been caused by the procedures involved in the research) 
• Suggests that the research places subjects or others at greater risk of harm (including 
physical, psychological, economic, or social harm). 
 
ADVERSE EVENTS 
An Adverse Event (AE) is defined as any new untoward medical occurrence or worsening of a 
preexisting medical condition in a clinical investigation subject administered an investigational 
(medicinal) product and that does not necessarily have a causal relationship with this treatment. An 
AE can therefore be any unfavorable and unintended sign (such as an abnormal laboratory finding), 


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symptom, or disease temporally associated with the use of investigational product, whether or not 
considered related to the investigational product. 
The causal relationship to study drug is determined by a physician and should be used to assess all 
adverse events (AE). The casual relationship can be one of the following: 
Related: There is a reasonable causal relationship between study drug administration and the AE. 
Not related: There is not a reasonable causal relationship between study drug administration and the 
AE.  
The term "reasonable causal relationship" means there is evidence to suggest a causal relationship.  
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 AEs.) 
 
SERIOUS ADVERSE EVENTS 
A Serious Adverse Event (SAE) is any untoward medical occurrence that at any dose:  
• 
Results in death 
• 
Is life-threatening (defined as an event in which the 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 causes prolongation of existing hospitalization (see 
NOTE below) 
• 
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 subject or may require intervention [e.g., medical, 
surgical] to prevent one of the other serious outcomes listed in the definition above.) Examples 
of such events include, but are not limited to, intensive treatment in an emergency room or at 
home for allergic bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization.)  
• 
Potential drug induced liver injury (DILI) is also considered an important medical event.  
• 
Suspected transmission of an infectious agent (e.g., pathogenic or nonpathogenic) via the 
study drug is an SAE.  
• 
Although pregnancy, overdose, and cancer are not always serious by regulatory definition, 
these events must be handled as SAEs. 
 
Pregnancy 
If, following initiation of the investigational product, it is subsequently discovered that a study 
subject is pregnant or may have been pregnant at the time of investigational product 
exposure, including during at least 6 half-lives after product administration, the investigational 
product will be permanently discontinued in an appropriate manner (e.g., dose tapering if 
necessary for subject safety).  


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The investigator must immediately notify Worldwide Safety @BMS of this event via the 
Pregnancy Surveillance Form in accordance with SAE reporting procedures. Also, it must be 
reported immediately to the regulatory specialist, research coordinator, PCC Assigned 
Medical Monitor, and NYUPCCsafetyreport@nyumc.org in accordance with the procedures 
described below.  Pregnancy in itself is not regarded as an adverse event unless there is a 
suspicion that the investigational product may have interfered with the effectiveness of a 
contraceptive medication.  This will be reported to the IRB if necessary. 
Follow-up information regarding the course of the pregnancy, including perinatal and 
neonatal outcome and, where applicable, offspring information must be reported on the 
Pregnancy Surveillance Form [provided upon request from BMS] 
Any pregnancy that occurs in a female partner of a male study participant should be reported 
to BMS. Information on this pregnancy will be collected on the Pregnancy Surveillance Form. 
 
Overdose 
An overdose is defined as the accidental or intentional administration of any dose of a product 
that is considered both excessive and medically important. All occurrences of overdose must 
be reported as an SAE. 
 
10.2 
Other Safety Considerations 
Any significant worsening noted during interim or final physical examinations, 
electrocardiograms, x-rays, and any other potential safety assessments, whether or not these 
procedures are required by the protocol, should also be recorded as a non-serious or serious 
AE, as appropriate, and reported accordingly. 
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-
serious adverse events.  
 
A non-serious adverse event is an AE not classified as serious.  
Non-serious Adverse Event Collection and Reporting 
The collection of non-serious AE information should begin at initiation of study drug. All non-
serious adverse events (not only those deemed to be treatment-related) should be collected 
continuously during the treatment period and for a minimum of 100 days following the last 
dose of study treatment.  
Non-serious AEs should be followed to resolution or stabilization, or reported as SAEs if they 
become serious. Follow-up is also required for non-serious AEs that cause interruption or 
discontinuation of study drug and for those present at the end of study treatment as 
appropriate.  
 
Adverse Event Reporting Period 


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The study period during which adverse events must be reported is normally defined as the 
period from the initiation of any study procedures to the end of the study treatment follow-up.  
For this study, the study treatment follow-up is defined as 30 days following the last 
administration of study treatment.  
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition 
should be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition.  At the end of the study, any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as an 
adverse event.  
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained.  At the 
last scheduled visit, the investigator should instruct each subject to report any subsequent 
event(s) that the subject, or the subject’s personal physician, believes might reasonably be 
related to participation in this study.  The investigator should notify the study sponsor of any 
death or adverse event occurring at any time after a subject has discontinued or terminated 
study participation that may reasonably be related to this study.  The sponsor should also be 
notified if the investigator should become aware of the development of cancer or of a 
congenital anomaly in a subsequently conceived offspring of a subject that has participated 
in this study.  
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of 
the following conditions is met:  
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change of dose, 
discontinuation of the drug, more frequent follow-up assessments, further diagnostic 
investigation, etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed otherwise 
in this protocol.  Any condition responsible for surgery should be documented as an adverse 
event if the condition meets the criteria for and adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as 
an adverse event in the following circumstances: 


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• Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition.  Surgery should not be reported as an outcome 
of an adverse event if the purpose of the surgery was elective or diagnostic and the 
outcome was uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy measurement for 
the study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the 
study, unless it is a worsening or increase in frequency of hospital admissions as 
judged by the clinical investigator. 
 
10.3 
Recording of Adverse Events 
At each contact with the subject, the investigator must seek information on adverse events 
by specific questioning and, as appropriate, by examination.  Information on all adverse 
events should be recorded immediately in the source document, and also in the appropriate 
adverse event module of the case report form (CRF).  All clearly related signs, symptoms, 
and abnormal diagnostic procedures results should recorded in the source document, though 
should be grouped under one diagnosis. 
 
All adverse events occurring during the study period must be recorded.  The clinical course 
of each event should be followed until resolution, stabilization, or until it has been determined 
that the study treatment or participation is not the cause.  Serious adverse events that are 
still ongoing at the end of the study period must be followed up to determine the final 
outcome.  Any serious adverse event that occurs after the study period and is considered to 
be possibly related to the study treatment or study participation should be recorded and 
reported immediately. 
 
10.4 
Reporting of Serious Adverse Events and Unanticipated Problems 
Investigators and the protocol sponsor must conform to the adverse event reporting 
timelines, formats and requirements of the various entities to which they are responsible, 
but at a minimum those events that must be reported within 5 days of PI notification are 
those that are: 
• related to study participation, 
• unexpected, and  
• Harmful or have the potential to cause harm (see definitions, section 10.1) 
   
Events should be reported using the NYU CTO Medical Events Form (see section 10.4.1 
below). 
 
Adverse events that do not fit the above immediately reportable criteria must still be 
reported to the IRB at each annual review, either in a summary or tabular format. 
 
 


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10.4.1 Investigator reporting:   notifying the study sponsor and Perlmutter 
Cancer Center Clinical Trials Office 
 
 
The following describes events that must be reported to the study sponsor in an expedited 
fashion. 
 
Initial Report: within 24 hours: 
The following events must be reported to the study sponsor within 24 hours of awareness 
of the event using the NYU CTO Medical Events Form:  
• Unanticipated problems related to study participation,  
• Serious adverse events, regardless of whether they are unexpected.  
 
Additionally, an FDA Form 3500A (MEDWATCH Form) must be completed by the 
investigator and faxed to the study sponsor within 24 hours.  The investigator shall maintain 
a copy of the MEDWATCH Form on file at the study site.  The study sponsor will then 
report all medical events to BMS directly. 
 
All report forms must be signed  and dated by the Principal Investigator.  If the Principal 
Investigator is not available at the time of the initial report, then the form can be submitted 
by a Sub-Investigator.  This form should be reviewed by the Principal Investigator, whom 
sign/date initial report upon return. 
   
Report to: 
NYUPCCsafetyreports@nyumc.org 
 
 
AND 
 
Jennifer Wu, MD 
462 First Ave 
New York, NY 10016 
Phone:  (212) 263-6530 
Email:  Jennifer.Wu@nyumc.org 
 
AND 
 
PCC Assigned Medical Monitor 
 
 
 
Follow-up report: within 48 hours: 
As a follow-up to the initial report, within the following 48 hours of awareness of the event, 
the investigator shall provide further information, as applicable, on the unanticipated device 


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event or the unanticipated problem in the form of a written narrative.  This should include 
any other diagnostic information that will assist in the understanding of the event.  
Significant new information on ongoing unanticipated adverse device effects shall be 
provided promptly to the study sponsor.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other external sites will be monitored and informed of other adverse events by the medical 
monitor within 7 days of toxicities and within 3 business days of SAE.  Adverse events and 
SAEs occurring at external sites should be reported as detailed above. Scheduled 
conference calls will be conducted after 3 patients are enrolled and at each dose escalation 
point.  Additional conference calls will be scheduled as indicated based on the 
recommendations from the medical monitor, the Overall PI of this study. 
 
 
Other Reportable events: 


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• Deviations from the study protocol 
Deviations from the protocol must receive both Sponsor and the investigator’s IRB 
approval before they are initiated. Any protocol deviations initiated without Sponsor 
and the investigator’s IRB approval that may affect the scientific soundness of the 
study, or affect the rights, safety, or welfare of study subjects, must be reported to the 
Sponsor and to the investigator’s IRB as soon as a possible, but no later than 5 
working days of the protocol deviation. 
 
• Withdrawal of IRB approval 
An investigator shall report to the sponsor a withdrawal of approval by the 
investigator’s reviewing IRB as soon as a possible, but no later than 5 working days 
of the IRB notification of withdrawal of approval. 
 
10.4.2 Investigator reporting: notifying the IRB 
Federal regulations require timely reporting by investigators to their local IRB of 
unanticipated problems posing risks to subjects or others.  The following describes the 
NYULMC IRB reporting requirements, though Investigators at participating sites are 
responsible for meeting the specific requirements of their IRB of record.  The NYU IRB 
address is: 
 
 
 
NYU School of Medicine IRB 
 
 
 
1 Park Avenue, 6th Floor 
 
 
 
New York, NY 10016 
 
Report promptly, but no later than 5 working days: 
Researchers are required to submit reports of the following problems promptly but no later 
than 5 working days from the time the investigator becomes aware of the event: 
• Unanticipated problems including adverse events that are unexpected and 
related 
– Unexpected: An event is “unexpected” when its specificity and severity are not 
accurately reflected in the protocol-related documents, such as the IRB-approved 
research protocol, any applicable investigator brochure, and the current IRB-
approved informed consent document and other relevant sources of information, 
such as product labeling and package inserts.  
– Related to the research procedures: An event is related to the research procedures 
if in the opinion of the principal investigator or sponsor, the event was more likely 
than not to be caused by the research procedures.  
– Harmful: either caused harm to subjects or others, or placed them at increased risk 
 
Other Reportable events: 
The following events also require prompt reporting to the IRB, though no later than 5 
working days: 
• Complaint of a research subject when the complaint indicates unexpected risks or 
the complaint cannot be resolved by the research team. 


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• Protocol deviations or violations (includes intentional and accidental/unintentional 
deviations from the IRB approved protocol) for any of the following situations:  
– one or more participants were placed at increased risk of harm  
– the event has the potential to occur again 
– the deviation was necessary to protect a subject from immediate harm 
• Breach of confidentiality 
• Incarceration of a participant when the research was not previously approved under 
Subpart C and the investigator believes it is in the best interest of the subject to remain 
on the study. 
• New Information indicating a change to the risks or potential benefits of the 
research, in terms of severity or frequency. (e.g. analysis indicates lower-than-
expected response rate or a more severe or frequent side effect; Other research finds 
arm of study has no therapeutic value; FDA labeling change or withdrawal from market) 
 
Reporting Process 
The reportable events noted above will be reported to the IRB using the form: “Reportable 
Event Form” or as a written report of the event (including a description of the event with 
information regarding its fulfillment of the above criteria, follow-up/resolution and need for 
revision to consent form and/or other study documentation). The contact information for 
submitting IND safety reports is noted below: 
 
 
 
 
 
Email:  NYUPCCsafety@nyumc.org 
 
 
 
 
Tel:  212-263-4427 
 
Copies of each report and documentation of IRB notification and receipt will be kept in the 
Clinical Investigator’s study file. 
10.4.3 Sponsor reporting: Notifying BMS 
Serious Adverse Event Collection and Reporting 
All Serious Adverse Events must be reported to BMS Worldwide Safety. 
BMS SAE forms should be used, or if performed under a US IND a MedWatch or CIOMS 
form can be used as required by regulatory authorities.  
Site specific forms will be requested for review. 
The sponsor/investigator will be required to reconcile SAEs reported in  the clinical database 
with 
SAE 
cases 
transmitted 
to 
BMS 
Global 
Pharmacovigilance 
(GPV&E); 
worldwide.safety@bms. BMS requests this is initiated by the sponsor investigator up to 
quarterly and prior to the database lock or final data summary. The process will be further 
defined. During reconciliation, any events found to not be reported previously to BMS must 
be sent to Worldwide.Safety@BMS.com 
 
Following the subject’s written consent to participate in the study, all SAEs, whether related 
or not related to study drug, must be collected, including those thought to be associated with 


ESCC Nivolumab  
 
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protocol-specified procedures. All SAEs must be collected that occur within 100 days of 
discontinuation of dosing.  
All SAEs must be collected that occur during the screening period. If applicable, SAEs must 
be collected that relate to any protocol-specified procedure (e.g., a follow-up skin biopsy).  
The investigator should report any SAE that occurs after these time periods that is believed 
to be related to study drug or protocol-specified procedure.  
SAEs, whether related or not related to study drug, and pregnancies must be reported to 
BMS within 24 hours. SAEs must be recorded on BMS or an approved form; pregnancies on 
a Pregnancy Surveillance Form. 
SAE Email Address:  Worldwide.Safety@BMS.com 
SAE Facsimile Number:  609-818-3804 
If only limited information is initially available, follow-up reports are required. (Note: Follow-
up SAE reports should include the same investigator term(s) initially reported.)  
If an ongoing SAE changes in its intensity or relationship to study drug or if new information 
becomes available, a follow-up SAE report should be sent within 24 hours to the BMS (or 
designee) using the same procedure used for transmitting the initial SAE report.  
 
All SAEs should be followed to resolution or stabilization. 
The Sponsor/Investigator will ensure that all SAEs in the clinical database are reported to 
BMS and any applicable health authority during the conduct of the study including periodic 
reconciliation. For studies conducted under an Investigator IND in the US, any event that is 
both serious and unexpected must be reported to the Food and Drug Administration (FDA) 
as soon as possible and no later than 7 days (for a death or life-threatening event) or 15 days 
(for all other SAEs) after the investigator’s or institution’s initial receipt of the information. 
BMS will be provided with a simultaneous copy of all adverse events filed with the FDA.  
SAEs should be reported on MedWatch Form 3500A, which can be accessed at: 
http://www.accessdata.fda.gov/scripts/medwatch/. 
MedWatch SAE forms should be sent to the FDA at: 
MEDWATCH 
5600 Fishers Lane 
Rockville, MD 20852-9787 
Fax: 1-800-FDA-0178 (1-800-332-0178) 
http://www.accessdata.fda.gov/scripts/medwatch/ 
 
10.4.4 Sponsor reporting: Notifying Participating Investigators 
 
It is the responsibility of the study sponsor to notify all participating investigators of any 
adverse event that meets the FDA 15-day reporting requirement criteria as noted above.  The 
same materials and timeline used to report to the FDA are used for notifying participating 
investigators. 
 


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10.5 
Stopping Rules  
Phase I:  Up to 12 patients 
6 patients treated and observed for 28 days after last day of treatment (Day 64) 
• ≤ 1 unacceptable toxicity (UT): use current regimen for Phase II 
• ≥ 2 UT: reduce total RT dose to 41.4 Gy and treat 6 additional patients, then 
observe for 28 days after Day 64   
• ≤ 1 UT: use reduced RT for Phase II 
• ≥ 2 UT: discontinue trial  
 
Phase II: 44 patients 
Stage I: 18 patients treated  
• ≤ 7 CRs (either pCR or cCR): discontinue trial as combination therapy 
deemed futile 
• ≥ 8 CRs (either pCR or cCR): continue on to Stage II. 
Stage II: 30 additional patients treated  
• ≤ 20 cCR + pCR out of all 44 patients: combination therapy rejected 
• ≥ 21 cCR + pCR out of all 44 patients: combination therapy is promising  
 
• Accrual to Stage II will continue while the 18 patients in Stage I are evaluated 
for cCR and pCR.  
 
• Accrual to Stage II will stop if Stage I analysis deems combination futile 
 
 
10.6 
Medical Monitoring 
It is the responsibility of the Principal Investigator at each site to oversee the safety of the 
study at his/her site.  This safety monitoring will include careful assessment and appropriate 
reporting of adverse events as noted above, as well as the construction and implementation 
of a site data and safety-monitoring plan.  The Data Safety and Monitoring Committee 
(DSMC) will review the study at least annually.  Medical monitoring will include a regular 
assessment of the number and type of serious adverse events. 
 
10.6.1 Data Monitoring Committee 
This investigator initiated and sponsored study will be monitored by the Data Safety 
Monitoring Committee (DSMC) of the New York University Perlmutter Cancer Center. The 
DSMC operates based on the 2014 National Cancer Institute approved Charter. It is an 
existing and multidisciplinary committee (consisting of clinical investigators/oncologists, 
biostatisticians, nurses and design and in proper conduct of clinical trials) that is responsible 
for monitoring safety, conduct and compliance in accordance with protocol data monitoring 
plans for interventional clinical trials conducted in the New York University Langone 
Perlmutter Cancer Center that are not monitored by another institution or agency. The DSMC 
reports to the director of the New York University Perlmutter Cancer Center (Benjamin Neel, 
MD/PhD).  


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Per the New York University Perlmutter Cancer Center Institutional Data Safety and 
Monitoring Plan, this Phase I/II trial will be monitored by the DSMC quarterly (from the date 
the first patient is enrolled), at times of RT dose reduction, completion of Phase I, interim 
analysis and completion of Phase II. This review includes accrual data, subject 
demographics, and adverse events. Principal Investigators are required to attend the review 
of their studies. Additional reviews can be scheduled based on SAE reports, investigator 
identified issues, external information, etc.  The DSMC will review safety data every 4 
months. 
 
Safety assessments will be performed at regular study intervals and include standard clinical 
and laboratory tests (hematology, serum chemistry, electrolytes,), physical examinations, 
pregnancy testing, concomitant medications, and reporting of AEs. The AE reporting period 
for a subject enrolled in the study will begin from the time the informed consent is signed 
through 90 days after the last dose.   
 
Toxicity grade will be defined by the National Cancer Institute (NCI) Common Terminology 
Criteria for Adverse Events (CTCAE) Version 4.03. Subjects will be monitored throughout the 
treatment and follow-up period for occurrence of AEs (acute, delayed, and/or cumulative), as 
well as for changes in clinical status, vital sign measurements, and laboratory data.  Safety 
parameters to be measured/assessed include eligibility assessment, medical history, 
performance status evaluation, vital sign measurements, physical examinations, hematology 
and serum chemistries. 
 
At the NYU Perlmutter Cancer Center, all investigator-initiated protocols are subject to a 
standardized data and safety monitoring, which includes scientific peer review, IRB review, 
Phase I/II committee review and DSMC review as well as internal auditing.  
The review of AEs and trial conduct for this trial occurs at several levels: 
 
1. Principal Investigator: Adverse events are evaluated monthly by the principal 
investigator in conjunction with the research nurses, data manager and research team.  
2. DSMC, quarterly 
3. IRB: An annual report to the IRB is submitted by the trial PI for continuation of the 
protocol. It includes a summary of all AEs, total enrollment with demographics, protocol 
violations, and current status of subjects as well as available research data. 
4. In addition, the quality assurance unit will provide extensive monitoring, including real-
time review of all eCRFs to ensure completeness and compliance with the protocol, with 
100% source documentation verification; the completeness, accuracy and consistency of 
the data; and adherence to ICH Good Clinical Practice guidelines.  Additionally, a first 
subject audit will be conducted within four weeks of enrollment.   
 
 
Any overdose of a study subject with, with or without associated AEs/SAEs, is required to be 
reported within 24 hours of knowledge of the event to the sponsor and BMS Patient Safety. 
 
 


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11.0 
Data Handling and Record Keeping 
 
11.1 
Data Collection 
The NYU Clinical Trials Office will act as the clinical research organization for this 
Investigator-Initiated Trial (Jennifer Wu, PI). We anticipate accrual to take place in four 
centers: Perlmutter Cancer Center, NYU (Jennifer Wu, PI); Memorial Sloan Kettering Cancer 
Center (Geoffrey Ku, PI); USC Norris Cancer Center (Syma Iqbal, PI) and Oregon Health 
Sciences University (Charles Thomas, PI).  
11.2 
Confidentiality 
All samples will be stored in a secure, locked room in the laboratory of Dr. Geoffrey Ku at 
MSKCC and Center for Biospecimen Research & Development at NYU:  
Geoffrey Y. Ku, MD  
Immune Monitoring Facility, Memorial Sloan Kettering Cancer Center 
Zuckerman Research Center, 15th floor 
417 East 68th Street 
New York, NY 10065 
Telephone: (646) 888-4588 
 
Center for Biospecimen Research & Development  
NYU Langone Medical Center: Medical Science Building 
550 First Avenue, Berg 3rd Fl., Rm. 381 
New York, NY 10016 
 
Samples will be identified by a unique identifier.  The patient’s name will not be used on the 
sample.  This unique identifier will be put into the sponsor database and will link in the 
sponsor database only to de-identified patient data (subject number).  Personal health 
information (PHI) will not be identifiable in the sponsor database or on the stored samples.  
Besides protecting confidentiality, this system will allow the sponsor to destroy the sample if 
the subject requests this.  Samples will be retained and used until they are exhausted. The 
log to PHI will be maintained at each individual study site.  Information will be stored in a 
secure, locked room and in a secure, password-protected database.  Only approved study 
personnel will have access to the samples.   
11.3 
Confidentiality and HIPAA 
Information about study subjects will be kept confidential and managed according to the 
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  
Those regulations require a signed subject authorization informing the subject of the 
following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information  
• The rights of a research subject to revoke their authorization for use of their PHI.  
 


ESCC Nivolumab  
 
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In the event that a subject revokes authorization to collect or use PHI, the investigator, by 
regulation, retains the ability to use all information collected prior to the revocation of subject 
authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (i.e. that the subject is 
alive) at the end of their scheduled study period. 
11.4 
Source Documents 
Source data is all information, original records of clinical findings, observations, or other 
activities in a clinical trial necessary for the reconstruction and evaluation of the trial.  Source 
data are contained in source documents.  Examples of these original documents, and data 
records include:   hospital records, clinical and office charts, laboratory notes, memoranda, 
subjects’ diaries or evaluation checklists, pharmacy dispensing records, recorded data from 
automated instruments, copies or transcriptions certified after verification as being accurate 
and complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, 
subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical 
departments involved in the clinical trial.  Source documentation should be consistent with 
data entered into Velos.  Relevant source documentation to be reviewed by the DSMC 
throughout the study includes: 
 
1.  Baseline measures to assess pre-protocol disease status 
2.  Concurrent medications 
3.  Treatment records 
4.  Adverse events 
 
11.5 
Data and Source Documentation 
Velos, an electronic database capture system will be created to record the data for this trial.  
Research coordinators will input clinical trial data into the database.  This database is 
password protected and only the PI, assigned research coordinator, and CTO quality 
assurance specialists will have access to the database.  Velos is the primary data collection 
instrument for the study.  All data requested in Velos must be reported.  All missing data must 
be explained.  The quality assurance specialists will monitor this trial every 4-6 weeks for 
data entry accuracy. 
11.6 
Records Retention 
It is the investigator’s responsibility to retain study essential documents for at least 2 years 
after the last approval of a marketing application in their country and until there are no 
pending or contemplated marketing applications in their country or at least 2 years have 
elapsed since the formal discontinuation of clinical development of the investigational 
product.  These documents should be retained for a longer period if required by an agreement 
with the sponsor.  In such an instance, it is the responsibility of the sponsor to inform the 
investigator/institution as to when these documents no longer need to be retained.  
 


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12.0 
Study Monitoring, Auditing, and Inspecting 
12.1 
Study Monitoring Plan 
This study will be monitored according to the monitoring plan. The investigator will allocate 
adequate time for such monitoring activities. The Investigator will also ensure that the monitor 
or other compliance or quality assurance reviewer is given access to all the above noted 
study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, 
etc.), and has adequate space to conduct the monitoring visit. 
12.2 
Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB/EC, 
the sponsor, government regulatory bodies, and University compliance and quality 
assurance groups of all study related documents (e.g. source documents, regulatory 
documents, data collection instruments, study data etc.).  The investigator will ensure the 
capability for inspections of applicable study-related facilities (e.g. pharmacy, diagnostic 
laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable University compliance and quality 
assurance offices.  The investigator will contact the PCC CTO immediately if contacted by a 
regulatory agency about an inspection at the center. 
 
13.0 
Ethical Considerations 
This study is to be conducted accordance with applicable US government regulations and 
international standards of Good Clinical Practice, and applicable institutional research 
policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted Institutional 
Review Board (IRB) in agreement with local legal prescriptions, for formal approval of the 
study conduct.  The decision of the IRB/EC concerning the conduct of the study will be made 
in writing to the investigator and a copy of this decision will be provided to the sponsor before 
commencement of this study.  The investigator should provide a list of IRB/EC members and 
their affiliate to the sponsor. 
 
All subjects for this study will be provided a consent form describing this study and providing 
sufficient information for subjects to make an informed decision about their participation in 
this study. This consent form will be submitted with the protocol for review and approval by 
the IRB/EC for the study.  The formal consent of a subject, using the IRB/EC-approved 
consent form, must be obtained before that subject undergoes any study procedure.  The 
consent form must be signed by the subject or legally acceptable surrogate, and the 
investigator-designated research professional obtaining the consent.  
 
 


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14.0 
Study Finances 
14.1 
Funding Source 
This study is being financed by Bristol-Myers Squibb.  
14.2 
Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or 
financial gain greater than the minimum allowable by their institution, etc.) must have the 
conflict reviewed by a properly constituted Conflict of Interest Committee with a Committee-
sanctioned conflict management plan that has been reviewed and approved by the study 
sponsor prior to participation in this study.  All NYULMC investigators will follow the applicable 
University conflict of interest policies. 
15.0 
Publication Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, 
nor any of the information provided by the sponsor for the purposes of performing the study, 
will be published or passed on to any third party without the consent of the study sponsor.  
Any investigator involved with this study is obligated to provide the sponsor with complete 
test results and all data derived from the study. 
 
The results of the trial may not be published in part or in full without written consent of the PI 
and Co-PI.   
 
 
16.0 
Potential Risks and Potential Benefits of Study Treatment 
 
16.1 
Risks of Study Drugs 
 
16.1.1 Potential Nivolumab Toxicities  
 
Patients Reporting AEs 
n=334 
Any 
Grade 3-4 
Treatment-related AE 
228  (68%) 
39  (11.7%) 
Fatigue 
86    (25.7%) 
2    (0.6%) 
Pruritis 
55    (16.5%) 
0     
Rash 
40    (12%) 
1    (0.3%)  
Diarrhea 
41    (12%) 
1    (0.3%) 
Nausea 
31    (9.3%) 
0 
Arthralgia 
20    (6.0%) 
0    (2.8%) 
Vitiligo 
18    (5.4%) 
0 
Rash, maculopapular 
18    (5.4%) 
0 
Hypothyroidism 
16    (4.8%) 
0 
Decreased appetite 
17    (5.1%) 
0 
AEs 
leading 
to 
discontinuation 
20    (6.0%) 
13  (3.9) 


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From “Efficacy and Safety of Nivolumab for BRAF V600 Mutant and BRAF Wild-Type 
Advanced Melanoma: A Pooled Analysis of 4 Clinical Trials.   JAMA Oncology July 2015 
Volume 1 No. 4  
 
Potential Nivolumab Toxicities:  
 
• Immune-Mediated Pneumonitis 
• Immune-Mediated Colitis 
• Immune-Mediated Hepatitis 
• Immune-Mediated Endocrinopathies 
• Immune-Mediated Nephritis and Renal Dysfunction 
• Immune-Mediated Rash 
• Immune-Mediated Encephalitis 
• Other Immune-Mediated Adverse Reactions 
• Infusion Reactions 
• Embryo-Fetal Toxicity 
 
Patients should call or see their healthcare provider right away if they develop any symptoms 
of the following problems or these symptoms get worse: 
 
Lung problems (pneumonitis). Symptoms of pneumonitis may include: 
 
● new or worsening cough  
● chest pain  
● shortness of breath 
 
Intestinal problems (colitis) that can lead to tears or holes in the intestine. Signs and 
symptoms of colitis may include: 
 
● diarrhea (loose stools) or more bowel movements than usual 
● blood in the stools or dark, tarry, sticky stools 
● severe stomach-area (abdomen) pain or tenderness 
 
Liver problems (hepatitis). Signs and symptoms of hepatitis may include: 
 
● yellowing of the skin or the whites of the eyes 
● severe nausea or vomiting 
● pain on the right side of the stomach area (abdomen) 
● drowsiness 
● dark urine (tea colored) 
● bleeding or bruising more easily than normal 
● feeling less hungry than usual 
 
Hormone gland problems (especially the thyroid, pituitary, adrenal glands, and 
pancreas). Signs and symptoms that hormone glands are not working properly may include: 
 


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● headaches that will not go away or unusual headaches 
● hair loss 
● feeling cold 
● constipation 
● voice gets deeper 
● excessive thirst or lots of urine 
● extreme tiredness 
● weight gain or weight loss 
● dizziness or fainting 
● changes in mood or behavior, such as decreased sex drive, irritability, or forgetfulness 
 
Kidney problems, including nephritis and kidney failure. Signs of kidney problems may 
include: 
● decrease in the amount of urine 
● swelling in the ankles 
● blood in the urine  
● loss of appetite 
 
Skin Problems. Signs of these problems may include: 
 
● rash  
● skin blistering 
● itching  
● ulcers in mouth or other mucous membranes 
 
Inflammation of the brain (encephalitis). Signs and symptoms of encephalitis may 
include: 
 
● headache 
● fever 
● tiredness or weakness 
● confusion 
● memory problems 
● sleepiness 
● seeing or hearing things that are not really there (hallucinations) 
● seizures 
● stiff neck 
 
Problems in other organs. Signs of these problems may include: 
 
● changes in eyesight  
● severe muscle weakness 
● severe or persistent muscle or joint pains 
 
Getting medical treatment right away may keep these problems from becoming more serious. 
The patient’s healthcare provider will check for these problems during treatment with 


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nivolumab . Treatment may include corticosteroid or hormone replacement medicines. 
Treatment with nivolumab  may also be delayed or stopped completely if the patient has 
severe side effects. 
 
What are the possible side effects of nivolumab ? 
 
Nivolumab  can cause serious side effects, including: 
 
● Severe infusion reactions. The patient should tell the doctor or nurse right away if he/she 
experiences these symptoms during an infusion of nivolumab : 
 
○ chills or shaking  
○ dizziness 
○ itching or rash  
○ fever 
○ flushing  
○ feeling like passing out 
○ difficulty breathing 
 
● Complications of stem cell transplant that uses donor stem cells (allogeneic) after 
treatment with . These complications can be severe and can lead to death, and will be 
monitored by the patient’s healthcare provider. 
 
The most common side effects of nivolumab  when used alone in people with 
melanoma include: 
 
● feeling tired  
● rash 
● pain in muscles, bones, and joints  
● itchy skin 
● diarrhea  
● nausea 
 
The most common side effects of nivolumab  when used in combination with 
ipilimumab include: 
 
● feeling tired  
● rash 
● diarrhea  
● nausea 
● fever  
● vomiting 
● shortness of breath 
 
The most common side effects of nivolumab  in people with non-small cell lung cancer 
include: 


ESCC Nivolumab  
 
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● feeling tired  
● cough 
● pain in muscles, bones, and joints  
● constipation 
● decreased appetite 
 
The most common side effects of nivolumab in people with renal cell carcinoma 
include: 
 
● feeling tired  
● nausea 
● shortness of breath  
● diarrhea 
● pain in muscles, bones, and joints  
● constipation 
● decreased appetite  
● rash 
● cough 
 
The most common side effects of  in people with classical Hodgkin lymphoma include: 
 
● feeling tired  
● diarrhea 
● upper respiratory tract infection  
● cough 
● fever 
 
Management Algorithms 
Guidelines for the management of immune related events can be found in the current Investigator 
Brochure and in the approved USPI in the US. Investigators should decide the appropriate source of 
AE management for each protocol. 
Immuno-oncology (I-O) agents are associated with AEs that can differ in severity and duration than 
AEs caused by other therapeutic classes. Nivolumab is considered an immuno-oncology agent in this 
protocol. Early recognition and management of AEs associated with immuno-oncology agents may 
mitigate severe toxicity. Management algorithms have been developed to assist investigators in 
assessing and managing the following groups of AEs: 
Gastrointestinal, Renal, Pulmonary, Hepatic, Endocrinopathies, Skin, Neurological. 
For subjects expected to require more than 4 weeks of corticosteroids or other immunosuppressants 
to manage an AE, consider recommendations provided in the algorithms. These algorithms are found 
in the Nivolumab IB [and in Appendix] of this protocol. The guidance provided in these algorithms 
should not replace the Investigator’s medical judgment but should complement it. 
 


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Discontinuation Criteria 
Treatment should be permanently discontinued for the following: 
• 
Any Grade 2 drug-related uveitis or eye pain or blurred vision that does not respond to topical 
therapy and does not improve to Grade 1 severity within the re-treatment period OR requires 
systemic treatment  
• 
Any Grade 3 non-skin, drug-related adverse event lasting > 7 days, with the following 
exceptions for drug-related laboratory abnormalities, uveitis, pneumonitis, bronchospasm, 
hypersensitivity reactions, and infusion reactions, and endocrinopathies: 
o Grade 3 drug-related uveitis, pneumonitis, bronchospasm, hypersensitivity reaction, 
or infusion reaction of any duration requires discontinuation 
o Grade 3 drug-related endocrinopathies adequately controlled with only physiologic 
hormone replacement do not require discontinuation 
o Grade 3 drug-related laboratory abnormalities do not require treatment discontinuation 
except those noted below 
• 
Grade 3 drug-related thrombocytopenia > 7 days or associated with bleeding 
requires discontinuation 
• 
Any drug-related liver function test (LFT) abnormality that meets the following 
criteria require discontinuation:  
• 
AST or ALT > 8 x ULN  
• 
Total bilirubin > 5 x ULN 
• 
Concurrent AST or ALT > 3 x ULN and total bilirubin > 2 x ULN 
• 
Any Grade 4 drug-related adverse event or laboratory abnormality, except for the following 
events which do not require discontinuation: 
• 
Isolated Grade 4 amylase or lipase abnormalities that are not associated with 
symptoms or clinical manifestations of pancreatitis and decrease to < Grade 4 within 
1 week of onset.  
• 
Isolated Grade 4 electrolyte imbalances/abnormalities that are not associated with 
clinical sequelae and are corrected with supplementation/appropriate management 
within 72 hours of their onset 
• 
Grade 4 lymphopenia or leucopenia 
• 
Grade 4 drug-related endocrinopathy adverse events, such as adrenal insufficiency, 
ACTH deficiency, hyper- or hypothyroidism, or glucose intolerance, which resolve or 
are adequately controlled with physiologic hormone replacement (corticosteroids, 
thyroid hormones) or glucose-controlling agents, respectively, may not require 
discontinuation after discussion with and approval from the Investigator [as allowed 
by protocol] 
• 
Any dosing interruption lasting > 6 weeks with the following exceptions: 


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• 
Dosing delays or interruptions to allow for prolonged steroid tapers to manage drug-
related adverse events are allowed. Prior to re-initiating treatment in a subject with 
a dosing interruption lasting > 6 weeks, the Investigator must be consulted. Tumor 
assessments should continue as per protocol even if dosing is interrupted or delayed 
• 
Dosing interruptions or delays lasting > 6 weeks that occur for non-drug-related 
reasons may be allowed if approved by the Investigator. Prior to re-initiating 
treatment in a subject with a dosing interruption lasting > 6 weeks, the Investigator 
must be consulted. Tumor assessments should continue as per protocol even if 
dosing is interrupted 
• 
Any adverse event, laboratory abnormality, or intercurrent illness which, in the judgment of 
the Investigator, presents a substantial clinical risk to the subject with continued nivolumab 
dosing 
 
Treatment of Nivolumab Related Infusion Reactions 
Since nivolumab contains only human immunoglobulin protein sequences, it is unlikely to be 
immunogenic and induce infusion or hypersensitivity reactions. However, if such a reaction were to 
occur, it might manifest with fever, chills, rigors, headache, rash, pruritis, arthralgias, hypo- or 
hypertension, bronchospasm, or other symptoms of allergic-like reactions.  
All Grade 3 or 4 infusion reactions should be reported as an SAE if criteria are met. Infusion reactions 
should be graded according to NCI CTCAE (version 4.03) guidelines. 
Treatment recommendations are provided below and may be modified based on local treatment 
standards and guidelines as appropriate: 
For Grade 1 symptoms: (Mild reaction; infusion interruption not indicated; intervention not indicated) 
Remain at bedside and monitor subject until recovery from symptoms. The following prophylactic 
premedications are recommended for future infusions: diphenhydramine 50 mg (or equivalent) and/or 
paracetamol 325 to 1000 mg (acetaminophen) at least 30 minutes before additional nivolumab 
administrations. 
For Grade 2 symptoms: (Moderate reaction requires therapy or infusion interruption but responds 
promptly to symptomatic treatment [e.g., antihistamines, non-steroidal anti-inflammatory drugs, 
narcotics, corticosteroids, bronchodilators, IV fluids]; prophylactic medications indicated for 24 hours). 
Stop the nivolumab infusion, begin an IV infusion of normal saline, and treat the subject with 
diphenhydramine 50 mg IV (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen); 
remain at bedside and monitor subject until resolution of symptoms. Corticosteroid or bronchodilator 
therapy may also be administered as appropriate. If the infusion is interrupted, then restart the 
infusion at 50% of the original infusion rate when symptoms resolve; if no further complications ensue 
after 30 minutes, the rate may be increased to 100% of the original infusion rate. Monitor subject 
closely. If symptoms recur then no further nivolumab will be administered at that visit. Administer 
diphenhydramine 50 mg IV, and remain at bedside and monitor the subject until resolution of 
symptoms. The amount of study drug infused must be recorded on the electronic case report form 
(eCRF). The following prophylactic premedications are recommended for future infusions: 
diphenhydramine 50 mg (or equivalent) and/or paracetamol 325 to 1000 mg (acetaminophen) should 


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be administered at least 30 minutes before additional nivolumab administrations. If necessary, 
corticosteroids (recommended dose: up to 25 mg of IV hydrocortisone or equivalent) may be used. 
 
For Grade 3 or Grade 4 symptoms: (Severe reaction, Grade 3: prolonged [i.e., not rapidly 
responsive to symptomatic medication and/or brief interruption of infusion]; recurrence of symptoms 
following initial improvement; hospitalization indicated for other clinical sequelae [e.g., renal 
impairment, pulmonary infiltrates]). Grade 4: (life threatening; pressor or ventilatory support 
indicated).  
Immediately discontinue infusion of nivolumab. Begin an IV infusion of normal saline, and treat the 
subject as follows. Recommend bronchodilators, epinephrine 0.2 to 1 mg of a 1:1,000 solution for 
subcutaneous administration or 0.1 to 0.25 mg of a 1:10,000 solution injected slowly for IV 
administration, and/or diphenhydramine 50 mg IV with methylprednisolone 100 mg IV (or equivalent), 
as needed. Subject should be monitored until the investigator is comfortable that the symptoms will 
not recur. Nivolumab will be permanently discontinued. Investigators should follow their institutional 
guidelines for the treatment of anaphylaxis. Remain at bedside and monitor subject until recovery 
from symptoms.  
In the case of late-occurring hypersensitivity symptoms (e.g., appearance of a localized or 
generalized pruritis within 1 week after treatment), symptomatic treatment may be given (e.g., oral 
antihistamine, or corticosteroids). 
 
16.1.2 Potential Carboplatin Toxicities 
Potential Adverse Reactions: 
▪ Hematologic Toxicity 
• Thrombocytopenia 
• Neutropenia 
• Leukopenia 
• Anemia 
• Infection 
• Bleeding 
• Need for Blood Transfusion 
 
▪ Gastrointestinal Toxicity 
• Nausea 
• Vomiting 
• Mucositis 
• Diarrhea 
• Constipation 
 
▪ Neurologic Toxicity 
• Peripheral Neuropathy 
• Ototoxicity 


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• Central Nervous System Toxicity 
 
▪ Renal Toxicity 
• Nephrotoxicity 
• Elevated Serum Creatinine 
• Elevated Blood Urea  
 
▪ Hepatic Toxicity 
• Elevated Bilirubin 
• Elevated SGOT/AST 
• Elevated Alkaline Phosphatase 
 
▪ Electrolyte Imbalance 
• Hyponatremia 
• Hypokalemia 
• Hypocalcemia 
• Hypomagnesemia 
 
▪ Other Side Effects 
• Allergic Reaction 
• Respiratory Toxicity 
• Injection Site Reactions 
• Cardiovascular Toxicity 
o Cardiac Failure 
o Embolism 
o Hypertension 
o Cerebrovascular Accident 
• Cancer-Associated Hemolytic Uremic Syndrome 
• Pain 
• Asthenia 
• Malaise 
• Anorexia 
• Alopecia 
 
 
16.1.3 Potential Paclitaxel  Toxicities 
Adverse Events of any grade during 
chemoradiotherapy n=171 
No patients (%) 
Anorexia 
51   (30) 
Alopecia 
25   (15) 
Constipation 
47   (27) 
Diarrhea 
30   (27) 


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Esophageal perforation 
  1   (  1) 
Esopghagitis 
32   (19) 
Fatigue 
115 (67) 
Nausea 
91   (53) 
Neurotoxic effects 
25   (15) 
Vomiting 
43    (25) 
Leukopenia 
103 (60) 
Neutropenia 
 16   (9) 
Thrombocytopenia 
  92  (54)  
 
Potential Adverse Reactions: 
▪ Bone Marrow Suppression 
▪ Neutropenia 
▪ Leukopenia 
▪ Thrombocytopenia 
▪ Anemia 
▪ Infection  
▪ Fever 
▪ Bleeding 
▪ Need for Red Cell and Platelet Transfusions 
▪ Peripheral Neuropathy 
▪ Autonomic Neuropathy 
▪ Parasthesia 
▪ Hyperesthesia 
▪ Arthralgia 
▪ Myalgia 
▪ Nausea 
▪ Vomiting 
▪ Diarrhea 
▪ Mucositis 
▪ Alopecia 
▪ Bradycardia 
▪ Hypotension 
▪ Elevated Bilirubin 
▪ Elevated Alkaline Phosphatase 
▪ Elevated AST/SGOT 
▪ Anaphylaxis and Hypersensitivity Reactions 
▪ Dyspnea 
▪ Angioedema 
▪ Urticaria 
▪ Pneumonia 
▪ Lung Fibrosis 
▪ Pulmonary Embolism 


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▪ Pleural Effusion 
▪ Respiratory Failure 
▪ Severe Cardiac Conduction Abnormalities 
▪ Edema 
▪ Optic Nerve and/or Visual Disturbances (Scintillating Scotoma) 
▪ Conjuctivitis 
▪ Photopsia 
▪ Visual Floaters 
▪ Increased Lacrimation 
▪ Seizures 
▪ Syncope 
▪ Ataxia 
▪ Neuroencephalopathy 
▪ Nail Changes 
▪ Increased Myelotoxicity 
▪ Paralytic Ileus 
▪ Intestinal Obstruction 
▪ Intestinal Perforation 
▪ Pancreatitis 
▪ Ischemic Colitis 
▪ Dehydration 
▪ Esophagitis 
▪ Constipation 
▪ Ascites 
▪ Neutropenic Enterocolitis (Typhlitis) 
▪ Infusion Site Reactions 
▪ Stevens-Johnson Syndrome  
▪ Toxic Dermal Necrolysis 
▪ Swelling, Thickening and Sclerosis of the Skin at Injection Site 
▪ Erythema 
▪ Tenderness 
▪ Skin Discolorations 
▪ Phlebitis 
▪ Induration 
▪ Cellulitis 
▪ Skin Exfoliation 
▪ Necrosis 
▪ Elevated Creatinine 
▪ Renal Insufficiency 
▪ Asthenia 
▪ Anorexia 
▪ Confusion 
▪ Vertigo 
 
What are the possible side effects of paclitaxel? 


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Patients should tell their healthcare provider right away if they have: 
• 
 
 severe stomach pain 
• 
 
 severe diarrhea 
 
The most common side effects of Paclitaxel  (those which occur in >10% of patients) 
include: 
• 
 
 low red blood cell count (anemia) feeling weak or tired 
• 
 
 hair loss 
• 
 
 numbness, tingling, or burning in the hands or feet (neuropathy) 
• 
 
 joint and muscle pain 
• 
 
 nausea and vomiting 
• 
 
 hypersensitivity reaction - trouble breathing; sudden swelling of the face, lips, 
tongue, throat, or trouble swallowing; hives (raised bumps) or rash 
• 
 
 diarrhea 
• 
 
 mouth or lip sores (mucositis) 
• 
infections - if the patient has a fever (temperature above 100.4°F) or other sign 
of infection, he/she should tell their healthcare provider right away 
• 
 
 swelling of the hands, face, or feet 
• 
 
 bleeding events 
• 
 
 irritation at the injection site 
• 
 
 low blood pressure (hypotension) 
 
16.2 
Risks of Radiation Therapy 
Potential adverse effects may include: 
▪ Fatigue 
▪ Nausea 
▪ Vomiting 
▪ Loss of Appetite 


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▪ Dysphagia 
▪ Odynophagia 
▪ Weight Loss 
▪ Skin changes in the area being treated which can range from mild redness and 
soreness to blistering and peeling 
 
16.3 
Risks of Biopsy 
Potential adverse effects may include: 
▪ Bleeding 
▪ Infection 
▪ Fever 
▪ Tearing/Perforation of the Esophagus  
▪ Chest Pain 
▪ Severe or Persistent Abdominal Pain 
▪ Vomiting 
▪ Black or Very Dark Colored Stool 
 
16.4 
Risks of Surgery 
Short-term risks of esophagectomy include reactions to anesthesia, excess bleeding, blood 
clots in the lungs or elsewhere, and infections. Most people will have at least some pain after 
the operation, which can usually be helped with pain medicines. 
 
Lung complications are common. Pneumonia may develop, leading to a longer hospital stay, 
and sometimes even death. 
 
Some people might have voice changes after the surgery. 
 
There may be a leak at the place where the stomach (or intestine) is connected to the 
esophagus, which might require another operation to fix.  
 
Strictures (narrowing) can form where the esophagus is surgically connected to the stomach, 
which can cause problems swallowing for some patients. To relieve this symptom, these 
strictures can be expanded during an upper endoscopy procedure. 
 
After the operation, the stomach may empty too slowly because the nerves that control its 
contractions can be affected by surgery. This can sometimes lead to frequent nausea and 
vomiting. 
 
After surgery, bile and stomach contents can enter the esophagus because the muscle that 
normally controls this (the lower esophageal sphincter) is often removed or changed by the 


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surgery. This can cause symptoms such as heartburn. Sometimes antacids or motility drugs 
can help relieve these symptoms. 
 
Some complications from this surgery can be life threatening.  
 
16.5 
Other Risks of Study Participation 
 
16.5.1 Side Effects of Having Blood Taken 
• Fainting or feeling faint 
• 
Redness, pain, bruising, bleeding or infection at the needle site 
 
 
16.5.2 Radiation Risks   
During this study, patients will be exposed to radiation from imaging tests and radiation 
therapy.  The risk from this amount of radiation is less than the risk from everyday exposure 
to the sun. The risks of receiving very small doses of radiation are thought to be low. These 
risks are not actually known.  The use of radiation may involve a low risk of cancer. Pregnant 
women cannot be exposed to radiation. Women must have a negative pregnancy test before 
they can enter the study. 
 
 
16.5.3 Electrocardiogram (ECG) Risks 
The sticky pads (electrodes) that are placed on the patient’s chest can sometimes cause 
discomfort, such as redness or itching. Shaving of the patient’s chest before attaching these 
pads may be necessary. Irritation from shaving also may occur. 
 
 
16.5.4 FDG-PET/CT Scan Risks 
A small amount of radioactive sugar will be injected (shot) into the patient’s blood through a 
vein in the patient’s arm about 1 hour before the scan. The patient should not feel any effects 
from the sugar as it is a small, safe amount of radioactive material. There is a small risk of 
allergic reaction to the radioactive material and there is always a slight risk from being 
exposed to any radiation. The patient may have swelling, soreness, or infection at the 
injection site. The radioactive material is passed out of the body through the urine within 24 
hours after the test is completed. 
 
The patient will need to lie still for up to 1 hour in the PET/CT scanner. The patient will have 
a brief CT scan that takes about a minute followed by the PET imaging that takes between 
25 and 45 minutes. There is a risk that the patient may feel anxious in the scanner due to the 
confined space. If the patient feels anxious in closed spaces, medication may be prescribed 
to help the patient relax.  
 


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16.5.5 Magnetic Resonance Imaging (MRI) Risks 
 
Fear of Closed Spaces 
When the patient is in the MRI scanner he/she will be in a relatively small, closed space. The 
patient will need to lie still for up to 1 hour inside the MRI scanner. If it is known that closed 
spaces make the patient anxious, the patient may be able to take medication to help him/her 
relax. Instruct the patient to tell the study staff or technologist if they become anxious or 
uncomfortable during the MRI, and the MRI will be stopped right away. 
 
Noise Level 
The MRI machine makes loud, tapping sounds. The patient will be given earplugs to help 
block the amount of noise heard during the MRI. 
 
MRI System Failure 
In rare cases, the magnet in the machine can stop working. If this happens, some cooling 
fluids could leak out and gas can form in the room. The gas is not dangerous. If this happens, 
the technologist will take the patient out of the room right away. 
 
Body Twitching and Heating 
In rare cases, the patient may have muscle twitching and/or tingling and a fever during the 
MRI. Instruct the patient to tell the technologist right away if he/she has any of these 
symptoms. 
 
Receiving Contrast Material 
The patient may need to have a dye called gadolinium injected (shot) into a vein in his/her 
arm during the MRI. This dye will make the pictures clearer. The patient may have bleeding, 
bruising, swelling, soreness or infection at the injection site. In rare cases, the patient may 
experience nausea and/or headache after this injection. These symptoms usually go away 
quickly and without medical treatment. Some systemic reaction may occur, such as a metallic 
taste, nausea, vomiting, and hives.  This is usually limited.  Very infrequently, there is difficulty 
in breathing, low blood pressure and dizziness that requires appropriate treatment. Severe 
reactions where death has occurred are extremely rare. If the patient has allergies, the 
possibility of reaction is higher than in a patient a without allergies. Instruct the patient to tell 
the study doctor if he/she has kidney disease or has had a reaction to intravenous contrast 
previously. Patients who have bad kidney function are at risk for worsening their kidney 
function.  The patient will need a blood test to make sure it is safe for him/her to get the 
gadolinium and may need pre-medication to decrease the possibility of complications of 
allergic reaction. If the patient is diabetic, and on oral medication, it is recommended that 
he/she stop taking the medication for two days after the contrast injection. 
 
Pregnancy 
If the patient is pregnant or thinks she might be pregnant, instruct her to tell the study doctor 
or the study staff. It is not safe for the patient to have the MRI or receive gadolinium if she is 
pregnant. 
 


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Magnetic Field Risk 
MRI uses a strong magnetic field to create images of the body. Because of the strong 
magnetic field, there are risks. These risks are detailed in this section.  
 
One possible risk is burns to the skin. There is an increased risk of burns from devices that 
conduct electrical energy. These devices can include metallic objects, pulse oximeters, EKG 
leads, or skin tattoos. These devices can be either in or on the patient in order for a skin burn 
to occur. The FDA has found that 70% of all reported injuries from MRIs were burns to the 
skin. 
 
To reduce this risk, all patients who are scanned in this study must complete thorough 
screening to ensure that no conductive materials are present in or on the patient’s body.  
Additionally, the power limits of the magnet will be adjusted as necessary.  
 
Another possible risk is that a metal object could be pulled into the scanner and hit the patient. 
The patient could be physically injured as a result.  
 
To reduce this risk, everyone near the magnet will remove all metal from their clothing or 
pockets when in the scanning environment.  The door to the scan room will remain closed 
during the exam for the patient’s safety.  
 
There are no known risks or adverse effects resulting directly from exposure to MRI.  
However, patients who have a pacemaker or metal objects in their body such as shrapnel or 
metal in the eye should not have the scan performed.  Instruct the patient to inform the 
technologist or investigators before entering the magnet room if he/she has any question 
about metal implants or metal fragments in the body. 
 
16.5.6 Unforeseeable Risks 
This research study may involve risks that are currently unforeseeable, including death.  
 
16.6 
Potential Benefits 
It is possible that some patients who receive the study therapies may experience an 
improvement in their cancer during the study. 
 
Others with squamous cell carcinoma of the esophagus cancer may benefit in the future from 
what we learn in this study. 
 
17.0 
References  
 
1. 
Siegel RL, M.K., Jemal A, Cancer Statistics, 2015. CA Cancer J Clin, 2015. 65: p. 5-
29. . 
2. 
Torre LA, B.F., Siegel RL, et al., Global Cancer Statistics, 2012. CA Cancer J Clin, 
2015. 65: p. 87-108. 


ESCC Nivolumab  
 
Page 110 
 
 
3. 
Cohen DJ, L.L., Controversies in the Treatment of Local and Locally Advanced Gastric 
and Esophageal Cancers. J Clin Oncol, 2015. 33: p. 1754-1759. 
4. 
Shridhar R, A.K., Meredith KL, et al., Radiation Therapy and Esophageal Cancer. 
Cancer Control, 2013. 20(2): p. 97-110. 
5. 
Leichman L, T.C., Squamous Cell Cancer of the Esophagus: The Forgotten One. 
Gastrointest Can Res, 2011. 4(1): p. 22-23. 
 
6. 
Huang TC, H.C., LCC, Tu YK, Systematic review and network meta-analysis: 
neoadjuvant chemoradiotherapy for locoregional esophageal cancer. Jpn J Clin 
Oncol, 2015. 45(11): p. 1023-1028. 
7. 
van Hagen P, H.M., van Lanschot JJB, et al., Preoperative Chemoradiotherapy for 
Esophageal or Junctional Cancer. N Engl J Med, 2012. 366: p. 2074-2084. 
8. 
Shapiro J, v.L.J., Hulshof MCCM, et al., Neoadjuvant chemoradiotherapy plus surgery 
versus surgery alone for esophageal or junctional cancer (CROSS): long-term results 
of a randomised controlled trial. Lancet Oncol, 2015. 16: p. 1090-1098. 
9. 
Swisher SG, H.W., Wu TT, et al., Proposed Revision of the Esophageal Cancer 
Staging System to Accomodate Pathologic Response (pP) Following Preoperative 
Chemoradiation (CRT) Ann Surg, 2005. 241: p. 810-820. 
10. 
Kumagai K, R.I., Tsai JA, , et al., Meta‐analysis of postoperative morbidity and 
perioperative mortality in patients receiving neoadjuvant chemotherapy or 
chemoradiotherapy for resectable oesophageal and gastro‐oesophageal junctional 
cancers. British Journal of Surgery, 2014. 101(4): p. 321-338. 
11. 
Cooper JS, G.M., Herskovic A, Macdonald JS, et al., Chemoradiotherapy of Locally 
Advanced Esophageal Cancer: Long-term Follow-up of a Prospective Randomized 
Trial (RTOG 85-01). JAMA, 1999. 281: p. 1623-1627. 
12. 
Stahl M, S.M., Lehmann N, et al., Chemoradiation With and Without Surgery in 
Patients with Locally Advanced Squamous Cell Carcinoma of the Esophagus. J Clin 
Oncol, 2015. 23(10): p. 2310-2317. 
13. 
Bedenne L, M.P., Bouche O, et al., Chemoradiation Followed by Surgery Compared 
with Chemoradiation Alone in Squamous Cell Cancer of the Esophagus: FFCD 9102. 
J Clin Oncol, 2007. 25: p. 1160-1168. 
14. 
Wu P, W.D., Li L, Chai Y, Huang J, PD-L1 and Survival in Solid Tumors: A Meta-
Analysis. PLoS ONE, 2015. 10(6): p. 1-15 
. 
15. 
Alexandrov LB, N.-Z.S., Wedge DC, et al., Signatures of mutational processes in 
human cancer. Nature, 2013. 500: p. 415-421. 


ESCC Nivolumab  
 
Page 111 
 
 
16. 
Wong RM, S.R., Lau RL,, et al., Programmed death-1 blockade enhances expansion 
and functional capacity of human melanoma antigen-specific CTLs. International 
Immunology, 2007. 19(10): p. 1223-1234. 
17. 
Brahmer JR, D.C., Wollner I,  Powderly JD., et al., Phase I Study of Single-Agent Anti–
Programmed Death-1 (MDX-1106) in Refractory Solid Tumors: Safety, Clinical 
Activity, Pharmacodynamics, and Immunologic Correlates. Journal of Clinical 
Oncology, 2010. 28(19): p. 3167-3175. 
18. 
Weber JS, D.A.S., Minor D, , et al., Nivolumab versus chemotherapy in patients with 
advanced melanoma who progressed after anti-CTLA-4 treatment (CheckMate 037): 
a randomised, controlled, open-label, phase 3 trial. The Lancet Oncology, 2015. 16(4): 
p. 375-384. 
19. 
Derman BA, M.K., Bonomi PD, , M. Batus, and M.J. Fidler, Treatment of advanced 
squamous cell carcinoma of the lung: a review. Transl Lung Cancer Res, 2015. 4(5). 
20. 
Le DT, U.J., Wang H, Bartlett BR, , et al., PD-1 Blockade in Tumors with Mismatch-
Repair Deficiency. The New England Journal of Medicine, 2015. 372(26): p. 2509-
2520. 
21. 
Rizvi NA, H.M., Snyder A, et al., Mutational landscape determines sensitivity to PD-1 
blockade in non-small cell lung cancer. Science, 2015. 348(6230). 
22. 
Topalian SL, H.F., Brahmer JR, et al., Safety, Activity, and Immune Correlates of Anti-
PD-1 Antibody in Cancer. N Engl J Med, 2012. 366(26). 
23. 
Robert C, L.G., Brady B, Dutriaux C, , et al., Nivolumab in Previously Untreated 
Melanoma without BRAF Mutation. The New England Journal of Medicine, 2015. 
372(4): p. 320-330. 
24. 
Borghaei H, P.-A.L., Horn L, Spigel DR, Steins, Martin, et al., Nivolumab versus 
Docetaxel in Advanced Nonsquamous Non–Small-Cell Lung Cancer. The New 
England Journal of Medicine, 2015. 373(17): p. 1627-1639. 
25. 
Brahmer J, R.K., Baas P, Crinò L, et al., Nivolumab versus Docetaxel in Advanced 
Squamous-Cell Non–Small-Cell Lung Cancer. The New England Journal of Medicine, 
2015. 373(2): p. 123-135. 
26. 
Ura T, M.K., Hara H, et al. , Phase 2 study of niovlumab (Anti-PD-1;ONO 4538) in 
patients with esophageal cancer: preliminary report. 2015. 
27. 
Formenti SC, D.S., Combining Radiotherapy and Cancer Immunotherapy: A 
Paradigm Shift. J Natl Cancer Inst, 2013. 105: p. 256-265. 
28. 
Tang C, W.X., Soh H, et al., Combining Radiation and Immunotherapy: A New 
Systemic Therapy for Solid Tumors? Cancer Immunol Res, 2014. 2: p. 831-838. 


ESCC Nivolumab  
 
Page 112 
 
 
29. 
Byrne KT, V.R., Jaffee EM, Armstrong TD, Special Conference on Tumor Immunology 
and Immunotherapy: A New Chapter. Cancer Immunol Res, 2015. 3(6): p. 590-597. 
30. 
Seyedin SN, S.J., Lee DA, , et al., Strategies for combining immunotherapy with 
radiation for anticancer therapy. Immunotherapy, 2015. 7(9): p. 653905368. 
31. 
Postow MA, C.M., Barker CA, Yamada, Yoshiya, et al., Immunologic Correlates of the 
Abscopal Effect in a Patient with Melanoma. The New England Journal of Medicine, 
2012. 366(10): p. 925-931. 
32. 
Stamell EF, W.J., Gnjatic S, , N.Y. Lee, and I. Brownell, The Abscopal Effect 
Associated With a Systemic Anti-melanoma Immune Response. International Journal 
of Radiation Oncology*Biology*Physics, 2013. 85(2): p. 293-295. 
33. 
Twyman-Saint Victor C, R.A., Maity A, Rengan, Ramesh, et al., Radiation and dual 
checkpoint blockade activate non-redundant immune mechanisms in cancer. Nature, 
2015. 520(7547): p. 373-377. 
34. 
Oh P, D.K., Leichman L, et al., PD-1 Blockade Enhances the Efficacy of 
Chemoradiation in a Mouse Model of Esophageal Cancer. . 2016. 
35. 
Schneider PM, B., SE, Metzger R, , et al., Histomorphologic tumor regression and 
lymph 
node 
metastases 
determine 
prognosis 
following 
neoadjuvant 
radiochemotherapy for esophageal cancer: implications for response classification. 
Annals of surgery, 2005. 242(5): p. 684-692. 
36. 
Lloyd S, C.B., Current strategies in chemoradiation for esophageal cancer. Journal of 
gastrointestinal oncology, 2014. 5(3): p. 156. 
37. 
Tepper J, K.M., Niedzwiecki D,, et al., Phase III Trial of Trimodality Therapy With 
Cisplatin, Fluorouracil, Radiotherapy, and Surgery Compared With Surgery Alone for 
Esophageal Cancer: CALGB 9781. Journal of Clinical Oncology, 2008. 26(7): p. 1086-
1092. 
38. 
U.S. Department of Heatlh and Human Services. Common Terminology Criteria for 
Adverse 
Events 
(CTCAE) 
Version 
4.03 
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-
14_QuickReference_5x7.pdf. 
 
39.  
PASS 14 Power Analysis and Sample Size Software (2015). NCSS, LLC. Kaysville,   
           Utah, USA, ncss.com/software/pass 
 
 
APPENDIX I 
 
TABLE 9: EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG)  
PERFORMANCE STATUS SCALE 
 


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APPENDIX II: SAMPLE PREPARATION AND SHIPMENT INSTRUCTIONS 
 
Ship Samples to: 
  
Geoffrey Y. Ku, MD  
Immune Monitoring Facility, Memorial Sloan Kettering Cancer Center 
Zuckerman Research Center, 15th floor 
417 East 68th Street 
New York, NY 10065 
Telephone: (646) 888-4588 
 
Isolation and Cryopreservation of Human 
Peripheral Blood Mononuclear Cells and Plasma from Whole Blood 
 
I. SCOPE 
A. This standard operating procedure provides instructions for the isolation and 
cryopreservation of peripheral blood mononuclear cells (PBMC), as well as the collection and 
freezing of plasma from human whole blood. 
 
II. GENERAL 
A. Human PBMC consists of nucleated white blood cells, including lymphocytes and 
monocytes, and can be separated from other components of whole blood by 
density gradient centrifugation. 
B. Human PBMCs are widely used in clinical research and can be evaluated by a variety of 
immune monitoring methods to assess cellular components of immunity after vaccination or 
immunotherapy. 
C. PBMC should be processed from whole blood as soon as possible and cryopreserved in 
liquid nitrogen to maintain long-term viability and allow downstream (batched) analyses of 
cellular immunity. 
D. The PBMC isolation and plasma collection procedure here applies to whole blood 
collected in BD vacutainer CPT Cell Preparation Tubes containing heparin as anti-coagulant. 
 
III. ROLES AND RESPONSIBILITIES 
A. It is the responsibility of personnel performing this procedure to be familiar with this 
protocol and perform it in a consistent manner as described herein. 
B. Assigned personnel should be proficient in basic sterile technique and tissue culture 
methods. 
 
IV. SAFETY 
A. All human blood-derived samples irrespective of donor status must be considered bio 
hazardous and handled minimally under Biosafety Level-2 conditions as defined in the 
CDC/NIH manual, “Biosafety in Microbiological and Biomedical Laboratories”, 5th edition, 
2009. Human blood may contain infectious organisms and should be handled according to 
universal safety policies and procedures. 


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B. Appropriate personal protective equipment including lab coats or disposable gowns, safety 
glasses, and disposable gloves should be worn when handling human specimens. Change 
gloves as frequently as needed to minimize contamination of work areas. 
C. Work should be performed in a certified biosafety cabinet. Spray work areas with 70% 
ethanol and/or 10% bleach to minimize contamination, before and after working. 
D. Used pipettes, tips, and tubes exposed to human blood are recommended to be soaked 
in 10% bleach solution at least 1 hr. prior to discarding in biohazard waste containers. 
Personnel should wash hands following completion of procedures. 
 
V. DEFINITIONS AND ABBREVIATIONS 
A. CFM cell freezing medium 
B. CPT Cell Preparation Tubes for PBMC isolation from BD Biosciences 
C. ddH2O deionized distilled water 
D. DMSO dimethyl sulfoxide 
E. FBS fetal bovine serum 
F. PBMC peripheral blood mononuclear cells 
G. PBS phosphate-buffered saline 
H. RBC red blood cells 
I. RCF relative centrifugal force (g force) 
J. RPM revolutions per minute 
K. RT room temperature (18-25°C) 
L. TC tissue culture 
 
VI. MATERIALS AND REAGENTS 
A. Human whole blood collected in BD Vacutainer CPT tubes with sodium heparin 
(16x125 mm size, 8 ml draw capacity, BD Biosciences Cat. 362753) 
B. Sterile disposable pipettes (25 ml, 10 ml, 5 ml, and 2 ml sizes; BD Falcon Cat. 357525, 
357551, 357543, 357507 or equivalent) 
C. Sterile 15-ml polypropylene conical tubes (BD Falcon, Cat. 352096, or equivalent) 
D. Sterile disposable 50-ml centrifuge tubes (Fisher Scientific, Cat. 06-443-19, or equivalent) 
E. Corning polypropylene 2.0-ml cryogenic vials (sterile, self-standing, silicone washer, 
internal thread, Fisher Scientific Cat. 03-374-21, Corning Ref #430488, or equivalent) 
F. Cryolabels for laser printers (GA International, Cat. CL-9T1) 
G. Corning sterile universal fit pipette tips, size 1-200 μl (Fisher Scientific Cat. 07- 
200-301, Corning Ref #4864, or equivalent) 
H. Dulbecco’s Phosphate Buffered Saline without magnesium or calcium (1X DPBS, Cellgro 
Cat. 21-031-CM, or equivalent), stored at 4°C. 
I. Heat inactivated fetal bovine serum (Gemini Bioproducts, Cat. 100-106, sterile, triple 0.1μm 
filtered) 
J. Cell wash buffer (D-PBS containing 10% FBS) 
• Prepare by adding 100 ml heat-inactivated FBS into 900 ml D-PBS. Store at 4°C, this 
can be used for up to 1 month after preparation 
K. Dimethyl sulfoxide (DMSO, ACS spectrophotometric grade, Sigma Aldrich Cat. 154938, 
or equivalent) 
L. Cell freezing medium (FBS containing 10% DMSO) 
• Prepare by adding 10 ml DMSO into 90 ml heat-inactivated FBS. Store at 


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           4°C in the dark, this can be used for up to 1 month after preparation 
M. Distilled, deionized water (ddH2O) (Cellgro, Cat. 25-055-CM, or equivalent) 
N. Cryogenic vial storage boxes (10 x 10), Taylor Wharton (Cat. R24K-9C44, Fisher Scientific 
Cat. 50-902-0656, or equivalent) 
O. CoolCell LX-1 freezing containers, 12- and 30-vial capacities (Fisher Scientific, Cat. 
13900856 and 13900679) or equivalent (e.g., NALGENE Mr. Frosty Cryo 
1°C Freezing Container) 
P. Ethanol (95%, Decon Labs Cat. 2801, Fisher Scientific Cat. 04-355-226) 
Q. Bleach diluted to 10% in distilled water (Clorox germicidal bleach, VWR, Cat. 21899-504, 
or equivalent) 
R. Powder-free nitrile gloves (Fisher Scientific, Cat. 19-130-1597, or equivalent) 
S. Non-sterile cotton gauze sponges, 4” x 4” 12 ply (Fisher Scientific, Cat. 13-761-52, or 
equivalent) 
 
VII. EQUIPMENT 
A. Certified biological laminar flow safety cabinet rated at BSL-2A 
B. Refrigerated centrifuge (Allegra 6KR with swinging bucket rotor GH3.8 and appropriate 
adapters for conical tubes, Beckman Coulter, or equivalent) 
C. Multipurpose lab rotator (Thermo Scientific Model #2314, Fisher Scientific Cat. 2314-
1CEQ) 
D. Single channel micropipetters (Finnpipette, Cat. 21-377-816, 21-377-818, Fisher 
Scientific, or equivalent) 
E. Muse™ Cell Analyzer with Count & Viability Kit (Cat. 0500-3115, MCH100102, EMD 
Millipore) for counting cells and measuring viability using 2 DNA-binding dyes 
F. Inverted microscope with 10X magnification (Eclipse TS100, Nikon, or equivalent), 
hemacytometer (BrightLine Hemacytometer, Cat. 15170-168, Hausser Scientific, or 
equivalent), and hand tally counter (Cat. 23609-102, VWR, or equivalent) for counting cells 
(if automated counting instrument unavailable) 
 
VIII. PROCEDURE 
The following procedures are conducted in a biosafety hood except for centrifugation. The 
BD Vacutainer® CPT Cell Preparation Tube with Sodium Heparin combines a blood 
collection tube containing a sodium heparin anticoagulant with a FICOLL Hypaque density 
fluid and a polyester gel barrier which separates the two liquids. The result is a convenient, 
single tube system for the collection of whole blood and the separation of mononuclear cells.  
 
NOTE: After blood collection, store CPT tubes (gently rocking on a plate rotator) at room 
temperature until centrifugation. Blood samples should be centrifuged within 2-4 hours of 
blood collection for best results. For this procedure, generally 4 CPT tubes or ~32 ml of blood 
(for PBMC and plasma) are collected per subject. 
 
A. Sample database entry 
1. For each sample, note the time and date of blood draw indicated on the sample requisition 
form for each sample, record time & date of receipt in the core lab, date of actual processing, 
patient ID number, patient initials, patient visit time point, study protocol number, items 


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received (number of CPT tubes and red top tubes), and processor’s initials in both laboratory 
notebook/records/sample worksheet and on original requisition form. 
2. Log the sample into electronic clinical database, including date and time of collection, 
date and time of processing, and items received. Generate and print labels for cryovials and 
sample processing tubes. 
B. Density gradient centrifugation of whole blood in CPT tubes 
1. Remix the blood samples immediately prior to centrifugation by gently inverting the tubes 
8 to 10 times. 
2. Carefully balance and centrifuge CPT tubes at 2500 rpm (~1500 x g), 
room temperature, no brakes, for 20 minutes. NOTE: Ensure that the tubes are in the proper 
centrifuge carrier/adapter and are balanced. Excessive centrifuge speed (over 2000 RCF) 
may cause tube breakage and exposure to blood and possible injury. 
3. During centrifugation, print barcoded sample ID labels for the vials into 
which plasma samples will be distributed. These labels will provide information regarding 
date of sample processing, study protocol number, patient ID, and study time point 
information. 
4. Place barcoded sample ID labels vertically (e.g., top to bottom of tube) onto the 6 cryovials 
into which the plasma will be later distributed. 
5. Aliquot 50 ml of cell wash buffer into one 50-ml conical for each sample and label each 
with sample ID label. This wash buffer will be used for all subsequent washes of PBMC 
samples (~50 ml buffer per sample). 
6. Place sample ID label on one 15 ml conical tube per sample for collection of PBMC 
monolayer from centrifuged CPT tubes. 
7. Place sample ID label on one 15 ml conical tube per sample for pooling of plasma from 
centrifuged CPT tubes. 
NOTE: Labeling of tubes for PBMC and plasma samples with proper sample ID information 
is important to minimize potential for incorrect identification of samples especially when 
multiple blood samples from different subjects are being processed simultaneously. 
8. Once the centrifuge has come to a complete stop, remove CPT tubes, place in rack, and 
place tubes and rack in sterile biological safety cabinet. Collection of cells immediately 
following centrifugation will yield best results. After centrifugation, mononuclear cells and 
platelets will be in a whitish layer just under the yellow plasma layer, with RBC at the bottom 
of the tube below the polyester gel. 
 


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C. Plasma collection from centrifuged CPT tubes 
1. Sterilize the exterior of the centrifuged CPT tubes with 70% ethanol. Wipe the CPT tubes 
with a clean disposable gauze sponge or Kimwipes. 
2. Carefully open the caps of the CPT tubes and pipet a final total of at least 9 ml of the yellow 
plasma layer collectively from all tubes per sample into the appropriate sample ID-labeled 
15-ml conical tube using 10-ml serological pipet without disturbing the cell layer. 
3. Remove as much as possible and discard any remaining plasma from CPT tubes above 
the PBMC monolayer without disturbing the PBMC monolayer. 
4. Pooled plasma from all blood collection tubes collected into the 15-ml conical should then 
distributed into 6 x 1.5 ml aliquots in the 6 labeled cryovials set aside for each sample. If 
collecting from >6 CPT tubes, distribute plasma into 12 x 1.5 ml aliquots instead. 
5. Store the plasma aliquots per sample in the appropriate protocol boxes in -20°C freezer, 
recording location of vials on the requisition form. Record volume of plasma collected (per 
vial and total). 
 
D. PBMC isolation from centrifuged CPT tubes 
1. After plasma collection, carefully collect the white PBMC layer from the CPT tubes using 
a 10-ml serological pipet or smaller sterile 1-2 ml transfer pipet (being careful not to touch 
the gel barrier of the CPT tube) and place into appropriately labeled 15-ml conical tube set 
aside earlier. Add cell wash buffer (PBS containing 10% FBS from 50-ml conical tube set 
aside above) to bring volume in each tube up to 15 ml. 
2. Centrifuge tube containing collected PBMC @ 1350 rpm (~400 x g) at 4°C, brakes on, for 
15 minutes. 
3. Pour off wash buffer supernatant from tube. 
4. Resuspend cells into a total of 15 ml fresh wash buffer (PBS/10% FBS) per tube, and 
centrifuge @ 1150 rpm (~300 x g), 4°C, brakes on, for 10 minutes. 
5. After spin is completed for 2nd wash of cells, pour off wash supernatant and resuspend 
cells in 10 ml fresh wash buffer. Keep cell suspension cold on ice. 
6. With sterile micropipet tip, remove 10 μl of the resulting cell suspension and dilute in the 
appropriate buffer to the proper concentration for counting cells using automated counting 
instrument or hemacytometer. 


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7. Count cells (taking into account dilution factor) and record viability. Calculate the number 
of cryovials of cells to be frozen based on a final cell concentration of 6-8x106 viable 
cells/ml/vial. 
NOTE: It may be necessary to refer to specific study protocol for appropriate cell 
concentration to be used for freezing. 
8. After counting, centrifuge the cell sample sitting on ice in 15-ml conical at 1050 rpm (~250 
x g), 4°C, brakes on, for 10 minutes. 
9. While cells spin down, enter post-processing sample information into electronic clinical 
database and sample requisition form (including cell yields, concentration, viability) and 
generate freezing labels for cryovials. Affix barcoded sample labels vertically (e.g., top to 
bottom) on the appropriate number of cryovials (based on cell yield and target cell 
concentration). 
10. After centrifugation, pour off supernatant, invert conical tube and tap gently on gauze to 
remove excess wash buffer. 
11. Resuspend cells at the target concentration of 6-8x106 viable cells/ml (up to a maximum 
of 1.5x107/ml for samples with excessive cell numbers) in ice-cold cell freezing media (FBS 
containing10% DMSO) and aliquot 1 ml into labeled cryovials for each sample. 
NOTE: If total cell counts for a sample are low and are between 6-12x106 cells, distribute 
cells equally into 2 individual cryovials instead of one, noting final cell volume per vial. For 
total cell counts below 6x106 cells, freeze in only 1 cryovial per sample to preserve cell 
viability upon thaw. 
12. Place cryovials in CoolCell -1°C/min controlled rate freezing container (stored at room 
temperature), making sure all remaining empty slots in vials’ containing 1 ml/vial of freezing 
medium (no cells). 
13. Place CoolCell container in -80°C Revco #3 for 24-72 hours (generally one business 
day). 
14. After 24-72 hours (next business day), transfer frozen PBMC vials from CoolCell 
container to cryobox in -80°C freezer to await transfer to liquid nitrogen storage (or frozen 
shipment to central lab if liquid nitrogen storage is not possible) within one week of initial 
freezing of PBMC. 
NOTE: Some study protocols may require the transfer of frozen PBMC from -80°C to liquid 
nitrogen within as soon as 24 hrs. so be sure to verify requirements for each particular study 
protocol. 
15. When samples have been transferred to liquid nitrogen, record location information 
including liquid nitrogen tank, rack, slot, box, and position numbers in clinical database for 
tracking of frozen PBMC specimens. 
 
IX. REFERENCES 
• BD Vacutainer CPT Cell Preparation Tube product insert 
• CoolCell freezing container product brochure 
 
X. ADDITIONAL RESOURCES 
A. Nomogram for converting g force (RCF) to RPM 
B. Isolation and Cryopreservation of Human Peripheral Blood Mononuclear Cells and Plasma 
from Whole Blood – Mini Protocol Worksheet 
 


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* * * * * 
 
 
A. Nomogram for converting g force (RCF) to RPM 
 
• rcf = 11.18 x r x (rpm/1000)2 
 
where rcf is the relative centrifugal force (in g), r is the radius of the rotor in centimeters (from 
center of rotation axis to bottom of test tube), and rpm is the speed of the centrifuge in 
revolutions per minute. 
 
 
 
 
 
 
 
 


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B. Isolation and Cryopreservation of Human Peripheral Blood Mononuclear Cells 
and Plasma from Whole Blood – Mini Protocol Worksheet 
 
 
 
 
 


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